471 Neb. Admin. Code, ch. 28, § 001

Current through September 17, 2024

Section 471-28-001 - Presumptive Eligibility for Pregnant Women

Under Section 1920 of the Social Security Act, Medicaid covers ambulatory prenatal care provided by an enrolled Medicaid provider to a pregnant woman during a presumptive eligibility period determined by a qualified provider. A pregnant woman is eligible for only one presumptive eligibility period per pregnancy.

Ambulatory prenatal care is defined as ambulatory services related to the pregnancy excluding inpatient hospital services, nursing home services, labor and delivery services, and services furnished to deliver or remove an embryo/fetus from the mother or services following such a procedure.

001.01 Definition of a Qualified Provider

001.02 Provider Approval

A provider who meets the requirements of 471 NAC 28-001.01 may request approval as a qualified provider for presumptive eligibility determinations from the Medicaid Division. The provider shall submit a written request for approval as a qualified provider to the Administrator of the Medicaid Division. The written request must identify the requirements of 471 NAC 28-001.01 the provider meets as well as how the provider will check active or pending Medicaid status for potential presumptively eligible pregnant women. The Medicaid Division shall coordinate with the Economic Assistance Division and the local Department of Health and Human Services (DHHS) office for the training of the qualified provider. The provider must be trained by the Medicaid and Economic Assistance Division staff, or staff approved by the Medicaid and Economic Assistant Division, before approval as a qualified provider is given. Final approval of the trained qualified provider is made in writing by the Medicaid Division. The designation of a qualified provider may be terminated by the Medicaid Division upon written 30-day notice to the qualified provider.

001.03 Presumptive Eligibility Determination

A pregnant woman may apply at a qualified provider's office (see 471 NAC 28-001.01) for ambulatory prenatal services. The provider makes a presumptive determination of the woman's eligibility based only on declared income and citizenship/eligible alien status. Income of the woman and spouse (if he is in the home) is counted. Income of the responsible parent(s) of a pregnant minor is counted unless the pregnant woman is an emancipated minor. The provider does not investigate resources or other eligibility requirements. See 477 NAC 1-004 for definition of emancipated minor. For income levels, see 471-000-202.

001.04 Responsibilities of the Qualified Provider

The qualified provider shall complete the following actions during the process of making a presumptive eligibility determination:

1. Check for any current or pending Medicaid eligibility prior to completing a presumptive eligibility determination;

2. Check for any past presumptive eligibility period during the client's current pregnancy. A pregnant woman may receive only one period of presumptive eligibility per pregnancy;

3. Inform the woman at the time the determination is made:

a. The copy of the presumptive eligibility application is the client's proof of coverage and is a Medicaid application;

b. She is required to provide verification and documentation as requested by DHHS;

c. Presumptive eligibility ends when DHHS makes a determination of eligibility for medical assistance or at the end of the 45-day presumptive period; and

4. Forward a copy of the presumptive eligibility application, along with the attestation form if applicable, to the local DHHS office within five working days after making a presumptive eligibility determination.

5. If the woman is not presumptively eligible, inform her in writing:

a. Of the reason for her ineligibility; and

b. That she may file an application for the Nebraska Medical Assistance Program (also known as medical assistance or Medicaid) at the local DHHS office.

6. A presumptive application approved in error will be closed by DHHS upon discovery.

001.05 Appeal Rights

The standard notice and appeal rights apply for a woman who has been denied continuous medical assistance (see 465 NAC 2-001). There are no appeal rights with regard to the denial of presumptive eligibility.

471 Neb. Admin. Code, ch. 28, § 001