Presumptive Eligibility (PE) Programs

1900.030.20 QE Performance Standards And Corrective Action

IM#51, May 18, 2017

To remain a QE, the provider must meet the following performance standards with respect to its presumptive eligibility determinations. The PE provider must:

  • Check for receipt of PE within the past 12 months, or if pregnant, during the current pregnancy (TEMP or SMHB-PE). It is the expectation of FSD that a correct determination is made on 98% or more of applications.
  • Check for existing MO HealthNet coverage prior to completing PE determinations. It is the expectation of FSD that a correct determination is made on 98% or more of applications.
  • Make accurate PE determinations based on applicant’s self-attestation, income guidelines, and household size. This includes accuracy of the following information:
    • Names spelled correctly
    • Date of birth
    • Correct address
    • Social Security Number (if given)

    It is the expectation of FSD that a correct determination is made on at least 95% of PE determinations.

  • Assist applicants in completing and submitting regular MO HealthNet applications (IM-1SSL). It is the expectation of FSD that 90% of PE participants will submit applications for the appropriate program prior to the end of the PE period, and that 95% of these applications must be approved for ongoing MO HealthNet coverage.

    NOTE:  Regular applications rejected because the applicant did not meet citizenship/qualified alien criteria or did not provide verification will not be used in this measurement.

If performance standards are not met:

  • QE receives notification of deficiencies from the Family Support Division (FSD)
  • QE submits a corrective action plan (CAP) for review by FSD
  • Upon approval of CAP, QE must implement and complete the CAP within a     30-day time frame
    • FSD will moniter the QE’s performance on the CAP at least every three months until FSD determines that the corrective action plan has been successfully completed. 
  • If QE does not submit a CAP accepted by Division or again fails to meet performance standard, QE may be disqualified as a PE qualified entity for the period of 3 years
    • If QE is disqualified, QE receives notice 30 days prior to disqualification
    • QE has 10 calendar days to submit a request for reconsideration to the department director
    • Reconsideration is within the discretion of the department director
    • Any request for reconsideration should include a detailed explanation of the reasons why the QE should not be disqualified for failing to meet performance standards, or any corrective action measures, and should contain any documentation the QE wishes the director to consider.