Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 28 - PRESUMPTIVE ELIGIBILITY › Section 471-28-001 - Presumptive Eligibility for Pregnant Women

Current through June 17, 2024
Under Section 1920 of the Social Security Act, Medicaid covers
	 ambulatory prenatal care provided by an enrolled Medicaid provider to a
	 pregnant woman during a presumptive eligibility period determined by a
	 qualified provider. A pregnant woman is eligible for only one presumptive
	 eligibility period per pregnancy.
Ambulatory prenatal care is defined as ambulatory services related to
	 the pregnancy excluding inpatient hospital services, nursing home services,
	 labor and delivery services, and services furnished to deliver or remove an
	 embryo/fetus from the mother or services following such a procedure.
001.01 Definition of a Qualified
  Provider
001.02 Provider Approval
A provider who meets the requirements of 471 NAC 28-001.01 may request
	 approval as a qualified provider for presumptive eligibility determinations
	 from the Medicaid Division. The provider shall submit a written request for
	 approval as a qualified provider to the Administrator of the Medicaid Division.
	 The written request must identify the requirements of 471 NAC 28-001.01 the
	 provider meets as well as how the provider will check active or pending
	 Medicaid status for potential presumptively eligible pregnant women. The
	 Medicaid Division shall coordinate with the Economic Assistance Division and
	 the local Department of Health and Human Services (DHHS) office for the
	 training of the qualified provider. The provider must be trained by the
	 Medicaid and Economic Assistance Division staff, or staff approved by the
	 Medicaid and Economic Assistant Division, before approval as a qualified
	 provider is given. Final approval of the trained qualified provider is made in
	 writing by the Medicaid Division. The designation of a qualified provider may
	 be terminated by the Medicaid Division upon written 30-day notice to the
	 qualified provider.
001.03
  Presumptive Eligibility Determination
A pregnant woman may apply at a qualified provider's office (see 471
	 NAC 28-001.01) for ambulatory prenatal services. The provider makes a
	 presumptive determination of the woman's eligibility based only on declared
	 income and citizenship/eligible alien status. Income of the woman and spouse
	 (if he is in the home) is counted. Income of the responsible parent(s) of a
	 pregnant minor is counted unless the pregnant woman is an emancipated minor.
	 The provider does not investigate resources or other eligibility requirements.
	 See 477 NAC
	 1-004 for definition of emancipated
	 minor. For income levels, see 471-000-202.
001.04 Responsibilities of the Qualified
  Provider
The qualified provider shall complete the following actions during the
	 process of making a presumptive eligibility determination:
1. Check for any current or pending Medicaid
  eligibility prior to completing a presumptive eligibility
  determination;
2. Check for any
  past presumptive eligibility period during the client's current pregnancy. A
  pregnant woman may receive only one period of presumptive eligibility per
  pregnancy;
3. Inform the woman at
  the time the determination is made:
a. The
  copy of the presumptive eligibility application is the client's proof of
  coverage and is a Medicaid application;
b. She is required to provide verification
  and documentation as requested by DHHS;
c. Presumptive eligibility ends when DHHS
  makes a determination of eligibility for medical assistance or at the end of
  the 45-day presumptive period; and
4. Forward a copy of the presumptive
  eligibility application, along with the attestation form if applicable, to the
  local DHHS office within five working days after making a presumptive
  eligibility determination.
5. If
  the woman is not presumptively eligible, inform her in writing:
a. Of the reason for her ineligibility;
  and
b. That she may file an
  application for the Nebraska Medical Assistance Program (also known as medical
  assistance or Medicaid) at the local DHHS office.
6. A presumptive application approved in
  error will be closed by DHHS upon discovery.