M E M O R A N D U M

IM-47  03/27/03  PRESUMPTIVE ELIGIBILITY FOR CHILDREN (PC Program)
0950.000.00 - 0950.045.00
  FORMS MANUAL REVISION #11
  PC-1 - Presumptive Eligibility Determination
  PC-2 - Presumptive Eligibility Authorization


 
SUBJECT:
PRESUMPTIVE ELIGIBILITY FOR CHILDREN (PC Program)
0950.000.00 - 0950.045.00
FORMS MANUAL REVISION #11
PC-1 - Presumptive Eligibility Determination
PC-2 - Presumptive Eligibility Authorization
DISCUSSION:
The Balanced Budget Act of 1997 created Section 1920A of the Social Security Act which gives states the option of providing a period of presumptive eligibility to children when a qualified entity determines their family income is below the state's applicable Medicaid or CHIP limit.  This allows children to receive medical care before they have formally had an eligibility determination completed for MC+/Medicaid.  House Bill 1111 appropriated funds enabling Missouri to exercise this option.  The income limit for presumptive eligibility in Missouri is 225% of the federal poverty level as that is the highest income limit that Missouri's MC+ program covers without a waiting period.

Children under 19 must meet the following criteria in order to qualify for presumptive eligibility:

  • Residents of the State Of Missouri,
  • Income below 225% FPL, and
  • Have not received presumptive eligibility within the last 12 months.
In the Presumptive Eligibility for Children program, designated staff of "Qualified Entities" are authorized to make limited eligibility determinations for children under age 19 who are Missouri residents.  The Qualified Entity determines that a family meets the income guidelines (under 225% FPL) of the Presumptive Eligibility for Children program and contacts DFS to determine that the children have not received presumptive eligibility in the last 12 months and obtain DCNs.  If eligible, the qualified entity provides the family with a presumptive eligibility authorization notice that reflects the DCN as the children's Medicaid number and an effective date of coverage.

Currently Missouri is limiting qualified entities to children's hospitals.  Additional types of qualified entities will be added at a later date.  A Qualified Entity Agreement has been signed with the following:

The Children's Mercy Hospital                     Kansas City, MO

Additional providers will be added as Agreements are signed.

The attached Presumptive Eligibility for Children policy fully explains procedures to be followed by staff.  This policy is being added to the Family Healthcare Manual online.
NECESSARY ACTION:
  • Review the Presumptive Eligibility for Children policy and procedures with appropriate staff.
  • File PC-1 and PC-2 with instructions in the Forms Manual.
CSW
ATTACHMENTS
PC-1 and instructions (pdf)
PC-2 and instructions (pdf)
0950.000.00 - 0950.045.00
Distribution #2
IM-46
[ 2003 Memorandums ]
IM-48