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32.1 Introduction

32.1.1 Definitions

32.1.2 Qualified Entities

32.1.2.1 Process for a Qualified Entity to Temporary Enroll a Person

32.1.3 Coverage Period

32.1.3.1 Begin Date

32.1.3.2 End Date

32.1.3.3 Early Termination

32.1.3.4 Automatic Extension

 

Presumptive eligibility is a streamlined eligibility determination for temporary enrollment in BadgerCare Plus or Family Planning Only Services. It is based on preliminary household and financial information provided by the applicant. It allows eligible applicants immediate health care coverage for a short period until an application for ongoing coverage is completed and processed.

 

Note: See the Medicaid Eligibility Handbook Section 36.2.2.1 Temporary Enrollment/Presumptive Eligibility Available Only To Women Enrolling Through WWWP for information on temporary enrollment under the Wisconsin Well Women  Medicaid program for women under age 65 with breast or cervical cancer.

32.1.1 Definitions

32.1.2 Qualified Entities

Qualified entities that can make presumptive eligibility determinations include hospitals, providers, and partners that are approved by ForwardHealth and have received Express Enrollment training. The table below explains which qualified entities can make presumptive eligibility determinations for a population and program:

 

Qualified Entities:

Can make presumptive eligibility determinations for:

Children

Pregnant Women

Family Planning Only Services

Adults, Parents, and Caretakers

Qualified Hospitals

X

X

X

X

Providers

X

X

X

 

Partners

X

 

 

 

 

Examples of qualified partners include:

32.1.2.1 Process for a Qualified Entity to Temporary Enroll a Person

A qualified entity follows the process below for a person to get temporary enrollment in BadgerCare Plus or Family Planning Only Services:

  1. Complete a presumptive eligibility application through one of the following methods:
    1. Online using ACCESS for Partners and Providers. This is also known as an Express Enrollment application.
    2. Fill out and submit a paper application.
      1. BadgerCare Plus Express Enrollment for Pregnant Women application (F-10081).
      2. Temporary Enrollment for Family Planning Only Services application (F-10119).
  2. If the applicant is found eligible:
    1. Provide a temporary ForwardHealth ID card.
    2. Advise the applicant that a permanent ForwardHealth ID card will be mailed within 3-5 business days, if the member has not already been issued a ForwardHealth card. If the member has been issued a ForwardHealth card in the past, a new one will not be mailed. The member can use his or her previously issued ForwardHealth card or contact Member Services at 1-800-362-3002 to request a new one.
  3. Provide a denial notice if the applicant is found not eligible.
  4. Stress the importance of applying through the local agency for ongoing health care coverage. The qualified entity is encouraged to assist the applicant with applying. Advise that the application can be submitted online, by telephone, by mail, or in person.

32.1.3 Coverage Period

32.1.3.1 Begin Date

Temporary enrollment in BadgerCare Plus or Family Planning Only Services begins on the date a person is found presumptively eligible by a qualified entity.

32.1.3.2 End Date

Temporary enrollment in BadgerCare Plus or Family Planning Only Services ends the month following the month in which the person was determined presumptively eligible or the date ongoing health care or Family Planning Only Services eligibility is determined (see Section 32.1.3.3 Early Termination and Section 32.1.3.4 Automatic Extension).

32.1.3.3 Early Termination

If a person applies for ongoing health care or Family Planning Only Services coverage and the IM agency makes an eligibility determination prior to the end date of the temporary enrollment period, the temporary enrollment period must end on the date the agency completes processing the application for ongoing coverage, regardless of the result of the eligibility determination. The early termination of temporary enrollment will be applied systematically. Tables 1 and 2 further explain when eligibility for ongoing health care or Family Planning Only Services coverage will end temporary enrollment.

