County of San Diego Health and Human Services Agency HHSA Program Guide Presumptive Eligibility for Pregnant Women Program Number Page 0516 1 of 3 Revision Date 05082017 Background In November 1992 the Legislature passed AB 501 which required the Department of Health Care Services DHCS to implement the federal option of Presumptive Eligibility PE for pregnant women as described in section 19520 of the Social Security Act The PE program allows qualified MediCal providers throughout the state to provide their lowincome pregnant patients immediate temporary MediCal coverage for prenatal care These patients must then apply formally for MediCal or CalWORKs within 60 days of their PE application On April 01 2017 DHCS implemented the California Medicaid Management Information System CAMMIS Online Portal for Qualified Providers QPs in the Presumptive Eligibility for Pregnant Women Program PE4PW to assist applicants applying for PE Purpose To inform staff of the Presumptive Eligibility for Pregnant Women Program PE4PW and the online application process Policy Eligibility Criteria Applicants must meet the following eligibility criteria to qualify for PE Income must not exceed 213 of the Federal Poverty Level FPL Must be a California resident Must attest to being pregnant Must not be currently enrolled in MediCal Must not have had PE enrollment for the current pregnancy Presumptive Eligibility Application Process Beneficiaries will apply for benefits in person at Qualified Providers QP offices The new MC 263P application is a onepage PE4PW program application that will allow QPs to collect the applicants selfattested information Authorized QP staff review the completed onepage application and input the applicants information via the PE4PW Online Portal CAMMIS The MC 263P paper application is not to be mailed or faxed to DHCS for the PE4PW program rather the purpose of this paper application is to assist QPs in collecting necessary information for input into the online portal PE4PW Eligibility determination results will be immediately displayed in real time If the applicant is determined eligible for PE4PW the beneficiary will be assigned aid code 7G and the QP will print out the eligibility determination and the Immediate Need Eligibility Document PE4PW beneficiaries must submit a completed IAP application no later than the last day of the month following the month in which PE4PW was granted If IAP application is submitted during the PE4PW period their coverage can be extended pending the MediCal determination approval or denial NOTE Applicants with a negative pregnancy test result or otherwise found to be not pregnant by the QP will not receive an Immediate Need Eligibility Document MEDS will place the applicant in aid code 7F and the QP will only be able to claim reimbursement for the pregnancy test and initial visit Criteria for Qualified Providers In order to become a Qualified Provider QP for the PE4PW Program providers must Be a MediCal Provider in good standing AND Provide prenatal care County of San Diego Health and Human Services Agency HHSA Program Guide Presumptive Eligibility for Pregnant Women Program Number Page 0516 2 of 3 For Providers wishing to become a QP they must request enrollment by downloading the application QP Application and Agreement for Participation in the PE4PW Program and follow the directions for submission Qualified Provider Responsibility Qualified Providers are responsible for the following Offering the PR4PW Program to pregnant patients who do not have MediCal or other adequate health coverage The MC 264Presumptive Eligibility Patient Fact Sheet should be given to the applicant for information Assist the applicant with completion of the MC 263 P application in order to collect the applicants selfattested information Inform the applicant at the time of the PE determination that she must file her IAP application within a specified time before the end of the month following the of the PE application in order for the PE to continue Assist the applicant in completing her IAP application if needed Notify the applicant in writing MC 267Explanation of Ineligibility for Presumptive Eligibility if she is determined ineligible for PE and that she may still file an application for MediCal with the County PE4PW QPs are required to provide beneficiaries of the PE4PW Program with an Insurance Affordability Program IAP application Printing out the eligibility determination and the Immediate Need Eligibility Document for the beneficiary Maintain records of PE applications and provide these records to DHCS upon request NOTE The County is not responsible for issuing a replacement of the Immediate Need Eligibility Document The QP who initially determined eligibility for PE is responsible for issuing a replacement document Procedure MediCal Application Process Women enrolled in the PE4PW Program must submit an IAP Application or a CalWORKs application no later than the last day of the month following the month in which PE4PW was granted Applicants can apply online by phone mail or in person at any Family Resource Center FRC Retroactive Coverage Some PE Beneficiaries may have received health care services not covered under the PE4PW program or prior to their application for PE or MediCal Eligibility staff shall ask if the applicant needs retroactive coverage for past medical services Minor Consent Eligible If a minor applies for the PE4PW Program she must selfattest to the total family income to the best of her knowledge If a minor applicant does not want her parents to know that she is applying for MediCal or is not able to attest to the family income the provider cannot offer PE4PW services The applicant will be referred to apply for MediCal under the Minor Consent Program MPG 0404 MEDS Interface MEDS will provide a response to the PE online portal CAMMIS with an immediate PE4PW eligibility determination in real time MEDS is programed to automatically terminate all PE4PW benefits for beneficiaries who reach the 60day limit unless MEDS has a record of a pending IAP application If MEDS shows a pending HX18 transaction Covered California application or AP18 Transaction county application MEDS will not automatically terminate the PE4PW benefits until the application is adjudicated with either HX20 or EW20 County of San Diego Health and Human Services Agency HHSA Program Guide Presumptive Eligibility for Pregnant Women Program Number Page 0516 3 of 3 The Immediate Need Eligibility Document issued by the provider is considered acceptable proof of eligibility for PE services Staff will not process 1428 MEDS online Request transactions to report terminate or update PE in MEDS Aid Codes PE4PW Aid Code Definitions 7F Valid for pregnancy test initial visit and services associated with the initial visit Persons placed in the 7F have pregnancy test results that are negative or have been found to be not pregnant by the QP 7G Valid for specific Ambulatory Prenatal Care Services Persons placed in 7G have selfattested to the pregnancy or have a pregnancy test result that is positive QP issues a paper Immediate Need Eligibility Document Applications in Counties Other Than the County of Residence If the PE4PW recipient applies in a county other than the county of residence the receiving county shall accept the application make the initial eligibility determination and forward to the appropriate county of residency Refer to MPG Article 3 Section 1 for information on Courtesy Application Processing If the applicant is approved MediCal benefits in San Diego County follow the procedures outlined in MPG Article 3 Section 2 to process an Intercounty transfer via an eICT Program Impacts None References ACWDL 1305 MEDIL I 1531 ACWDL 1709 Sunset Date This policy will be reviewed for continuance on or by 05312020