700-1 Presumptive Eligibility for Children

Policy Effective: April 1, 2012

  1. What is Presumptive Eligibility?

  1. Presumptive Eligibility (PE) allows low income children to receive temporary medical assistance while the eligibility agency (The Dept. of Workforce Services-DWS) determines their eligibility for ongoing Medicaid or CHIP.  

  2. The Department of Health has designated the Divisions of Child and Family Services and Juvenile Justices Services under the Department of Human Services (DHS) to determine Presumptive Eligibility for children.

  1. Application:  

  1. A single application form is used for both Presumptive Eligibility and ongoing Medicaid and CHIP.  Upon making a decision on the presumptive eligibility application, DHS will send the application to DOH to enter the eligibility into the system.  DOH will then send the medical application to DWS to determine ongoing Medicaid or CHIP eligibility.

  2. Considerations for Ongoing CHIP:

  1. All regular CHIP eligibility requirements apply.  

  2. See Section K to determine the start date for ongoing CHIP when presumptive eligibility is approved AND the child is later found eligible for ongoing CHIP.

  1. Eligibility Requirements

  1. To be presumptively eligible for CHIP, a child must meet the following requirements based on preliminary information received by DHS:

  1. Is under the age of 19

  2. Is a U.S. citizen or a qualified alien

  3. Is a Utah resident

  4. Has a gross household income that exceeds the applicable Medicaid limit, but is not over 200% of the FPL (Medicaid Policy 356 C). Refer to section D below to determine the applicable household size for PE.

  5. Is not already covered on CHIP or Medicaid

  6. Not enrolled in other health insurances.

  1. There is no resource test for PE.

  1. Household Size

  1. The presumptive eligibility for Medicaid and CHIP covers only children under age 19.  Only individuals having direct relationship and/or financial responsibility are included in the household size.

  1. The following individuals who reside together are counted in the child’s household size for PE.

  1. If there is another child in the home who is not directly related to the applicant AND presumptive eligibility determination is requested for this child, a separate application must be filed.  Consider eligibility for this other child in a separate household.

  1. For example, there will be 2 households for PE if child, child’s parents, child’s sibling and child’s aunt and her child  (child’s cousin) all reside in the same home:

  1. CHIP PE Determination

  1. DHS must make a presumptive eligibility decision and notify the Department within 5 business days from the date of determination.  

  2. The applicant must provide all PE information that DHS needs to determine presumptive eligibility.  

  3. The PE determination is based on the customer’s declaration; no verifications are needed.

  4. A child can only receive one period of presumptive eligibility in any 6 month period.  The 6 month period starts the first month PE benefit is issued.

  1. CHIP Period of Presumptive Eligibility  

  1. CHIP Presumptive Eligibility is effective the 1st of the month in which PE is approved.

  2. Presumptive Eligibility ends on the day DWS completes an eligibility decision for regular medical assistance, or on the last day of the month following the PE approval month if an application was not filed on behalf of the child.

  3. When a child is approved for presumptive eligibility and applies for medical assistance, presumptive eligibility continues only until the eligibility agency makes an eligibility decision based on that application.  Filing additional medical applications does not extend the presumptive eligibility period.   

  4. CHIP PE months do not count as a certification month unless ongoing CHIP is approved for that month.   See Policy Section 602.

  1. CHIP Premiums and Co-Payments

  1. Presumptive eligible children are not required to pay PE CHIP premiums, but are required to pay PE CHIP co-payments.  

  2. Applicable CHIP premiums will apply starting with the month regular ongoing CHIP coverage begins, even if the months are the same months as the CHIP presumptive eligibility period.

  3. Exception:  American Indians and Alaska Native children are exempt from both CHIP premiums and co-payments for the presumptive eligibility period and regular CHIP certification.

  1. Health Plan

  1. A health plan will be automatically assigned to PE CHIP children upon approval.  If the customer’s provider is not within the assigned health plan, the customer may contact the Health Department to change the health plan.

  1. Notices

  1. If a child is determined presumptively eligible, the customer must be informed of the following in writing:

  1. That presumptive eligibility ends on the day DWS completes an eligibility decision for regular medical assistance, or on the last day of the month following the PE approval month if a regular medical application was not filed on behalf of the child.

  1. If a child is determined not presumptively eligible, inform the customer in writing:

  1. The denial reason, and

  2. That the application for regular medical assistance has been forwarded to DWS; and DWS will send a notice of decision based on that medical application.

  1. Appeal Rights

  1. The standard notice and appeal rights do not apply to decisions about Presumptive Eligibility.

  1. Benefit Start Date for Ongoing Medical

  1. When a presumptively eligible child is determined eligible for ongoing CHIP, the benefit start date is either the first day of the application month subject to the limitations in 602, or any of the 4 day grace period if the customer applies during the first four days of the month and the 4-day grace period is allowed.

  2. When a presumptively eligible child is determined eligible for ongoing Medicaid, see Medicaid policy 356 to determine the benefit start date for Medicaid.