14-03 Version of 32.2 Presumptive Eligibility for Pregnant Women
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State of Wisconsin
Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

32.2 Presumptive Eligibility (PE) for Pregnant Women

32.2.1 Eligible Pregnant Women for PE

32.2.2 Qualified Entities

 

Note: Wisconsin’s presumptive eligibility programs are known by multiple terms: Express Enrollment, Temporary Enrollment, and Presumptive Eligibility. Express Enrollment (EE) is the online application in ACCESS for making PE determinations. Presumptive Eligibility (PE) is the determination of whether an applicant is eligible to temporarily enroll in BadgerCare Plus (BadgerCare Plus) or Family Planning Only Services (FPOS). Temporary Enrollment (TE) is when an applicant has been found eligible to temporarily enroll in BadgerCare Plus or FPOS. All such policy in this handbook will be collectively referred to as Presumptive Eligibility.

32.2.1 Eligible Pregnant Women for PE

A Medicaid qualified entity certified by ForwardHealth can temporarily enroll a pregnant woman in BadgerCare Plus through the Express Enrollment program.

 

BadgerCare Plus Express Enrollment (EE) for pregnant women provides pregnancy related out patient care, including pharmacy services, to pregnant women who are presumptively eligible for BadgerCare Plus by meeting the following financial and non-financial criteria:

 

  1. Currently pregnant,

  2. A U.S. Citizen or lawfully present in the United States (no requirement for the amount of time the person is lawfully present in the U.S.), and

  3. Through January 31, 2014,

    • Family income at or below 300% of FPL 

 

  1. Effective February 1, 2014,

 

Through January 31, 2014, if the pregnant woman’s income is at or below 200% of the FPL, she will be eligible for prenatal services under the Standard Plan, if it is between 201% and 300% of the FPL, she will be eligible for prenatal services under the Benchmark Plan. Beginning February 1, 2014, she will be eligible for out-patient services under the Standard Plan, regardless of her income  at or below 306% of the FPL.

32.2.2 Qualified Entities

The qualified entity will:  

 

  1. Medically verify the pregnancy.

    Note: Pregnancy will no longer be required to be verified for PE effective February 1, 2014.
     

  2. Complete a BadgerCare Plus PE for Pregnant Women applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. .

  3. Provide a temporary BadgerCare Plus card if she meets the non-financial and financial criteria for PE.

  4. Provide a denial notice if she does not meet the requirements for PE.

  5. Advise the applicantA request for BadgerCare Plus coverage. The request must be on the Department's or Federally-facilitated Marketplace’s application, registration form or account transfer (from Federally-facilitated Marketplace) and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. that a ForwardHealth Card will replace the temporary card and provide prenatal services through BadgerCare Plus for up to two months.  (The new card will be received within 3-5 business days.)

  6. Stress the importance of applying through the local agency for ongoing BadgerCare Plus eligibility. And, advise that the application can be submitted through https://access.wisconsin.gov/, over the telephone, through the mail or in person.
     

The qualified entity will also:

 

  1. Submit the completed PE application form to the fiscal agent.

  1. When circumstances allow, assist the woman in completing and submitting the BadgerCare Plus application with the IM agency.

 

If she applies for ongoing BadgerCare Plus by the end of the month following the month in which she was found presumptively eligible, the enrollment period ends the day on which the agency determines her eligibility, regardless of the result of the determination.

 

If she does not apply by the end of the month following the month in which she was enrolled through PE for pregnant women, the PE period ends the last day of the month following the month in which she was determined eligible for PE for pregnant women.

 

Example: Sandra was enrolled in BadgerCare Plus through the EE for Pregnant Women Program from January 10th through February 28th. She applied for ongoing BadgerCare Plus eligibility through the IM agency on January 15th and was found eligible effective January 1st. Her PE will end because the BadgerCare Plus eligibility will retroactively cover her with full benefits.

 

 

 

 

 

This page last updated in Release Number: 14-03

Release Date: 09/05/14

Effective Date:02/01/14

The information concerning the BadgerCare Plus program provided in this handbook release is published in accordance with: Titles XI, XIX and XXI of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapter 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2 and 101 through 109 of the Wisconsin Administrative Code.

Publication Number: P-10171