 

Table 1: Systematic Early Termination of Temporary Enrollment—Applicant Applied for One Program

Applicant is confirmed in CARES as:

Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:

Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:

Eligible for BadgerCare Plus or other ongoing Medicaid coverage

End temporary enrollment

End temporary enrollment

Eligible for Family Planning Only Services

No change to temporary enrollment

End temporary enrollment

Not eligible for BadgerCare Plus or other ongoing Medicaid coverage

End temporary enrollment

No change to temporary enrollment

Not eligible for Family Planning Only Services

No change to temporary enrollment

End temporary enrollment

 

Table 2: Systematic Early Termination of Temporary Enrollment—Applicant Applied for Multiple Programs

Applicant is confirmed in CARES as:

Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:

Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:

Eligible for BadgerCare Plus or other ongoing Medicaid coverage but not for Family Planning Only Services

End temporary enrollment

End temporary enrollment

Eligible for Family Planning Only Services but not for BadgerCare Plus or other ongoing Medicaid coverage

End temporary enrollment

End temporary enrollment

Not eligible for Family Planning Only Services, BadgerCare Plus, or other ongoing Medicaid coverage

End temporary enrollment

End temporary enrollment

 

Example 1: Joe Green applied for presumptive eligibility for BadgerCare Plus for his son Jim on February 4 at the Center Street Boys Club. Jim was found presumptively eligible for BadgerCare Plus from February 4 through March 31. Joe submits a BadgerCare Plus ACCESS application to the local IM agency on February 10. The agency determines Jim’s eligibility for ongoing BadgerCare Plus coverage on March 1. Jim is found ineligible for BadgerCare Plus for February and March and the application is denied. A notice is sent to Joe informing him Jim is not eligible for BadgerCare Plus and his BadgerCare Plus temporary enrollment is terminated effective March 1.

 

Example 2: Sandra was determined presumptively eligible for BadgerCare Plus for pregnant women on January 10. Her temporary enrollment period lasts from January 10 through February 28. She applied for ongoing BadgerCare Plus through her local income maintenance agency on January 15 and was found eligible on January 28 with an effective date of January 1. Her temporary enrollment will end on January 28.

32.1.3.4 Automatic Extension

If the income maintenance agency is unable to finish processing the application for ongoing coverage by the end of the temporary enrollment period, the system will automatically extend the temporary enrollment period for two additional calendar months. Tables 3 and 4 further explain when temporary enrollment will be extended.

 

Table 3: Systematic Extension of Temporary Enrollment—Applicant Applied for One Program

Applicant has applied for one program and eligibility has not been confirmed:

Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:

Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:

BadgerCare Plus or other ongoing Medicaid coverage

Extend temporary enrollment for BadgerCare Plus

Do not extend temporary enrollment for Family Planning Only Services

Family Planning Only Services

Do not extend temporary enrollment for BadgerCare Plus

Extend temporary enrollment for Family Planning Only Services

 

Table 4: Systematic Extension of Temporary Enrollment—Applicant Applied for Multiple Programs

Applicant has applied for multiple programs but eligibility has not been confirmed for all programs:

Applicant is currently receiving temporary enrollment benefits for Badger Care Plus:

Applicant is currently receiving temporary enrollment benefits for Family Planning Only Services:

Eligibility has been confirmed for BadgerCare Plus or other ongoing full-benefit Medicaid coverage but not for Family Planning Only Services

Do not extend temporary enrollment for BadgerCare Plus

  • Do not extend temporary enrollment for Family Planning Only Services if the applicant is eligible for BadgerCare Plus or other ongoing full-benefit Medicaid coverage
  • Extend temporary enrollment for Family Planning Only Services if the applicant is not eligible for BadgerCare Plus or other ongoing full-benefit Medicaid coverage
Eligibility has been confirmed for Family Planning Only Services but not for BadgerCare Plus or other ongoing full-benefit Medicaid coverage

Extend temporary enrollment for BadgerCare Plus

Do not extend temporary enrollment for Family Planning Only Services

 

 

This page last updated in Release Number: 18-03

Release Date: 12/14/2018

Effective Date: 09/24/2016