PRIA, Government Policy, Made Personal

Summary

States may let people who look like they meet Medicaid income rules get family planning care right away while their full application is being decided. That immediate help is limited to the family planning services and supplies listed in 1396d(a)(4)(C). A State may also choose to cover medical diagnosis and treatment that happen with a family planning service in a family planning setting. The law defines two key terms. A "presumptive eligibility period" is the time from when a qualified entity makes a preliminary eligibility finding until the State decides on the full Medicaid claim or, if the person does not file an application, until the last day of the month after the month the finding was made. A "qualified entity" is a provider that can get payments under the State plan and that the State says can make these preliminary determinations. The State must give qualified entities the needed application forms and help information. A qualified entity must tell the State within 5 working days when it finds someone presumptively eligible and must tell the person to file a full application by the last day of the month after the month the finding was made. The person must apply by that deadline.

Title 42, §1396r–1c

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

(a)State 11 So in original. Probably should be preceded by “A”. plan approved under section 1396a of this title may provide for making medical assistance available to an individual described in section 1396a(ii) of this title (relating to individuals who meet certain income eligibility standard) during a presumptive eligibility period. In the case of an individual described in section 1396a(ii) of this title, such medical assistance shall be limited to family planning services and supplies described in 1396d(a)(4)(C) 22 So in original. Probably should be preceded by “section”. of this title and, at the State’s option, medical diagnosis and treatment services that are provided in conjunction with a family planning service in a family planning setting.

(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(ii) 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)Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse.

(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 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 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 law, medical assistance that—

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

(A)during a presumptive eligibility period; and

(B)by a 33 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 effective Mar. 23, 2010, and applicable to items and services furnished on or after such date, see section 2303(d) of Pub. L. 111–148, set out as an Effective and Termination Dates of 2010 Amendment note under section 1396a of this title.

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

Summary

Title 42, §1396r–1c

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Citations & Metadata