Current through Register Vol. 56, No. 18, September 16, 2024
(a) "Presumptive
eligibility" means an expedited process whereby selected certified HealthStart
Comprehensive Maternity Care providers make preliminary Medicaid eligibility
determinations on behalf of pregnant women (see HealthStart in applicable
Provider Services Manuals and N.J.A.C. 10:49-19). This is a preliminary
process to determine presumptive eligibility prior to the determination of
Medicaid eligibility or ineligibility by the CWA.
1. Approved HealthStart Maternity Care
providers (independent clinics and hospital outpatient departments) may
determine presumptive eligibility for pregnant women who require ambulatory
prenatal services from Medicaid participating providers.
2. A NJ FamilyCare one-page application can
be used to apply for presumptive eligibility (PE) for Medicaid/NJ FamilyCare
services. This is the only application that the pregnant woman will need to
complete. The HealthStart PE provider shall send a copy of the completed
one-page application to the CWA to determine full Medicaid/NJ FamilyCare
eligibility using the NJ FamilyCare application instructions and documentation
requirements.
(b) A
presumptively eligible pregnant woman is entitled to all Medicaid covered
services with the exception of inpatient hospital and nursing facility care
services. Although Medicaid HealthStart services must be provided only by a
HealthStart provider, other Medicaid covered services may be provided to a
presumptively eligible pregnant woman by any participating Medicaid
provider.
(c) A presumptively
eligible pregnant woman is eligible for a period of time, which will end:
1. If the woman has not provided verification
documents to the CWA, on or before the last day of the month subsequent to the
date of the presumptive eligibility determination; or
2. If the woman has provided verification
documents to the CWA, by the last day of the month subsequent to the month in
which she was determined presumptively eligible, or on the day eligibility or
ineligibility for Medicaid benefits is determined by the CWA.
(d) A presumptively eligible
pregnant woman will be issued a plastic Medicaid/NJ FamilyCare Health Benefits
Identification (HBID) Card. This card is the only document acceptable for the
identification of a presumptively eligible pregnant woman. The HBID Card is for
identification purposes only and is not a proof of current eligibility.
1. As part of the presumptive eligibility
process, a presumptively eligible pregnant woman will be given an HBID
Emergency Services Letter to use as identification when seeking emergency
services prior to receiving the HBID card in the mail (see Appendix, N.J.A.C.
10:49). This HBID Emergency Services Letter contains pertinent information,
which the provider will need in order to submit claims for services provided to
the beneficiary. This is not valid proof of eligibility for Medicaid/NJ
FamilyCare and should not be used by the provider for presumptive eligibility
purposes. A request for reimbursement based solely upon the presentation of the
HBID Emergency Services Letter does not guarantee payment.
2. Even with the identification through the
HBID Card, each time a service is rendered the provider shall verify the
presumptive eligibility status of a pregnant woman, prior to the delivery of
ambulatory services. Eligibility can be verified by calling the toll free
telephone number listed on the HBID Card which is available seven days a week,
24 hours a day, inquiring online at
http://www.njmmis.com or swiping the HBID
card through the reader provided by an eligibility vendor.
3. A provider's failure to verify eligibility
prior to the delivery of services shall result in the denial of payment for
those services if the individual was not eligible at that time. The provider
should note that a pregnant woman's presumptive eligibility may be terminated
at any time.
