Presumptive Eligibility

PURPOSE: The purpose of this rule is to establish the conditions under which MO HealthNet eligibility will be temporarily available to certain categories of participants based on preliminary determinations by certain categories of providers. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) The department shall provide MO HealthNet benefits to individuals during a period of presumptive eligibility for individuals who have been determined eligible for MO HealthNet benefits on the basis of preliminary information by a presumptive eligibility qualified entity in accordance with this rule, and pursuant to sections 435.1100, 435.1101, 435.1102, 435.1103, and 435.1110 of Title 42, Code of Federal Regulations, which is incorporated by reference and made part of this rule as published by the Office of the Federal Register, 800 North Capitol St. NW, Suite 700, Washington, D.C. 20408, and available at its website (https://www.ecfr.gov/current/title42/chapter-IV/subchapter-C/part-435?toc=1), October 20, 2021. This rule does not incorporate any subsequent amendments or additions. (2) For the purposes of this rule— (A) “Presumptive eligibility” means temporary MO HealthNet benefits for children under the age of nineteen (19) (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1a and 42 CFR sections 435.1102 and 435.1110), parents and other caretaker relatives (pursuant to 42 CFR sections 435.1103 and 435.1110), former foster care children (pursuant to 42 CFR sections 435.1103 and 435.1110), pregnant women (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1 and 42 CFR sections 435.1103 and 435.1110), individuals with breast cancer or cervical cancer (pursuant to 42 U.S.C. sections 1396a(47) and 1396r-1b and 42 CFR sections 435.1103 and 435.1110), and adults between ages nineteen (19) and sixty-four (64) (pursuant to 42 CFR 435.1110), allowing them to receive MO HealthNet benefits before they have applied for MO HealthNet benefits through the division; (B) “Qualifying hospital” has the same meaning as in 42 CFR 435.1110(b); (C) “Federally qualified health center” has the same meaning as in 42 U.S.C. section 1396(l)(2)(B); (D) “Rural health clinic” has the same meaning as in 42 U.S.C. section 1395x(aa)(2); (E) “Presumptive eligibility qualified entity” means a MO HealthNet provider organization responsible for screening individuals/families regarding presumptive eligibility for MO HealthNet benefits. 1. For presumptive eligibility determinations for children under the age of nineteen (19), “presumptive eligibility qualified entity” means a federally qualified health center, rural health clinic, or qualifying hospital that meets the requirements for a “qualified entity” in 42 U.S.C. section 1396r–1a(b)(3)(A). 2. For presumptive eligibility determinations for pregnant women, “presumptive eligibility qualified entity” means a county health department, federally qualified health center, rural health clinic, or qualifying hospital that meets the requirements for a “qualified provider” in 42 U.S.C. section 1396r– 1(b)(2). 3. For presumptive eligibility determinations for parents and caretaker relatives, “presumptive eligibility qualified entity” means a qualifying hospital as provided in section 42 CFR 435.1110. 4. For presumptive eligibility determinations for breast and cervical cancer treatment, “presumptive eligibility qualified entity” means a Show-Me Healthy Women provider which has a participation agreement with the Missouri Department of Health and Senior Services that meets the requirements for a “qualified entity” in 42 U.S.C. section 1396r–1b(b)(2). 5. For presumptive eligibility determinations for former foster care children, “presumptive eligibility qualified entity” means a qualifying hospital. 6. For presumptive eligibility determinations for adults between ages nineteen (19) and sixty-four (64), “presumptive eligibility qualified entity” means a qualifying hospital. (3) In order to be eligible to be a presumptive eligibility qualified entity, a MO HealthNet provider must first— (A) Apply to be a presumptive eligibility qualified entity in a manner prescribed by the division which shall include the following information: 1. The name and mailing address of the MO HealthNet provider applying to be a presumptive eligibility qualified entity; 2. The state in which the provider is licensed, registered, or incorporated; 3. The national provider identifier (NPI) number of the provider; 4. The MO HealthNet programs for which the provider intends to be a presumptive eligibility qualified entity; and 5. The name, mailing address, telephone number, and email address of the individual who will serve as principal contact between the qualified entity and the division with respect to presumptive eligibility determinations; (B) Be approved as a presumptive eligibility qualified entity by the division; (C) Through representatives, attend and successfully complete all training required by the division for presumptive eligibility qualified entities; (D) Comply with section 208.155, RSMo and shall execute agreements, as required by the division, relating to security, confidentiality, and computer access; and (E) Post an informational poster regarding the availability of MO HealthNet benefits in its facility reception area or in some other appropriate area of the facility if requested to do so by the division. (4) A presumptive eligibility qualified entity shall make presumptive eligibility determinations subject to the requirements listed below: (A) Designated staff or other