Individuals Needing Treatment for Breast or Cervical Cancer

Implementation Guide:

Medicaid State Plan Eligibility

Individuals Needing Treatment for Breast or Cervical

Cancer – Presumptive Eligibility

Contents

POLICY CITATION .................................................................................................................. 2

BACKGROUND ........................................................................................................................ 2

Overview ................................................................................................................................. 2

Presumptive Eligibility Determination ................................................................................... 2

Qualified Entities .................................................................................................................... 3

Application for Presumptive Eligibility .................................................................................. 3

Presumptive Eligibility Period ................................................................................................ 3

INSTRUCTIONS ........................................................................................................................ 5

A. Presumptive Eligibility Period ...................................................................................... 5

B. Application for Presumptive Eligibility ....................................................................... 5

C. Presumptive Eligibility Determination ......................................................................... 5

D. Qualified Entities .......................................................................................................... 5

E. Additional Information (optional) ................................................................................ 6

REVIEW CRITERIA.................................................................................................................. 6

Individuals Needing Treatment for Breast or Cervical Cancer – Presumptive

Eligibility

POLICY CITATION

Statute: 1920B

Regulations: 42 C.F.R. §§435.1101, 435.1102, 435.1103

BACKGROUND

Overview

This reviewable unit (RU) describes the provisions under which the state determines presumptive

eligibility (PE) for the optional group for individuals needing treatment for breast or cervical

cancer. This option, as described at 42 C.F.R. §435.1103, allows an individual to be determined

presumptively eligible by a qualified entity and to access Medicaid-covered services while his or

her full application is being processed. A full eligibility determination is not immediately

needed and cannot be required in order for PE to be approved. An individual may attest to

information needed to make a PE determination, but verification of such information is not

required.

States may fill out this RU once they have completed the Individuals Needing Treatment for

Breast or Cervical Cancer RU to elect the eligibility group. See the corresponding

implementation guide for background information about the eligibility group.

Before establishing PE for any optional eligibility group, including the group for individuals

needing treatment for breast or cervical cancer, states must provide PE for pregnant women or

for children, or both. PE for pregnant women is described in the Presumptive Eligibility for

Pregnant Women RU and PE for children is described in the Presumptive Eligibility for

Children under Age 19 RU.

Presumptive Eligibility Determination

To be determined presumptively eligible, an individual must meet the categorical requirements

of the Individuals Needing Treatment for Breast or Cervical Cancer group. Individuals who

qualify under this group are individuals who: 1) are under age 65, 2) have been screened under

the CDC’s breast and cervical cancer early detection program and found to need treatment for

breast or cervical cancer, and 3) have no other creditable coverage. An individual cannot be

required to provide a Social Security Number in order to receive a PE determination.

Option: Additional PE Determination Factors of Residency and Citizenship. In addition to the

categorical eligibility requirements, states may elect to consider state residency and U.S.

citizenship or eligible immigration status when making a PE determination. Verification of such

information is not required. If a state does not elect these options in the state plan, then

attestation of residency, citizenship and immigration status cannot be required as part of the PE

application process.

Qualified Entities

A qualified entity is an entity that is determined by the agency to be capable of making PE

determinations. Qualified entities can also help families gather the documents needed to

complete the full application process, thereby reducing the administrative burden on states to

obtain missing information.

Many different types of entities can serve as a qualified entity to make PE determinations.

Qualified entities may include health care providers, schools, community-based organizations,

agencies that determine eligibility for other health or social services programs, jails, or entities of

the courts, among others.

The qualified entities selected by a state must be appropriately trained on the state’s PE

screening process and the requirements for PE, as described at section 1920B(c) of the Social

Security Act (the Act). A copy of the state’s training materials is submitted with this RU for

CMS review.

Application for Presumptive Eligibility

States have different options for developing and administering the PE application, but they must

establish a standardized screening process for determining PE. States are not required to use a

written application for PE; they may utilize verbal screening questions, a written application, or

an online portal. Whichever process is used, the qualified entity is responsible for collecting and

recording all information necessary to make a PE determination.

If the state requires a written application, either the single, streamlined application or a PE-

specific application may be used. When the single, streamlined application is used, it must

denote those fields that are required for a PE determination. A PE-specific application may not

include questions that are not relevant to a PE determination. If an online portal or electronic

screening tool is used for PE, it must meet the same guidelines. Both written and electronic

applications are submitted with the Individuals Needing Treatment for Breast or Cervical

Cancer – Presumptive Eligibility RU for approval.

