PRIA, Government Policy, Made Personal

Summary

Lets states give temporary Medicaid to people who may have breast or cervical cancer while their full Medicaid application is being decided. The temporary period starts when a qualified group uses quick, basic information to say the person likely meets the special cancer-related rule. The period ends when the state makes a final eligibility decision, or, if the person does not file a full application, on the last day of the month after the month of the quick decision. A “qualified entity” is an organization that can get Medicaid payments and that the state says can make the quick decision. The federal government can limit which groups can be qualified, and states can set limits too. States must give qualified entities the needed application forms and help information. If a qualified entity finds someone presumptively eligible, it must tell the state agency within 5 working days and must tell the person to file a full Medicaid application by the last day of the month after the month of the quick decision. The law covers medical care given during that temporary period by providers eligible for payments and by services the State plan includes.

Title 42, §1396r–1b

The Public Health and Welfare, Source: USLM XML via OLRC

(a)A State plan approved under section 1396a of this title may provide for making medical assistance available to an individual described in section 1396a(aa) of this title (relating to certain breast or cervical cancer patients) during a presumptive eligibility period.

(b)For purposes of this section:

(1)The term “presumptive eligibility period” means, with respect to an individual described in subsection (a), the period that—

(A)begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in section 1396a(aa) of this title; and

(B)ends with (and includes) the earlier of—

(i)the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or

(ii)in the case of such an individual who does not file an application by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.

(2)(A)Subject to subparagraph (B), the term “qualified entity” means any entity that—

(i)is eligible for payments under a State plan approved under this subchapter; and

(ii)is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).

(B)The Secretary may issue regulations further limiting those entities that may become qualified entities in order to prevent fraud and abuse and for other reasons.

(C)Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities, consistent with any limitations imposed under subparagraph (B).

(c)(1)The State agency shall provide qualified entities with—

(A)such forms as are necessary for an application to be made by an individual described in subsection (a) for medical assistance under the State plan; and

(B)information on how to assist such individuals in completing and filing such forms.

(2)A qualified entity that determines under subsection (b)(1)(A) that an individual described in subsection (a) is presumptively eligible for medical assistance under a State plan shall—

(A)notify the State agency of the determination within 5 working days after the date on which determination is made; and

(B)inform such individual at the time the determination is made that an application for medical assistance under the State plan is required to be made by not later than the last day of the month following the month during which the determination is made.

(3)In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance under such plan by not later than the last day of the month following the month during which the determination is made.

(d)Notwithstanding any other provision of this subchapter, medical assistance that—

(1)is furnished to an individual described in subsection (a)—

(A)during a presumptive eligibility period;

(B)by a 11 So in original. Probably should be “an”. entity that is eligible for payments under the State plan; and

(2)is included in the care and services covered by the State plan,

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Section applicable to medical assistance for items and services furnished on or after Oct. 1, 2000, without regard to whether final

Regulations

to carry out such

Amendments

have been promulgated by such date, see section 2(d) of Pub. L. 106–354, set out as an

Effective Date

of 2000 Amendment note under section 1396a of this title.

§1396r–1b Presumptive Eligibility for Certain Breast or Cervical Cancer Patients

Summary

Title 42, §1396r–1b

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Regulations

Amendments

Effective Date

Citations & Metadata