representatives of the presumptive eligibility qualified entity will offer interested individuals/families the opportunity to apply for and receive benefits based on a presumptive eligibility determination; (B) Designated staff or other representatives of the presumptive eligibility qualified entity will determine presumptive eligibility for the program; (C) The presumptive eligibility qualified entity shall provide applicable MO HealthNet application forms to individuals, parents, and caretakers pursuant to 13 CSR 40-7.015 and assist such persons in completing and filing such forms, or shall assist individuals, parents, and caretakers to apply at mydss.mo.gov; (D) The presumptive eligibility qualified entity shall notify the individual, parent, or caretaker of the presumptive eligibility determination in writing at the time the determination is made on a form provided or approved by the division; (E) The presumptive eligibility qualified entity shall notify the division that the participant is presumptively eligible within five (5) working days after the date of a presumptive eligibility determination; (F) Where a determination of presumptive eligibility is made, the presumptive eligibility qualified entity shall notify the individual, parent, or caretaker in writing on a form provided or approved by the division, that— 1. If a MO HealthNet application is not filed by the last day of the month following the month in which the presumptive eligibility determination is made, the period of presumptive eligibility will end on that last day; and 2. If a MO HealthNet application is filed by the last day of the month following the month in which the presumptive eligibility determination is made, the period of presumptive eligibility will end on the day a decision is made on the MO HealthNet application; (G) Where a determination is made that the individual is not presumptively eligible, the presumptive eligibility qualified entity shall notify the individual, parent, or caretaker in writing on a form provided or approved by the division, at the time the determination is made, of the reason for the determination and that the individual, parent, or caretaker may file an application for MO HealthNet benefits pursuant to 13 CSR 40-7.015; (H) In making a presumptive eligibility determination, the presumptive eligibility qualified entity shall apply preliminary eligibility criteria established by applicable law and regulation, using forms provided by the division, and shall approve an application for presumptive eligibility only if the following requirements are met: 1. For children under the age of nineteen (19)— A. The child must meet the same requirements for income and United States and Missouri residency required for regular Medicaid coverage for children under nineteen (19); and B. There can be no more than one (1) presumptive eligibility period within a twelve- (12-) month period starting with the effective date of the initial presumptive eligibility period; 2. For parents and caretaker relatives— A. Individuals must be parents or other caretaker relatives (as defined in 42 CFR 435.4), including pregnant women, of a dependent child (as defined in 42 CFR 435.4) under age eighteen (18); B. The individual must meet the same requirements for income and United States and Missouri residency required for regular Medicaid coverage for parents; and C. There can be no more than one (1) presumptive eligibility period within a twelve- (12-) month period starting with the effective date of the initial presumptive eligibility period; 3. For pregnant women— A. The individual must be pregnant; B. The woman must meet the same requirements for income and United States and Missouri residency required for regular Medicaid coverage for pregnant women or for coverage under the Show-Me Healthy Baby program; and C. The individual must not have already received benefits under a MO HealthNet presumptive eligibility program during the current pregnancy; 4. For breast and cervical cancer treatment— A. The individual must be diagnosed with breast or cervical cancer by a Show-Me Healthy Women provider unless the participant is diagnosed by a MO HealthNet provider while currently receiving MO HealthNet benefits; B. The woman must meet the same requirements for income and United States and Missouri residency required for regular coverage under the Breast and Cervical Cancer Coverage program; and C. There can be no more than one (1) presumptive eligibility period within a twelve- (12-) month period starting with the effective date of the initial presumptive eligibility period; 5. For former foster care children— A. The individual must be in foster care under the responsibility of the state of Missouri as of their eighteenth birthday or within thirty (30) days prior to their eighteenth birthday; B. The individual must be under the age of twenty-six (26) years old; C. The individual must not be eligible for another MO HealthNet benefits group; D. The individual must have been covered by MO HealthNet while they were in foster care; E. The individual must be a Missouri resident; and F. There can be no more than one (1) presumptive eligibility period within a twelve- (12-) month period starting with the effective date of the initial presumptive eligibility period; and 6. For adults between ages nineteen (19) and sixty-four (64)— A. The adult must meet the requirements for income and United States and Missouri residency required for regular Medicaid coverage for adults between ages nineteen (19) and sixty-four (64) pursuant to 42 CFR 435.1103 