Presumptive Eligibility Period

Individuals may be covered under a PE determination only for a limited period of time. Section

1920B(b)(1) of the Act, codified at 42 C.F.R. §435.1101, discusses the beginning and end dates

for coverage based on PE, as follows.

 Beginning: The PE period begins on the day that a qualified entity determines the

individual to be presumptively eligible.

 End: The end date varies depending on whether or not the individual submits a Medicaid

application.

1. If the individual submits a Medicaid application by the last day of the month

following the month in which PE was determined, the PE period will continue until

full Medicaid eligibility is either approved or denied.

2. If the individual does not submit a timely Medicaid application, the PE period ends

on the last day of the month following the month in which PE was determined.

Example: PE is determined on the 5

of February. If a full Medicaid application is not

submitted by March 31

, coverage will end on that date.

If a full Medicaid application is

filed by March 31

, PE coverage ends on the day the full Medicaid application is either

approved or denied.

States must establish reasonable standards limiting the number of PE periods that will be

authorized. These standards may be based on the calendar year – no more than one PE period

per calendar year – or they may be based on a specific timeframe, such as no more than one PE

period every 12 months. States may establish other reasonable limitations that reflect the needs

of the population.

INSTRUCTIONS

A. Presumptive Eligibility Period

 A.1. has a general rule that the PE period begins on the date the determination is

made.

 A.2. has rules for the end date of the PE period.

 At A.3., select one of the five options to indicate how the periods of PE are limited.

o If A.3.e. Other reasonable limitation is selected:

 Provide the name of the limitation and a description in the text boxes

provided.

 If there is more than one other limitation, select the +Name of

Limitation link and repeat the above step.

 To delete a previously added limitation, select Delete next to its name

and description.

B. Application for Presumptive Eligibility

 At B.1., indicate that a standardized screening process is used for determining PE. To

do this, check the box next to the assurance.

 Select one or more of the three options at B.2. through B.4. You may select:

o Option B.2. alone

o Option B.3. alone

o Option B.4. alone

o Both options B.3. and B.4.

 Upload at least one document (application form or screen shot) for each option that is

selected. These uploaded documents are part of the state plan.

 If you select both B.3. and B.4., at B.5., describe the PE screening process in the text

box provided.

C. Presumptive Eligibility Determination

 C.1. has a statement that the individual must meet the categorical requirements of the

Individuals Needing Treatment for Breast or Cervical Cancer eligibility group (42

C.F.R. §435.213).

 Select C.2. and/or C.3. only if applicable in your state.

D. Qualified Entities

 D.1. describes the use of qualified entities to determine PE.

 At D.2., select one or both of the options to describe the qualified entities.

o If D.2.b. Other Entity is selected, provide additional information as follows:

 Enter the name of the other entity in the text box provided.

 Enter a description of the entity in the text box provided.

 To add additional entities, select the +Type of Entity link and repeat

the above steps.

 To delete another entity type, click the Delete link below the entity’s

name and description.

 At D.3., indicate that the requirements for qualified entities at 1920B of the Act have

been communicated and adequate training has been provided to the entities involved.

To do this, check the box next to the assurance.

 At D.4., upload a copy of the qualified entity training materials for review (e.g.,

PowerPoint or webinar training slides, written instructions or manual for PE

determinations). These uploaded documents are submitted for reference only and will

not become part of the state plan.

E. Additional Information (optional)

Except in limited circumstances, this field remains blank. Please consult with CMS before

adding any additional information concerning this RU.

REVIEW CRITERIA

If the state selects the “Other reasonable limitation” option at A.3.e., it must name any such

limitation and provide a description. The description must be sufficiently clear, detailed and

complete to permit the reviewer to determine that the state’s election meets applicable federal

statutory, regulatory and policy requirements.

If the state selects Other entity at D.2., the description of the entity needs to explain why the

state believes this entity is qualified to determine presumptive eligibility, including such factors

as knowledge of Medicaid policy and experience with Medicaid beneficiaries. The description

must be sufficiently clear, detailed and complete to permit the reviewer to determine that the

state’s election meets applicable federal statutory, regulatory and policy requirements.