1900.030.00 QUALIFIED ENTITY

A qualified entity (QE) is an organization that is determined by Missouri to be capable of making presumptive eligibility determinations if they meet federal and state requirements.  The state uses qualified entities, as defined in Sections 1920 and 1920A of the Social Security Act to determine eligibility presumptively.

The following entities may make PE determinations as follows:

• Federally Qualified Health Centers (FQHCs)
  • TEMP/SMHB-PE
  • PC
• Rural Health Clinics (RHCs)
  • TEMP/SMHB-PE
  • PC
• County Health Departments
  • TEMP/SMHB-PE
• Qualified hospitals 
  • TEMP/SMHB-PE
  • PC
  • MHF-PE
  • Former Foster Care Youth

Refer all requests to become a qualified entity to IM Program and Policy at COLE.MHNPOLICY@dss.mo.gov .

1900.030.10 Qualified Entity Responsibilities:

An organization must complete and submit a Memorandum of Agreement (MOA) to begin the process of becoming a presumptive eligibility Qualified Entity (QE)

After the MOA is approved, designated employees (not contracted staff) of the QE must:

• Attend and successfully complete all training required by the FSD;
• Provide the FSD with a list of all trained staff.  This list must be kept current at all times by sending notification of staff changes to COLE.MHNPOLICY@dss.mo.gov;
• Offer interested individuals/families the opportunity to complete the Application for Presumptive Eligibility (PE-1SSL) to receive benefits based on a presumptive eligibility determination;

  NOTE: To receive presumptive eligibility, an Application for Presumptive Eligibility (PE-1SSL) must be completed, signed, and dated.

• Encourage and assist the individual/parent/caretaker to complete a regular MO HealthNet application:
  • on-line at mydss.mo.gov;
  • by calling the Contact Center at 1-855-373-9994; or
  • by completing a paper IM-1SSL;

  NOTE: Completion of the IM-1SSL is in addition to completing the PE-1SSL.

  Do not delay presumptive eligibility determination for completion of the IM-1SSL, telephone application, or online application.  Explain that they will be notified in writing when FSD makes a determination on their regular MO HealthNet application.

• Advise the individual/parent/caretaker that the end date for the presumptive period is the earlier of:
  • The date an application for regular MO HealthNet is approved or denied (if an application is filed by the last day of the month following the month in which the PE determination is made); or
  • The last day of the month following the month in which the PE determination is made (if no MO HealthNet application is filed by that date);

  EXCEPTION:  Temporary MO HealthNet During Pregnancy (TEMP) program is an exception when determining end dates.  If determined ineligible for regular MO HealthNet coverage, TEMP coverage will continue until the last day of the month following the month in which the determination for PE was made. (This exception DOES NOT apply to SMHB-PE.)

  NOTE: Inform the applicant that if a regular application (on-line, phone, or paper IM-1SSL) is not completed and submitted to FSD, PE coverage will end on the last day of the month following the month they are approved.

• Complete the PE determination using the QE Presumptive Eligibility Determination Worksheet (PE-2 Worksheet);
  • If you have access to eMOMED, check to see if the applicant:
    • is already receiving regular MO HealthNet coverage; or
    • has received PE within the last 12 months or if pregnant, during the current pregnancy.
  • If unable to determine:
    • Call the Family Support Division (FSD) at (573) 751-9023 and an Eligibility Specialist (ES) will assist you.  The ES can also find or assign a DCN; or
    • Send an email to FSD.MEDESIVR@dss.mo.gov requesting the necessary information.
  • Provide a copy of the appropriate form to applicant/family:
    • Not eligible – Qualified Entity Presumptive Eligibility Determination Worksheet (PE-2 Worksheet)
    • Eligible –
      • MO HealthNet Presumptive Eligibility Authorization (PE-3) for Children, Parents/Caretaker Relatives, or Former Foster Care Youth; or
      • MO HealthNet TEMP/SMHB-PE Authorization (PE-3TEMP) for all pregnant women.

      Explain the use of the PE-3 or PE-3 TEMP and the coverage provided.