and 435.1110; and B. There can be no more than one (1) presumptive eligibility period within a twelve- (12-) month period starting with the effective date of the initial presumptive eligibility period; (I) The presumptive eligibility qualified entity shall verify with the division that prospective participants are not currently covered by MO HealthNet or have not already had a period of presumptive eligibility during the past twelve (12) months or, if applicable, during the current pregnancy; (J) The presumptive eligibility qualified entity shall adhere to the following application processing procedures established by the division: 1. The presumptive eligibility qualified entity shall date stamp the presumptive eligibility applications and MO HealthNet applications on the same day received if paper applications are used; 2. In connection with presumptive eligibility determinations, the division will provide to presumptive eligibility qualified entity only the applicant’s or participant’s Departmental Client Numbers (DCN), dates of MO HealthNet coverage, correct spelling of names, correct type of assistance, and level of care. All other requests for applicant or participant information from the presumptive eligibility qualified entity to the division shall be accompanied by an appropriate authorization for release of information; and 3. To the extent it receives a completed MO HealthNet application, the presumptive eligibility qualified entity shall transmit MO HealthNet applications to the division for final processing so they are received by the division within five (5) business days of the applicant’s or participant’s signature; (K) The presumptive eligibility qualified entity shall maintain written or electronic records of all presumptive eligibility applications and determinations along with any related supporting documentation for a period of five (5) years from the date of the determination or application unless litigation or an audit by the department, State Auditor’s Office, or the Center for Medicare and Medicaid Services relating to the records has been started prior to the sixth year, then records must be maintained until the litigation or audit is resolved. These records shall be made available to the department, at its request, for the purposes of determining whether the presumptive eligibility qualified entity is in compliance with this rule; (L) The presumptive eligibility qualified entity’s staff that are, or will be, involved in making presumptive eligibility determinations shall attend or otherwise receive and satisfactorily complete training from the division in the manner prescribed by the division; (M) The presumptive eligibility qualified entity shall keep up-to-date the identity and contact information of the person who will be the primary contact between the division and the presumptive eligibility qualified entity under paragraph (3)(A)5. of this rule; (N) The presumptive eligibility qualified entity shall not delegate or subcontract the authority to determine presumptive eligibility to another entity. However, they may implement their presumptive eligibility program with the support of third party contractors. (5) MO HealthNet benefits begin on the date the presumptive eligibility qualified entity determines that the individual is presumptively eligible. The presumptive eligibility period shall end on the date a decision is made on the individual’s MO HealthNet application or, in the event no regular application is filed, on the last day of the month following the month in which the presumptive eligibility determination was made. (6) After a determination of presumptive eligibility is made, MO HealthNet providers shall provide applicable services during the period the presumptive eligibility determination remains in effect. (7) In order to remain a presumptive eligibility qualified entity, a presumptive eligibility qualified entity must meet the following performance standards with respect to its presumptive eligibility determinations: (A) The presumptive eligibility qualified entity must make, and be capable of making, presumptive eligibility determinations in accordance with this rule, including compliance with quality assurance and on-site monitoring efforts by the division; (B) The division must receive a regular MO HealthNet application for the appropriate program before the end of the presumptive eligibility period with respect to ninety percent (90%) of the participants determined to be presumptively eligible by the presumptive eligibility qualified entity in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility; (C) Ninety-five percent (95%) or more of the applications actually received by the division from participants determined to be presumptively eligible by the presumptive eligibility qualified entity must be approved as eligible for MO HealthNet benefits by the division in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility. However, applications denied because the applicant failed to meet eligibility criteria that are not listed in subsection (4)(H) of this rule will not count against the presumptive eligibility qualified entity for the purposes of this performance standard; (D) The presumptive eligibility qualified entity is required by subsection (4)(I) of this rule to check whether the applicant already has current MO HealthNet coverage. The presumptive eligibility qualified entity shall make this determination of prior coverage accurately with respect to ninety percent (90%) or more of its presumptive eligibility