Module 1 Overview of Presumptive Eligibility PE Process
Module 1: Overview of Presumptive Eligibility (PE) Process for Pregnant Women Sponsored by the New York State Department of Health through a training and administrative services agreement with the CAI Global
2 MODULE 1: Overview of Presumptive Eligibility for Pregnant Women § Glossary of Terms and Acronyms § Steps in Presumptive Eligibility Process
3 Why is Presumptive Eligibility Important? § Early, regular prenatal care results in fewer low birth weight babies and lower infant mortality rates § NYS has large number of women who do not seek out prenatal care early in their pregnancy § Greatest barrier to prenatal care is inability to pay
4 Why is Presumptive Eligibility Important? , cont. • NYS implemented Presumptive Eligibility for pregnant women • Simplifies the process of establishing Medicaid coverage in three ways • Presumptive Eligibility through Qualified Providers • Eased requirements for pregnant women • Expanded eligibility
5 Presumptive Eligibility • Allows Qualified Providers to screen pregnant women’s financial eligibility • Establishes immediate, limited Medicaid coverage for women presumed to be financially eligible for Medicaid • Qualified Providers assist women in the Medicaid application process
6 Qualified Providers May Be: § Article 28 Facilities – hospital and diagnostic treatment centers
7 Eased Requirements § Qualified Providers help pregnant women apply for public health insurance § No verification required for • Citizenship or immigration status • Social Security Number
8 Eased Requirements q No pursuit of paternity or medical support during pregnancy and post partum period
9 Expanded Eligibility q Provides Medicaid coverage to pregnant women with incomes above traditional Medicaid standards § Pregnant women can be eligible with income at 223% of the Federal Poverty Level (FPL)
10 Terms and Acronyms § Many of the terms and acronyms used in the Presumptive Eligibility process may be unfamiliar § Terms and acronyms with their definitions are in the training materials
11 Ambulatory Prenatal Medicaid Services § Available to pregnant women found presumptively eligible with income is <223% FPL § All outpatient Medicaid-covered services • Does NOT include inpatient • Does NOT include institutional services, long term home health care or alternate level of care
12 Ambulatory Prenatal Medicaid Services • • • Physician Care Midwife Care Outpatient Care Pharmacy Dental Laboratory • • • Eye Care Transportation Home Health Care Personal Care Nursing Services Podiatry
Ambulatory Prenatal Medicaid Services, cont. • Outpatient/Mental • Physical Therapy • Occupational Therapy Health & Alcoholism • Health Education • Speech Pathology • Nutritional • Durable Medical Equipment • Abortion • Clinical Psychology Counseling • Family Planning Adapted by © 2011 Research Foundation of SUNY/BSC/CDHS
14 Inpatient Coverage for Pregnant Women • Ambulatory Prenatal Medicaid Services include outpatient services, only • To receive coverage for inpatient care, pregnant women must meet requirements for full Medicaid coverage.
15 Expanded Eligibility • Determined by local department of social services. • To receive Expanded Eligibility coverage, pregnant women must: § Complete the Medicaid application process and § Be found fully eligible for Medicaid
16 NY State of Health Online Marketplace • It is recommended that the patient either use a Certified Application Counselor (CAC) or Navigator from the outset and use the NY State of Health online insurance marketplace, or they can go to a provider and complete the Presumptive Eligibility Process, which might include a full application.
17 Household Income § No income is counted for a pregnant woman if she is under 21 years of age
18 Household Income, cont. q Includes income of: §Pregnant Woman §Legally responsible relatives (spouse) who live with the pregnant woman §If the pregnant woman wishes, include legally dependent relatives who live with her • If counting legally dependent relatives, MUST count their income, if any, as well
19 Household Income, cont. • If a person in the PW’s household receives SSI or TA cash, they and their income are not counted
20 Family Planning Benefit Program • Medicaid coverage for family planning services only • For men and women • Income levels < 223% FPL • Services through all Medicaid providers of family planning services
21 Family Planning Extension Program (FPEP) • • Covers women for 24 months, after their 60 -day postpartum period ends, who are not eligible for MA or FPBP at renewal o. Can be due to income, citizenship/immigration status, or failure to complete the renewal process FPEP Covers family planning services only
22 Gross Income §Countable earned and unearned income o. Based on modified adjusted gross income (MAGI) §Amount of income before any deductions or exemptions have been made
23 Managed Care and Pregnant Women §Presumptively eligible pregnant women CANNOT enroll in Managed Care §Pregnant women must enroll if found fully eligible for Medicaid §Must use providers within Health Plans provider network §They will be auto-enrolled if they do not choose a plan
24 Managed Care Coverage After the Post Partum Period q After the post partum period, the LDSS will redetermine the woman's Medicaid eligibility. § If eligible, the woman may stay enrolled in the Managed Care plan § May be disenrolled after the post partum period if the woman is found ineligible for on-going Medicaid coverage
25 Post Partum Period • Extension of Medicaid eligibility for pregnant woman • Begins the day pregnancy ends and continues through the last day of the calendar month in which the 60 th day occurs • Pregnant woman receives this coverage regardless of how the pregnancy ends
