Current through Register Vol. 41, No. 3, September 23, 2024
A. Qualified hospitals shall administer
presumptive eligibility in accordance with the provisions of this section. A
qualified hospital is a hospital that meets the requirements of
42 CFR
435.1110(b) and that:
1. Has entered into a valid provider
agreement with the Department of Medical Assistance Services (DMAS),
participates as a Virginia Medicaid provider, notifies DMAS of its election to
make presumptive eligibility determinations, and agrees to make presumptive
eligibility determinations consistent with DMAS policies and procedures;
and
2. Has not been disqualified by
DMAS for failure to make presumptive eligibility determinations in accordance
with applicable state policies and procedures as defined in subsections C, D,
and E of this section or for failure to meet any standards established by the
Medicaid agency.
B. The
eligibility groups or populations for which hospitals determine eligibility
presumptively are:
(i) pregnant women;
(ii) infants and children younger
than age 19 years;
(iii) parents
and other caretaker relatives;
(iv)
individuals eligible for family planning services;
(v) former foster care children;
(vi) individuals needing treatment for breast
and cervical cancer; and
(vii)
adults 19 years of age or older but younger than 65 years of age.
C. The presumptive eligibility
determination shall be based on:
1. The
individual's categorical or nonfinancial eligibility for the group, as listed
in subsection B of this section, for which the individual's presumptive
eligibility is being determined;
2.
Household income shall not exceed the applicable income standard for the group,
as the groups are listed in subsection B of this section, for which the
individual's presumptive eligibility is being determined if an income standard
is applicable for this group;
3.
Virginia residency; and
4.
Satisfactory immigration status in accordance with
42 CFR
435.1102(d)(1) and as
required in subdivision 3 of
12VAC30-40-10
and
42 CFR
435.406.
D. Qualified hospitals shall ensure that at
least 85% of individuals deemed by the hospital to be presumptively eligible
will file a full Medicaid application before the end of the presumptive
eligibility period.
E. Qualified
hospitals shall ensure that at least 70% of individuals deemed by the hospital
to be presumptively eligible are determined eligible for Medicaid based on the
full application that is submitted before the end of the presumptive
eligibility period.
F. The
presumptive eligibility period is determined in accordance with
42 CFR
435.1101 and shall begin on the date the
presumptive eligibility determination is made. The presumptive eligibility
period shall end on the earlier of:
1. The
date the eligibility determination for regular Medicaid is made if an
application for Medicaid is filed by the last day of the month following the
month in which the determination of presumptive eligibility is made;
or
2. The last day of the month
following the month in which the determination of presumptive eligibility is
made if no application for Medicaid is filed by last day of the month following
the month in which the determination of presumptive eligibility is
made.
G. Periods of
presumptive eligibility are limited to one presumptive eligibility period per
pregnancy and one per calendar year for all other covered groups.
Statutory Authority: §
32.1-325
of the Code of Virginia;
42 USC §
1396 et
seq.
