CurrentMississippi Division of MedicaidPolicy MS2024MS0001O

Presumptive Eligibility for Medicaid (Pregnant Women)

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Defines Mississippi Medicaid's presumptive eligibility policy for pregnant women, who may receive ambulatory prenatal care during a limited presumptive eligibility period when determined eligible by a qualified entity. Applies to entities making presumptive determinations and affected pregnant applicants.

Policy Summary

PayerMississippi Division of Medicaid

PolicyPresumptive Eligibility for Medicaid (Pregnant Women)

Policy CodePolicy MS2024MS0001O

Change TypeNo material change

Effective DateJul 1, 2024

Next Review Date

Key ActionProviders that determine presumptive eligibility must notify the Division within five working days and inform the woman she must file a Medicaid application by the last day of the month following the month of determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

onepresumptive eligibility period per pregnancy (max)

5 daysprovider notification timeframe

end of next monthapplication deadline

ambulatory prenatal care

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CurrentMississippi Division of MedicaidPolicy MS2024MS0001O

Presumptive Eligibility for Medicaid (Pregnant Women)

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Policy Summary

PayerMississippi Division of Medicaid

PolicyPresumptive Eligibility for Medicaid (Pregnant Women)

Policy CodePolicy MS2024MS0001O

Change TypeNo material change

Effective DateJul 1, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

onepresumptive eligibility period per pregnancy (max)

5 daysprovider notification timeframe

end of next monthapplication deadline

ambulatory prenatal care

Presumptive Eligibility Coverage and Determination

Presumptive Eligibility Criteria for Pregnant Women

Covered when ALL of the following are met:

Applicant must be pregnant.

Household income does not exceed the applicable income standard at 42 CFR 435.116 (a reasonable MAGI-based estimate may be used).

ALL of the following

Presumptive period begins on the date the determination is made.
End of presumptive period is the earlier of
- The date regular Medicaid eligibility is determined, if a Medicaid application is filed by the last day of the month following the month in which the presumptive eligibility determination is made.
- The last day of the month following the month in which the presumptive eligibility determination is made, if no Medicaid application is filed by that date.

No more than one period of presumptive eligibility is allowed per pregnancy.

Covered services during presumptive eligibility: ambulatory prenatal care for individuals qualifying as pregnant women under 42 CFR 435.116.

ALL of the following

The provider that determines presumptive eligibility must notify the Division within five working days of the PE determination.
The provider must inform the woman that she must file a Medicaid application by the last day of the month following the month of the PE determination to allow linkage to a regular eligibility determination.

Applicant requirement: the applicant must complete/file a Medicaid application by the last day of the month following the determination to permit regular Medicaid eligibility determination.

Presumptive Eligibility Criteria and Administrative Requirements

Presumptive eligibility determinations must be made by authorized qualified entities in accordance with state communication and training requirements.

State authority and process: the State uses qualified entities, as defined in section 1920A of the Act, to determine presumptive eligibility for this eligibility group; a qualified entity is an entity the agency determines capable of making presumptive eligibility determinations based on household income and other requirements.

Authorized qualified entities include: Federally Qualified Health Centers (FQHCs); Mississippi Department of Health County Health Departments; Rural Health Clinics (RHCs); Obstetricians; Primary Practice Clinics; and other entities the agency determines capable of making presumptive eligibility determinations.

ALL of the following

The state assures it has communicated the requirements for qualified entities (per 1920A(b)(3)) and has provided adequate training to the entities and organizations involved.
A copy of training materials for provider training has been uploaded for review (DOM PowerPoint - Presumptive Eligibility for Pregnant Women, dated 6/25/2025).

Income & Eligibility Standards

inv-03: Income standard

Income thresholdHousehold income must not exceed the applicable income standard at 42 CFR 435.116

Income test methodA reasonable MAGI-based income estimate may be used to determine household income

Household size determinationGross income is used to determine household size (per screening tool guidance)

Provider Notification and Qualified Entities

Documentation Required

Notify Division within 5 working days and instruct applicant to file Medicaid application

The provider that determines presumptive eligibility must notify the Division within five (5) working days after the determination is made and must inform the woman at the time of determination that she must complete an application for Medicaid by not later than the last day of the month following the month during which the determination is made.

Notify the Division within five (5) working days of the presumptive eligibility determination.
Inform the applicant at the time of determination that she must file a full Medicaid application by the last day of the month following the month of the presumptive determination.

Prior Authorization

Use of Authorized Qualified Entities (per section 1920A) for Presumptive Eligibility

The state uses qualified entities, as defined in section 1920A of the Act, to make presumptive eligibility determinations for pregnant women; authorized entity types are listed and determinations must follow the section 1920A definition and requirements.

Key Definitions

inv-06: Qualified entity

DefinitionAn entity determined by the agency to be capable of making presumptive eligibility determinations based on an individual's household income and other requirements (per section 1920A of the Act).

Statutory basisDefined in section 1920A of the Social Security Act

Agency determinationEntity must be designated by the Division as capable of making presumptive eligibility determinations

inv-07: Presumptive eligibility period

Start of periodBegins on the date the presumptive eligibility determination is made

End — if application filedEnds on the date regular Medicaid eligibility is determined, if an application is filed by the last day of the month following the month of determination