26 Acronyms q CBIC Common Benefit Identification Card q CHPlus Child Health Plus q CIN Client Identification Number q EDC Expected Date of Confinement q MEVS Medicaid Eligibility Verification System q FPBP Family Planning Benefit Program
27 Acronyms q FPEP q LDSS q PE q PW q SSI q NY State of Health Family Planning Extension Program Local Department of Social Services Presumptive Eligibility Pregnant Woman Supplemental Security Income New York State of Health
28 Acronyms q TA q WIC q MOMS q HSS Temporary Assistance Special supplemental nutritional food program for Women, Infants and Children Medicaid Obstetrical and Maternal Services Health Supportive Services
29 Forms q DOH-5224 PE Screening Checklist q DOH-4220 Access NY Health Care Application q OHIP-0025 Screening Determination Letter
30 Overview of Presumptive Eligibility Process Pregnant woman contacts Qualified Provider completes Presumptive Eligibility Screening Checklist Does pregnant woman (PW) meet Presumptive Eligibility (PE) criteria? Yes No
31 Overview of Presumptive Eligibility Process Does PW meet PE Criteria? No Give PW notice of ineligibility and refer to NY State of Health END
32 Overview of Presumptive Eligibility Process Pregnant woman contacts Qualified Provider completes Presumptive Eligibility Screening Checklist Does pregnant woman (PW) meet Presumptive Eligibility (PE) criteria? Yes No
33 Overview of Presumptive Eligibility Process Does PW meet PE Criteria? Yes Provider gives notice of PE to PW (PE Determination Letter) Provider helps PW complete the ACCESS NY Health Care Application
34 Overview of Presumptive Eligibility Process Provider sends PE Screening Checklist, completed ACCESS NY Application, Documentation Checklist, and any documentation collected to LDSS within 5 working days.
35 Overview of Presumptive Eligibility Process LDSS Registers ACCESS NY App LDSS contacts PW or Representative if additional documentation is needed LDSS determines ongoing Medicaid eligibility Eligible Ineligible
36 Overview of Presumptive Eligibility Process LDSS determines eligibility Eligible Ineligible Medicaid Authorization END
37 Overview of Presumptive Eligibility Process LDSS determines eligibility Ineligible Eligible Medicaid Authorization END Deny
38 Overview of Presumptive Eligibility Process Provider sends PE Screening Checklist, completed ACCESS NY Application, Documentation Checklist, and any documentation collected to LDSS within 5 working days. Copy application and documentation for other family members to send to LDSS for public health insurance eligibility determination.
39 Facts About Presumptive Eligibility • Allows ambulatory prenatal Medicaid for women who appear Medicaid eligible until full Medicaid determination is made • Only one period of PE is allowed for each pregnancy • Once PE, PW can go to any Medicaid provider
40 Pregnant Women in Managed Care §Pregnant women who are Presumptively Eligible will not be enrolled in Managed Care during the presumptive period §After she is determined to be eligible for Medicaid, the Pregnant woman must enroll in Managed Care • Must use providers who participate in the Managed Care plan to have services covered by Medicaid §Pregnant women applying for Medicaid must choose a plan
41 Pregnant Woman and Managed Care q. When the PW enrolls in Managed Care she must: § Complete an enrollment form on Section I of the Access NY Health Care Application
42 Pregnant Woman and Managed Care • Enrollment in Managed Care is prospective • Enrollment occurs on the 1 st of the month • Providers should check the PW’s eligibility status to ensure billing practices are appropriate
43 Documentation for PW • PW does not have to document or verify info provided for PE unless applying in a district in which she does NOT live § For courtesy applications, PW must provide documentation of residency and identity • • Must document info for Medicaid PW do NOT have to verify their citizenship, or legal immigration status or their Social Security numbers
44 Timeframes in PE § PE starts as soon as provider determines PW eligible for PE § PE continues until LDSS makes final Medicaid eligibility determination § Medicaid coverage continues until the end of the post partum period
45 Review and Self-Test § Review material covered in this module § Pause the presentation and complete the matching exercise in the training materials § Once the matching exercise is completed, re-start the module for the correct answers.
46 Matching Exercise Answers q Presumptive Eligibility § Means of providing Medicaid services to pregnant woman for prenatal care pending a full Medicaid determination; outpatient coverage only
47 Matching Exercise Answers, cont. q Postpartum Period § Extension of Medicaid eligibility which begins the day pregnancy ends and continues through the last day of the calendar month in which the 60 th day occurs q LDSS § Local Department of Social Services
48 Matching Exercise Answers, cont. q Household Income § If she is over 21, income of the Pregnant Woman, any legally responsible relatives and possibly the income of legally dependent relatives who live with her q CIN § Client Identification Number
49 Exercise Answers, cont. Matching q Expanded Eligibility § Medicaid coverage to pregnant women and infants with income under 223% FPL; determined by LDSS
50 Matching Exercise Answers, cont. q FPEP § Family Planning Extension Program
51 Further Review q If the concepts covered in this module are still unclear, play the module again for review.
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