§1396r–1c Presumptive Eligibility for Family Planning Services

Summary

States may allow people who seem to meet the income rules to get short-term, immediate family planning care while their full Medicaid eligibility is being decided. That care must be limited to family planning services and supplies, and the state can also allow medical diagnosis and treatment tied to family planning if given in a family planning setting. A “qualified entity” that the state approves and that can get Medicaid payments can decide, using basic information, that a person is presumptively eligible. The presumptive eligibility period starts the day that decision is made and ends when the state makes the final eligibility decision or, if the person does not file a full application, on the last day of the month after the month when the preliminary decision was made. The state must give these qualified entities the application forms and help them assist people in filing. When an entity finds someone presumptively eligible, it must tell the state within 5 working days and must tell the person they need to file a full Medicaid application by the deadline above. The person must apply by that deadline. Services given during the presumptive period by providers who can be paid under the state plan and that are covered by the plan will be treated as Medicaid services for payment purposes.