GIS 17 MA/004: Clarification of Presumptive Eligibility Programs and Introduction of Revised Forms

The purpose of this General Information System message is to clarify Presumptive Eligibility (PE) policy and introduce revised screening forms, DOH-5224, "Medicaid Presumptive Eligibility for Pregnant Women Screening Form" (formerly LDSS-4150) and DOH-4441 “Medicaid Presumptive Eligibility for Children Screening Form.” The attached screening forms will be used by providers to screen pregnant women and children under the age of nineteen who appear to be Medicaid eligible.

Presumptive Eligibility for Pregnant Women

The DOH-5224, “Medicaid Presumptive Eligibility for Pregnant Women Screening Form” has been updated to reflect the Modified Adjusted Gross Income (MAGI) budget methodology, which utilizes gross income amounts without income disregards. The update also reflects the appropriate poverty level for pregnant women, which is 223% of the Federal Poverty Level (FPL) for the applicable family size. The income section of the form has been revised to reflect current policy regarding eligibility for pregnant minors and the treatment of Title II income received by dependent children. As noted in GIS 14 MA/22, “Medicaid Eligibility for Pregnant Minors,” pregnant women who are under the age of 21 do not have an income test. In addition, Title II income received by dependent children will not be counted during a presumptive eligibility (PE) screening. The policy outlined in GIS 15 MA/08, “Treatment of Income of Dependents Under MAGI-like Rules”, should be followed when determining eligibility for ongoing coverage.

Districts should process the PE screening form (DOH-5224) even if there is no application (DOH-4220) submitted for ongoing coverage. In this situation, presumptive coverage would begin on the date the presumptive eligibility determination was made and would end on the last day of the following month. Presumptive coverage for pregnant women should be authorized using Coverage Code 13, as there is only one benefit package. Coverage Code 14, used for presumptive eligibility, and Coverage Code 15, used for ongoing eligibility, have been disabled to ensure eligible pregnant women receive the appropriate level of coverage.

If the district receives a DOH-5224 or a DOH-5224 and an application (DOH-4220) and determines that the applicant has current active coverage through New York State of Health (NYSOH) or WMS, the DOH-5224 should not be processed and the application should be denied due to concurrent benefits.

The provider should be notified whenever a DOH-5224 cannot be processed due to current active coverage. Such notification should also include the individual’s Client Identification Number (CIN).

Presumptive Eligibility for Children

The DOH-4441, “Medicaid Presumptive Eligibility for Children Screening Form” has also been updated to reflect the MAGI budget methodology, which utilizes gross income amounts without income disregards. The update also reflects the appropriate poverty level for both infants under age one, which is 223% of the FPL for the applicable family size, and children ages one through eighteen, which is 154% of the FPL for the applicable family size. The income section of the form has been revised to reflect current policy regarding the treatment of Title II income received by dependent children. Title II income received by dependent children will not be counted during a presumptive eligibility (PE) screening. The policy outlined in GIS 15 MA/08 should be followed when determining eligibility for ongoing coverage.

The citizenship/immigration status questions have been updated to reflect the new policy of allowing lawfully present temporary non-immigrants, who are State residents, coverage other than for the treatment of an emergency medical condition or pregnancy, if determined to be otherwise eligible. Information concerning this change was issued in GIS 16/MA 02, “Changes in Medicaid Coverage for Temporary Non-Immigrants.”

Effective immediately, districts should accept and process these revised forms. The previous versions of these forms can be accepted up to 60 days after the issuance of this GIS. If previous versions are received beyond the 60th day, the form should be returned to the provider along with the revised form for completion.

Please direct any questions to your local district liaison.

Attachments

• Attachment I - DOH-5224, “Medicaid Presumptive Eligibility for Pregnant Women Screening Form” (PDF)
• Attachment II - DOH–4441, “Medicaid Presumptive Eligibility for Children Screening Form” (PDF)