1. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 1 Pregnant Women Presumptive Eligibility Division of Eligibility Policy 1

2. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 2 What is it? Under pregnant women presumptive eligibility, pregnant women can receive Medicaid coverage for ambulatory prenatal care only. Coverage Period – The presumptive eligibility period will begin on the day that the presumptive eligibility determination was made and will end on either; The date a full determination for continual Medicaid is made Or if no application is filed, then the presumptive eligibility coverage period will end the last day of the following month from which the original presumptive eligibility determination was made. – Only one presumptive eligibility period is allowed per pregnancy. 2

3. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 3 Eligibility Factors Eligibility factors can be self attested by the applicant in order to determine presumptive eligibility – No additional verification is needed – Financial Factors A pregnant woman must be at or below 319% FPL – Non-Financial Factors Must be pregnant Must be a resident of the District of Columbia Must be a U.S. citizen or be a non-citizen in a satisfactory immigration status 3

4. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 4 Qualified Entities A qualified entity is one that: – Participates as a provider under the Medicaid state plan or a Medicaid 1115 Demonstration – Notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures. – Has not been disqualified by the Medicaid agency for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency. – Assists individuals in completing and submitting the full application and understanding any documentation requirements. – Must assist in the completion of presumptive eligibility applications. 4

5. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 5 Responsibilities of Qualified Entities and the Economic Securities Administration (ESA) Responsibilities of Qualified Entities include: – Assisting in the completion of presumptive eligibility applications. – Determining eligibility according to state policies and procedures. – Assisting in the completion and submission of full Medicaid applications. Responsibilities of ESA include: – ESA staff must review presumptive eligibility applications and submit all information into ACEDS – ESA staff must also send eligibility notifications to all applicants. – Following an eligible determination, information for presumptive eligibility benefits and a combined Medicaid application must be sent to the beneficiary. 5

6. Government of the District of Columbia Department of Health Care Finance ‹#› For Government Use Only 6 Application Process 6 A pregnant woman visits a qualified entity or an ESA Service Center. The qualified entity or ESA staff will assist the pregnant woman in completing the separate presumptive eligibility application. Pregnant woman will self attest to all eligibility factors. (Financial and Non-Financial) If completed in a service center, the a completed and signed application is then sent to the Economic Securities Administration (ESA). Applications can be submitted via email, fax, mail, or in person. ESA staff will review the information, enter it into ACEDS, and then determine Eligibility. If found eligible, then an approval notice will be sent to the beneficiary along with a full Medicaid application to be completed. If application is completed at a qualified entity then the qualified entity will determine eligibility. If found eligible, then the qualified entity will assist the beneficiary in completing a full Medicaid application.