Sec. 120.66 - Medicaid Presumptive Eligibility for Pregnant Women

ยง 120.66. Medicaid Presumptive Eligibility for Pregnant Women

a) The purpose of Medicaid Presumptive Eligibility (MPE) for pregnant women is to encourage early and continuous prenatal care of low income pregnant women who otherwise may postpone or do without that care. Qualified MPE Providers may make presumptive determinations for MPE.

b) A pregnant woman, as defined in Section 5-2(5)(a) and (b) of the Public Aid Code [305 ILCS 5] may be found presumptively eligible by a qualified MPE Provider as long as she has not been previously determined presumptively eligible under this Section or Section 120.68 during the current pregnancy.

c) The presumptive eligibility period shall be the period that:

1) begins with the date on which a qualified provider determines that the family income does not exceed 200 percent of the Federal Poverty Level (FPL) as determined pursuant to Section 120.64; and

2) ends with and includes the earlier of:

A) in the case of a woman who files an application pursuant to 89 Ill. Adm. Code 110.10 by the last day of the month following the month during which the qualified MPE Provider makes the determination that she is presumptively eligible, the day on which a determination is made by the State with respect to the eligibility of the woman for medical assistance under the Illinois State Medicaid Plan; or

B) in the case of a woman who does not file an application as described in subsection (2)(A), the last day of the month following the month during which the qualified MPE Provider makes the determination that she is presumptively eligible.

d) Covered Services - Services covered during the presumptive eligibility period under this Section shall include ambulatory care consisting of all outpatient medical care covered by the Illinois State Medicaid Plan.

e) Qualified MPE Providers are those providers that comply with all the following:

1) Enroll as a Medicaid provider under the Illinois State Medicaid Plan;

2) Enter into and abide by the terms of the Medicaid Presumptive Eligibility Provider Agreement with the Department; and

3) Meet one or more of the following requirements:

A) Provider furnishing health care items or services covered under the State's approved Medicaid State Plan or the Public Aid Code that is eligible to receive payments under the plan or the Public Aid Code;

B) Federally Qualified Health Center that receives funding under the federal community or migrant health center program (sections 330 and 330A of the Public Health Service Act ( 42 USC 201 et seq.));

C) Community Based Health Clinic, including a maternal/child health center that receives funding under Title V of the Social Security Act (42 USC 701-713);

D) Local Public Health Department that participates in Illinois' perinatal health services program (77 Ill. Adm. Code 640);

E) Entity authorized to determine a child's eligibility to receive assistance under the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (section 17 of the Child Nutrition Act of 1966 ( 42 USC 1771));

F) Community Service Organization that receives a grant under the Commodity Supplemental Food Program (section 4(a) of the Agriculture and Consumer Protection Act of 1973 (PL 93-86)); or

G) Indian Health Service provider or health program facility operated by a tribe or tribal organization under the Indian Self-Determination Act ( 25 USC 450).

f) Duties of the Department and qualified MPE Providers

1) The Department shall:

A) provide such forms as are necessary for a qualified MPE Provider to submit an MPE enrollment and such forms as are necessary for a pregnant woman to make application for medical assistance pursuant to 89 Ill. Adm. Code 110.10;

B) provide information on how to make MPE determinations and assist women in completing and filing applications for medical assistance; and

C) process MPE enrollments as submitted by qualified MPE Providers.

2) A qualified MPE Provider who determines that a pregnant woman is presumptively eligible for medical assistance under this Section shall:

A) notify the Department of the determination within 5 business days after the date on which the determination is made;

B) inform the woman at the time the determination is made that:

i) her coverage is temporary and will end on the last day of the month following the month in which the MPE determination has been made;

ii) services covered are limited to ambulatory care;

iii) she must complete and submit an application for medical assistance in order to be considered for full coverage; and

C) assist the woman to apply for medical assistance prior to the end of her presumptive eligibility period.

(Added at 40 Ill. Reg. 02784, effective January 20, 2016 Amended at 44 Ill. Reg. 2829, effective January 29, 2020)

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