1900.020.00 ELIGIBILITY REQUIREMENTS

Applicant self-attestation is accepted for all eligibility factors. Applicants must meet the following eligibility requirements in addition to the requirements listed below under each specific category:

• They must be Missouri residents;
• They must not be receiving MO HealthNet under any other category;

  EXCEPTION: The Uninsured Women's Health Services (UWHS/ME89) , Extended Women's Health Services (EWHS/ME80), and Gateway to Better Health (GTBH/ME91) only provide limited coverage. An individual receiving coverage from any of these programs would be able to receive PE if he/she met all other eligibility requirements.

• Household Composition status will be determined using Modified Adjusted Gross Income (MAGI) Methodology and be based on requirements for the individual PE programs; and
• Income calculations will be based on MAGI guidelines plus 5% of Federal Poverty Level disregard. See Appendix A.

  NOTE: BCCT and Former Foster Care Youth do not use income calculations.

1900.020.10 Temporary MO HealthNet During Pregnancy (TEMP)

Temporary MO HealthNet During Pregnancy (TEMP), a Medicaid program mandated by Section 208.151 (13) RSMo (enacted by SB 765 in 1990) began July 1, 1990.

Federal law (Section 1920 of the Social Security Act) and State law refer to this Medicaid coverage as "Presumptive Eligibility". Family Support Division (FSD) chose to implement the program under the name Temporary MO HealthNet During Pregnancy (TEMP). Staff should be aware of the term "presumptive eligibility" as it relates to the TEMP program to aid in communication with MO HealthNet providers.

The Omnibus Budget Reconciliation Act of 1990 (OBRA '90), effective July 1, 1991, lengthened the presumptive eligibility period to give the pregnant woman until the last day of the month following the month she was determined presumptively eligible. It also extends her presumptive eligibility period to the date the state makes the final determination of eligibility on her formal MO HealthNet application. If the formal MO HealthNet application is rejected the coverage will continue to the last day of the PE period.

The purpose of the TEMP program is to provide early access to prenatal care for pregnant women while they await the formal determination of MO HealthNet eligibility.

In addition to the eligibility requirements in section 1900.020.00, TEMP determinations are made by QE based upon the following requirements:

• Pregnancy;
• Household gross income must be at or below 196% of the Federal Poverty Level; and
• There can be no more than one PE eligibility period per pregnancy.

NOTE: A QE may accept self-attestation from the participant that she is pregnant, the estimated due date, and the number of children expected with the pregnancy.

1900.020.20 Show-Me Healthy Babies Presumptive Eligibility (SMHB-PE)

Section 2112 of the Social Security Act authorized states to offer coverage under the Children's Health Insurance Program (CHIP) for uninsured pregnant women. Senate Bill 716 (2014) established the Show-Me Babies (SMHB) program for uninsured pregnant women:

• whose income is above the MO HealthNet for Pregnant Women (MPW) maximum; and
• who are uninsured and do not have access to affordable coverage.
  • A pregnant woman with insurance which does not inclue pregnancy related services is considered uninsured and eligible for SMHB-PE.

In addition to the eligibility requirements in section 1900.020.00, SMHB-PE determinations are made by QE based upon the following requirements. The parent of an unborn child must:

• Be pregnant;
• Have household gross income above 196% of the Federal Poverty Level (FPL)and at or below 300% of the FPL; and
• There can be no more than one PE eligibility period per pregnancy.

  NOTE: SMHB-PE provides only ambulatory services (medical care provided on an outpatient basis) while the individual is pregnant.

  Services included:

  • physician/clinic;
  • nurse-midwife;
  • diagnostic x-ray and lab;
  • pharmacy; and
  • outpatient hospital services.

  Services NOT included:

  • Delivery;
  • D&C's;
  • inpatient hospital;
  • dental;
  • optical; or
  • any other services which are not Ambulatory Prenatal Services.

1900.020.30 Presumptive Eligibility for Children (PC)

The Balanced Budget Act of 1997 created Section 1920A of the Social Security Act which gives states the option of providing a period of presumptive eligibility to children (ages 0 through 18) when a qualified entity (QE) determines their family income is at or below Missouri's applicable Medicaid or CHIP limit. Presumptive Eligibilty for Children (PC) allows these children to receive medical care before they have formally applied for MO HealthNet. House Bill 1111 appropriated funds enabling Missouri to exercise this option.

