Section 120.12  Healthy Start − Medicaid Presumptive Eligibility Program For Pregnant Women

The purpose of the Healthy Start −  Medicaid Presumptive Eligibility (MPE) Program is to encourage early and continuous prenatal care to low income pregnant women who otherwise may postpone or do without such care. Presumptively eligible pregnant women shall receive ambulatory prenatal care before completing an application for medical assistance under the State plan at the local Public Aid Office.

a)         Eligibility:  To be eligible for the Healthly Start −  Medicaid Presumptive Eligibility Program, the woman must have:

1)         a medically verified pregnancy; and

2)         family income not exceeding 133% of the Federal Poverty Level.

b)         Qualified providers shall make all determinations as to eligibility in the MPE Program (42 U.S.C. 1396).

c)         The presumptive eligibility period shall be the period that:

1)         begins with the date on which a qualified provider determines, on the basis of preliminary information, that the family income does not exceed 133% of the Federal Poverty Level; and

2)         ends with (and includes) the earlier of:

A)        the day on which a determination is made with respect to the eligibility of the woman for medical assistance under the State plan; or

B)        in the case of a woman who does not file an application by the last day of the month following the month during which the provider makes the determination, such last day.

d)         Duties of the State agency, qualified providers, and presumptively eligible pregnant women.

1)         The Department shall provide qualified providers with:

A)        such forms as are necessary for a pregnant woman to make application for medical assistance under the State plan; and

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

2)         A qualified provider who determines that a pregnant woman is presumptively eligible for medical assistance under a State plan shall:

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

B)        inform the woman at the time the determination is made that she is required to make application for medical assistance under the State plan by no later than the last day of the month following the month during which the determination is made.

3)         A pregnant woman who is determined by a qualified provider to be presumptively eligible for medical assistance under a State plan shall make application for medical assistance under such plan by no later than the last day of the month following the month during which the determination is made.

e)         Ambulatory prenatal care consists of all outpatient medical care covered by the State plan.

(Source:  Added at 15 Ill. Reg. 14240, effective September 23, 1991)