determinations, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility; (E) The presumptive eligibility qualified entity is required by subsection (4)(I) of this rule to check whether the applicant has received MO HealthNet benefits under presumptive eligibility in the past twelve (12) months or, for pregnancy determinations, during the current pregnancy. The presumptive eligibility qualified entity shall make this determination correctly with respect to ninety-eight percent (98%) or more of its presumptive eligibility applicants, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division first approves the qualified entity’s application to determine presumptive eligibility; (F) The presumptive eligibility qualified entity shall make an accurate presumptive eligibility determination based on the information provided from the applicant on the presumptive eligibility application on ninety percent (90%) of its presumptive eligibility applicants, whether presumptive eligibility is approved or denied, in the aggregate, for each calendar year, and for any shorter review period designated by the division. This standard shall be effective twelve (12) months from the date that the division approves the qualified entity’s application to determine presumptive eligibility; (G) In the event a presumptive eligibility qualified entity fails to meet any of the standards set forth in subsections (7)(A) through (7)(F), the presumptive eligibility qualified entity, upon notification by the division that it has not met the standard(s), shall submit to the division a corrective action plan to ensure future compliance with subsections (7)(A) through (7)(F). The presumptive eligibility qualified entity must amend the corrective action plan as required by the division. Once the division has approved the corrective action plan, the qualified entity must implement and satisfactorily complete the corrective action plan within the time frames set forth in the plan. The division shall monitor the qualified entity’s performance on the corrective action plan at least every three (3) months until the division determines that the corrective action plan has been successfully completed; and (H) In the event the presumptive eligibility qualified entity does not submit a corrective action plan acceptable to the division or again fails to meet the performance standards set forth in subsections (7)(A) through (7)(F) after approval by the division of a corrective action plan, the division may disqualify the provider as a presumptive eligibility qualified entity. 1. The qualified entity shall receive thirty (30) days prior notice of its disqualification as a presumptive eligibility qualified entity. 2. The presumptive eligibility qualified entity shall have ten (10) calendar days after receipt of a notice of disqualification to submit a request that the department director reconsider the decision to disqualify. Any such request for reconsideration shall include a detailed explanation of the reasons why the presumptive eligibility qualified entity should not be disqualified for failing to meet performance standards and shall contain any documentation the presumptive eligibility qualified entity wishes the director to consider. It is entirely within the discretion of the department director whether to reconsider the disqualification decision. 3. Disqualification shall be for a minimum of a three- (3-) year period. At the conclusion of the disqualification period, the presumptive eligibility qualified entity may reapply and shall successfully complete training required by the department director in order to be reinstated. (8) Applicants and participants may not appeal the presumptive eligibility determination made by a presumptive eligibility qualified entity under this rule. However, nothing in this rule limits the ability of an applicant or participant to appeal the final determination of eligibility for MO HealthNet benefits made by the division as otherwise provided by law. (9) Upon the effective date of this rule, any existing agreements regarding presumptive eligibility between the division and MO HealthNet providers, including providers designated as “qualified providers” or “qualified entities” in such agreements, shall terminate and shall be superseded by this rule, except as follows: (A) Any provider that is party to such an agreement that notifies the division within thirty (30) days of the effective date of this rule that it intends to continue as a presumptive eligibility qualified entity will not be required to be approved as a presumptive eligibility qualified entity under subsection (3)(B) of this rule with respect to the MO HealthNet program for which it was previously authorized by contract to make presumptive eligibility determinations; and (B) Any provider who notifies the division under subsection (9)(A) of its intention to continue as a presumptive eligibility qualified entity shall remain subject to all other requirements of this rule, including the requirement to submit the information specified in subsection (3)(A). AUTHORITY: sections 207.022 and 660.017, RSMo 2016, and section 208.151.1(22), RSMo Supp. 2021.* Original rule filed March 31, 2016, effective Sept. 30, 2016. Emergency amendment filed Oct. 5, 2021, effective Oct. 20, 2021, expired April 17, 2022. Amended: Filed Oct. 5, 2021, effective April 30, 2022. *Original authority: 207.022, RSMo 2014; 208.151, RSMo 1967, amended 1973, 1981, 1982, 1987, 1988, 1989, 1990, 1991, 1993, 1995, 2001, 2005, 2007, 2011, 2013, 2018, 2019, 2020; and 660.017, RSMo 1993, amended 1995.