In addition to the eligibility requirements in section 1900.020.00 , PE determinations for infants and children under age 19 are based upon the following requirements:

• Household gross income must be at or below 196% of the Federal Poverty Level for children under age 1;  
• Household gross income must be at or below 150% of the Federal Poverty Level for children between age 1 up to, but not including age 19;
• There can be no more than one period of PE eligibility within 12-months starting with the effective date of the initial PE period.

1900.020.40 Parents And Caretaker Relatives (MHF-PE)

The Patient Protection and Affordable Care Act of 2010 established presumptive eligibility (PE) criteria to include parents and caretaker relatives of children ages 0 through 18. In addition to the eligibility requirements in section 1900.020.00, parents and caretaker relatives must meet the following requirements:

• MO HealthNet for Families (MHF) relationship criteria;
• Have income at or below the MHF guidelines.
• There must be a child in the home under the age of 19 over which the parent/caretaker relative has assumed primary care and responsibility;

  OR

  If a non-custodial parent is claiming a child as a dependent on their federal taxes, the non- custodial parent may be considered for MHF-PE.

  Example 1: John is claiming his son, Rodney, as a dependent on his federal taxes. Rodney lives with his mother and only visits his father on a part-time basis. John could receive MHF-PE if he meets all other eligibility requirements.

  Example 2: Mary is a non-custodial parent to Albert and does not claim him on federal taxes. Albert lives with his father and only visits his mother on a part-time basis. Mary is not eligible to receive MHF-PE.

• There can be no more than one period of PE eligibility within 12-months starting with the effective date of the initial PE period.

1900.020.50 Breast and Cervical Cancer Treatment (BCCT-PE)

Section 1902 [42 U.S.C. 1396a] (a) (10) (A) (ii)(XVIII) of the Social Security Act allows states the option of providing medical assistance to uninsured women under age 65, that have been screened and need treatment for breast and cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program. Section 1920B [42 U.S.C. 1396r.lb] allows states to provide a period of Presumptive Eligibility. Missouri opted to provide this coverage to Missouri residents when the Breast and Cervical Cancer Treatment Act (HB 762) was signed June 21, 2001. The program began effective August 28, 2001.

The Department of Health and Senior Services (DHSS) is responsible for insuring that providers meet criteria for screening under the Breast and Cervical Cancer Treatment Act.

Eligibility requirements for BCCT-PE are found in section 1305.000.00 ELIGIBILITY CRITERIA.

Presumptive Eligibility determinations for BCCT (BCCT PE) are made by Show Me Healthy Women (SMHW) providers who have signed a SMHW Participation Agreement with the Department of Health and Senior Services (DHSS). When a SMHW provider determines a woman is eligible for PE, they will issue a BCCT Temporary MO HealthNet approval letter (BCC-1).

NOTE: Only hospitals that are SMHW providers are allowed to determine eligibility for BCCT PE.

1900.020.60 Former Foster Care Youth Ages 19 up to but not including age 26

The Patient Protection and Affordable Care Act of 2010 established presumptive eligibility (PE) criteria to include former Foster Care Youth ages 19 up to but not including age 26. In addition to the eligibility requirements in section 1900.020.00, to be eligible for the Former Foster Care Youth coverage individuals must:

• Have been in Missouri foster care and received alternative care MO HealthNet on, or 30 days prior to, their 18th birthday;
• Must have been covered by MO HealthNet while in Foster Care;
  • ME codes used for Foster Care would have been 07, 08, 36, 37, 56, or 57.
• Be ineligible for any other MO HealthNet PE program.
• Not be receiving any regular MO HealthNet coverage.
• Must be under the age of 26; and
• Not have received presumptive eligibility within 12-months starting with the effective date of the initial PE period.

Screen any individual who indicate that he/she was previously in Foster Care according to the above eligibility requirements.

NOTE: Hospitals are the only qualified entities who can determine eligibility for PE for former Foster Care Youth.

1900.020.70 No Automatic Newborn Coverage

Individuals approved for presumptive eligibility (PE) are not considered regular MO HealthNet participants. Children born to PE only participants are not eligible for MO HealthNet coverage under the Newborn policy.