Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 477 - MEDICAID ELIGIBILITY
Chapter 19 - MODIFIED ADJUSTED GROSS INCOME (MAGI) BASED PROGRAMS
Section 477-19-008 - PRESUMPTIVE ELIGIBILITY

Universal Citation: 477 NE Admin Rules and Regs ch 19 ยง 008

Current through March 20, 2024

008.01 ELIGIBILITY REQUIREMENTS. To be presumptively eligible in accordance with the policies and procedures established by the Department, a presumptive eligibility determination must be made by a qualified provider on the basis of preliminary information indicating the individual has gross income at or below the income standard established for the applicable group, has attested to being a citizen or national of the United States or is in satisfactory non-citizen status, and is a resident of Nebraska.

008.02 EFFECTIVE DATE. Presumptive eligibility begins on the date the provider completes a presumptive eligibility determination.

008.03 ELIGIBILITY PERIOD. If the individual files an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination of presumptive eligibility, the presumptive eligibility ends on the day the Department makes the determination of Medicaid eligibility based on that application. If the individual does not file an application for Medicaid by the last day of the month following the month in which the qualified provider made the determination, the presumptive eligibility ends on that day. A presumptive application approved in error will be closed by the Department upon discovery of the error.

008.04 NOTICES. Notice and fair hearing regulations do not apply to determinations and closures of presumptive eligibility.

008.05 RESPONSIBILITIES OF QUALIFIED ENTITIES. An entity qualified to make presumptive eligibility determinations must:

(A) Notify the appropriate individual at the time a determination regarding presumptive eligibility is made, in writing or orally if appropriate, of such determination, and of the presumptive eligibility period, and
(i) If a Medicaid application on behalf of the eligible individual is not filed by the last day of the following month, the individual's presumptive eligibility will end on that last day;

(ii) If a Medicaid application on behalf of the eligible individual is filed by the last day of the following month, the individual's presumptive eligibility will end on the day that a decision is made on the Medicaid application;

(iii) If the individual is not determined presumptively eligible, the qualified entity must notify the appropriate individual of the reason for the determination and he or she may file an application for Medicaid with the Department;

(B) Provide the individual with a Department approved application for Nebraska Medicaid;

(C) Notify the Department the individual is presumptively eligible within five working days from the date the determination is made; and

(D) Refrain from delegating the authority to determine presumptive eligibility to another entity.

008.06 FAILURE TO MEET CATEGORICAL ELIGIBILITY. If a client fails to satisfy any of the eligibility criteria for a presumptive eligibility Medicaid category, other than income, at any time during the client's presumptive eligibility period, presumptive eligibility must be discontinued regardless of the client's submission of an application.

008.07 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN. Medicaid covers ambulatory prenatal care for pregnant women on the basis of presumptive eligibility. The qualified provider may authorize a period of presumptive eligibility once per pregnancy. There is no presumptive eligibility under the 599 Children's Health Insurance Program (CHIP).

008.07(A) AMBULATORY PRENATAL CARE. See 471 NAC 28.

008.07(B) QUALIFIED PROVIDER. Only a qualified provider may make presumptive eligibility determinations. See 471 NAC 28 for requirements of a qualified provider.

008.08 HOSPITAL PRESUMPTIVE ELIGIBILITY. The Department will provide Medicaid during a presumptive eligibility period to individuals who are determined eligible by a qualified hospital.

008.08(A) ELIGIBLE GROUPS. Determinations are limited to:
(i) Children, see 477 NAC 19;

(ii) Pregnant women, see 477 NAC 19. A pregnant woman is eligible for ambulatory care only;

(iii) Parents and caretaker relatives, see 477 NAC 19;

(iv) Effective October 1, 2020, the Heritage Health Adult Program, see 477 NAC 29;

(v) Former foster care children, see 477 NAC 28; and

(vi) Breast and cervical cancer patients, see Women's Cancer Program at 477 NAC 27. Hospitals which may determine presumptive eligibility for such patients are limited to those participating in the National Breast and Cervical Cancer Early Detection Program under authority of the Centers of Disease Control and Prevention.

008.08(B) FREQUENCY. Presumptive eligibility determination is limited to no more than one period within two calendar years per person. A qualified provider may authorize a period of presumptive eligibility once per pregnancy.

008.08(C) QUALIFIED HOSPITAL CRITERIA. A hospital qualified to make presumptive eligibility determinations must:
(i) Participate as a Medicaid provider;

(ii) Notify the Department of its decision to make presumptive determinations;

(iii) Agree to make determinations consistent with state policy and procedures;

(iv) Assist individuals in completing and submitting full Medicaid applications;

(v) Assist individuals in understanding required documentation requirements; and

(vi) Not be disqualified by the Department.

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