2067 Presumptive Eligibility Medical Assistance

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Presumptive Eligibility Medical Assistance

Effective Date:

July 2024

Chapter:

2050

Policy Number:

2067

Previous Policy Number(s):

MT 69

Updated or Reviewed in MT:

MT-72

Requirements

Presumptive Eligibility (PE) Medical Assistance allows Qualified Providers (QP) and Qualified Hospitals (QH) authorized by the Department of Community Health (DCH), to make temporary determinations of Medical Assistance eligibility for applicants whose statement of net BG income is less than the appropriate FPL for the Class of Assistance (COA) requested. PE continues while a formal determination of eligibility for ongoing and/or retroactive Medical Assistance is pending with the Division of Family and Children Services (DFCS) office.

Basic Considerations

PE Medical Assistance provides outpatient prenatal care to pregnant women during the period that a formal Medical Assistance application pends with DFCS. All Medical Assistance services given by any participating Medical Assistance provider are covered during the presumptive period with exceptions of inpatient hospital and delivery services.

Hospital Presumptive Eligibility (HPE) covers all Medical Assistance related services that are covered by the specific COA requested.

Emergency Medical Assistance (EMA) cannot be completed in the Presumptive Eligibility process.

Hospital Presumptive Eligibility may be determined for the following groups:

  • Pregnant Women

  • Parent/Caretaker with Child(ren) under age 19

  • Child(ren) under 19

  • Former Foster Care Children

  • Women in treatment for Breast or Cervical Cancer (WHM)

The PE Medical Assistance eligibility period begins on the date the PE application is approved and ends when DFCS determines eligibility or ineligibility, but no later than at the end of the month following the month of the PE approval. (Ex. PE application approved 4/5/24 which begins coverage 4/5/24 through 5/31/24.)

The QP or QH issues temporary Medical Assistance certificates and Notice of Action (Approval/Denial) to applicants. If the applicant is approved for PE Medical Assistance, a plastic card is sent. The applicant should receive this within 7 to 10 business days. If the plastic card is not received, lost or stolen, the member must contact the Member Contact Center at 1-866-211-0950.

DFCS cannot process applications for PE or issue eligibility forms for PE.

Potential Qualified Providers include the Department of Public Health, federally funded health centers, primary care centers receiving migrant funding and/or homeless funding, hospital outpatient clinics and hospital-based special prenatal clinics.

As of July 1, 2011, Public Health became the Department of Public Health and is now a Qualified Provider.

Procedures

Responsibilities of a Qualified Provider or Qualified Hospital

The QP or QH determines eligibility for PE Medical Assistance based on the applicant’s pregnancy statement (Pregnant Women), certificate of diagnosis (Women’s Health), the net income of the budget group (BG), citizenship or immigrations status and residency. The QP or QH conducts a face-to-face (FTF) interview with the applicant and performs the following functions:

  • Screens the applicant in GAMMIS to see if he/she is already active on Medical Assistance. If a woman is already active on Medical Assistance (except Planning for Health Babies®(P4HB)) DO NOT complete a PE application. (See Note below.)

  • Accepts the applicant’s statement of net income and obtains adequate information from the applicant to complete the following forms: (See Note below.)

    • Form 632, Pregnant Women Presumptive Eligibility application

    • Form 632H Qualified Hospital Presumptive Eligibility application

    • Form 632W, Women’s Health Presumptive Eligibility application

    • Form 216, Declaration of Citizenship/Immigration Status

    • Form 5460, HIPPA Notice of Privacy Practices

    • Form 94A, Single Streamlined Medical Assistance application

    • Form 94, Medical Assistance application (Women’s Health only)

  • Determines if the applicant meets eligibility criteria for PE Medicaid.

  • QP forwards the PE Packet to DFCS within five business days of the PE application date.

  • QH forward the PE Packet to DCH within five business days of the PE application date.

If the QP or QH determines that the applicant is eligible for PE Medicaid, the QP or QH completes the determination process as follows:

  • provides the applicant with a Temporary Medical Assistance Certificate and form 634, 634H, 634W – Notice of Action (Approval)

  • provides the applicant with the Quick Guide on Presumptive Eligibility Medical Assistance, Quick Guide on Presumptive Eligibility for Pregnant Women or Quick Guide on Women’s Health Medical Assistance

  • informs the applicant of the PE Medical Assistance period and covered services

  • informs the applicant about P4HB

  • QP forwards the PE Packet to DFCS within five business days of the PE application date

  • QH forwards the PE Packet to DCH within five business days of the PE application date


If the QP or QH determines that the applicant is ineligible for PE Medical Assistance, the QP or QH completes the determination process as follows:

  • informs the applicant that he/she is not eligible and provides him/her with the form 634, 634H or 634W – Notice of Action (Denial)

  • advises the applicant that if his/her circumstances change, he/she may have another determination of PE Medical Assistance completed by a QP or QH

  • informs the applicant that his/her application for ongoing and/or retroactive Medical Assistance will be forwarded to DFCS for a formal determination of eligibility

A PE application cannot be completed on an already active Medical Assistance member. Qualified Providers and Qualified Hospitals are unable to update pregnancy information in GAMMIS on active Medical Assistance members. If the applicant is pregnant and actively receiving Women’s Health, inform member to report pregnancy to their caseworker. If the applicant is actively SSI, QH/QP should complete the SSI Pregnant Women Update form and send to DCH by email at pecorrections@dch.ga.gov . All other active members need to contact DFCS at 1-877- 423-4746 or submit a Change Report via Gateway “Report My Change” to report their pregnancy.
Form 216 is not required when Forms 632, 632H, or 632W are used as the language is included.
For Women’s Health, a certificate of diagnosis is required at the time of application.
The Temporary Medical Assistance Certificate and the Notice of Action-Approval will serve as proof of eligibility.

The PE Packet being sent to DFCS consists of the following:

  • PE Application (Form 632, 632H, or 632W)

  • Notice of Action (Form 634, 634H or 634W) and Temporary Medical Assistance Certificate

  • Third Party Liability Questionnaire (DMA 285)

  • Single Streamlined Medical Assistance application (94A) or Medical Assistance application (94 - Women’s Health Only)

  • Certificate of Diagnosis (Women’s Health only)

  • Any documentation the applicant provides

To ensure that applications for pregnant women are processed within the 10-day standard of promptness, the local QP(s) should contact DFCS to discuss procedure for forwarding PE Packets to DFCS daily. All other COAs processed as Hospital Presumptive are subject to a 45-day standard of promptness.

Responsibilities of DFCS

Upon receipt of the PE Medicaid packet, complete a formal determination for Medical Assistance eligibility for the applicant and any other individuals for whom Medical Assistance is requested.

The application date is the date the applicant applies for benefits with the QP or QH and signs the 94 or 94a. Process the 94 or 94A application using the appropriate COA. Refer to Section 2162 Parent/Caretaker with Child(ren), Section 2182 Children Under 19, 2184 Pregnant Women, Section 2198 Women’s Health and Section 2819 Former Foster Care.