Presumptive eligibility (PE) provides medicaid benefits
under one of the eligible groups outlined in Subsection B of
8.291.400.10 NMAC, starting with
the date of the PE determination and ending with the last day of the following
month or, if an ongoing application is submitted at the time the PE is granted
or at any time during the approved PE period, the PE will remain open until the
ongoing application is approved or denied.
A. Only one PE approval is allowed per
pregnancy or per 12-month period for other ACA related categories.
B. Determinations can only be made by
individuals employed by eligible entities and certified as presumptive
eligibility determiners (PEDs) by the medical assistance division (MAD).
(1) Processing PE information: PEDs must
notify MAD within 24 hours of the determination of presumptive
eligibility.
(2) PE: The PED must
process the presumptive eligibility and encourage clients to submit an ongoing
application for medicaid eligibility. If the client elects to do so, the PED
must assist the client with the submission of an application for medical
assistance.
(3) Provider
eligibility: Entities who may participate in the PE program must be:
(a) a qualified hospital that participates as
a provider under the medicaid state plan or a medicaid 1115 demonstration who
notifies the medicaid agency of its election to make presumptive eligibility
determinations and agrees to make PE determinations consistent with state
policies and procedures; or
(b) an
entity or provider that has not been disqualified by the medicaid agency for
failure to make PE determinations in accordance with applicable state policies
and procedures or for failure to meet any standards that may have been
established by the medicaid agency; or
(c) a federally qualified health center
(FQHC), an Indian health service (IHS) facility, a state of New Mexico agency,
a school, or a head start agency or a primary care provider who is contracted
with at least one HSD contracted MCO; or
(d) other entities HSD has determined as an
eligible presumptive participant.
C. PE approval limitations:
(1) all MAD authorized PE determiners can
approve PE for children and pregnant women ACA categories;
(2) hospitals opting to participate in the PE
program and correctional facilities (state prisons and county jails), health
facilities operated by the Indian health service, a tribe, or tribal
organization or an urban Indian organization can approve PE for all ACA related
categories.
D. If, at
the time of a PE approval, the client agrees to submit an application for
ongoing coverage, the PED must submit the application within ten days of the PE
approval.
E. A pregnant individual
who has been approved for PE can receive ambulatory prenatal care during the PE
approval period as defined in
8.291.400.13 NMAC.
(1) For PE, an approved PED must accept
self-attestation of pregnancy.
(2)
The needs and income of the unborn child(ren) are considered when determining
the woman's countable family size.