  • Date stamp the Presumptive Eligibility application (PE-1SSL), MO HealthNet Single Streamlined application (IM-1SSL) if received, and all other supporting documentation on the date received. 
  • Fax or email the appropriate forms to FSD the same or next working day after PE determination is completed;
    • If not eligible, send the following documents:
      • Paper Family MO HealthNet application (IM-1SSL) if completed;
      • Copy of Presumptive Eligibility Determination (signed PE-2 Worksheet); and
      • Any other documentation submitted by the  individual
    • If eligible, send the following documents:
      • Paper Family MO HealthNet application (IM-1SSL) if completed;
      • Copy of Presumptive Eligibility Determination (signed PE-2 Worksheet);
      • Copy of the MO HealthNet TEMP/SMHB-PE Authorization (PE-3TEMP); and
      • Any other documentation submitted by the  individual

      NOTE: DO NOT send the Presumptive Eligibility Application (PE-1SSL) to FSD.  This is kept on file in your facility.

      Documents should be:

      • faxed to (573) 751-0282 with subject line PE or Presumptive Eligibility;
      • scanned and emailed to: FSD.MEDES@dss.mo.gov with subject linePE or Presumptive Eligibility; or

      NOTE: PE applications may be mailed to or dropped off at a local FSD Resource Center only if they are unable to scan and email or fax the documents.

      NOTE: QEs should submit PE documentation in only one of the above methods.

  • Comply with all state, federal, and Missouri Department of Social Services rules and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), when conducting presumptive eligibility determinations;
  • Maintain written or electronic records of all documents used in PE determination along with any related supporting documentation for a period of five (5) years from the date of the determination, unless litigation or audit has been started prior to the sixth year, then the record must be maintained until the litigation, or audit is resolved. These records will be made available to the department upon request;
  • Notify the FSD, within ten (10) days, of any changes in the point of contact information;
  • If individual is found eligible, applicable services will be provided by MO HealthNet Providers while the presumptive period remains in effect.  
  • Any documentation received after initial fax or email should be sent by the same method with the same subject line as soon as it is received by the QE.

  1900.030.20 QE Performance Standards And Corrective Action

  IM#51, May 18, 2017

  To remain a QE, the provider must meet the following performance standards with respect to its presumptive eligibility determinations. The PE provider must:

  • Check for receipt of PE within the past 12 months, or if pregnant, during the current pregnancy (TEMP or SMHB-PE). It is the expectation of FSD that a correct determination is made on 98% or more of applications.
  • Check for existing MO HealthNet coverage prior to completing PE determinations. It is the expectation of FSD that a correct determination is made on 98% or more of applications.
  • Make accurate PE determinations based on applicant's self-attestation, income guidelines, and household size. This includes accuracy of the following information:
    • Names spelled correctly
    • Date of birth
    • Correct address
    • Social Security Number (if given)

    It is the expectation of FSD that a correct determination is made on at least 95% of PE determinations.

  • Assist applicants in completing and submitting regular MO HealthNet applications (IM-1SSL). It is the expectation of FSD that 90% of PE participants will submit applications for the appropriate program prior to the end of the PE period, and that 95% of these applications must be approved for ongoing MO HealthNet coverage.

    NOTE:  Regular applications rejected because the applicant did not meet citizenship/qualified alien criteria or did not provide verification will not be used in this measurement.

  If performance standards are not met:

  • QE receives notification of deficiencies from the Family Support Division (FSD)
  • QE submits a corrective action plan (CAP) for review by FSD
  • Upon approval of CAP, QE must implement and complete the CAP within a     30-day time frame
    • FSD will moniter the QE's performance on the CAP at least every three months until FSD determines that the corrective action plan has been successfully completed. 
  • If QE does not submit a CAP accepted by Division or again fails to meet performance standard, QE may be disqualified as a PE qualified entity for the period of 3 years
    • If QE is disqualified, QE receives notice 30 days prior to disqualification
    • QE has 10 calendar days to submit a request for reconsideration to the department director
    • Reconsideration is within the discretion of the department director
    • Any request for reconsideration should include a detailed explanation of the reasons why the QE should not be disqualified for failing to meet performance standards, or any corrective action measures, and should contain any documentation the QE wishes the director to consider. 

  1900.030.30 Responsibility For Training Qualified Providers

  IM#51, May 18, 2017

  FSD is responsible for providing training when:

  • A new MOA is approved;
  • QE's have new staff; or
  • If there are changes in PE Policy.

  If additional training is needed email FSD at COLE.MHNPOLICY@dss.mo.gov to request training.

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