Section DHS 103.11 - Presumptive eligibility for pregnant women and women diagnosed with breast or cervical cancer or precancerous conditions(1) REQUIREMENTS FOR PREGNANT WOMEN. Pregnant women may be determined presumptively eligible for MA on the basis of a statement of pregnancy, and preliminary household and financial information provided by the applicant. That determination shall be made by providers or hospitals designated by the department who are qualified in accordance with this section.(1e) PROVIDER REQUIREMENTS. A provider qualified to make determinations of presumptive eligibility for pregnant women, and women diagnosed with breast or cervical cancer or precancerous conditions shall meet the following requirements:(a) Be certified as an MA provider under ch. DHS 105.(b) Provide one or more of the following services:1. Outpatient hospital services.2. Rural health clinic services.3. Clinic services furnished by or under the direction of a physician.(c) Receive funding or participate in a program under:1. The migrant health center or community health center programs under section 330 of the public health service act.2. The maternal and child health services block grant programs.3. The special supplemental food program for women, infants and children under section 17 of the child nutrition act of 1966, 42 USC 1786.4. The commodity supplemental food program under section 4 (a) of the agriculture and consumer protection act of 1973.5. A state prenatal program.(d) Have been determined by the department to be a qualified provider under this section.(1m) REQUIREMENTS FOR WOMEN DIAGNOSED WITH BREAST OR CERVICAL CANCER OR PRECANCEROUS CONDITIONS. Women may be determined presumptively eligible for MA on the basis of a diagnosis of breast or cervical cancer or precancerous conditions if they meet the requirements in s. 49.473 (2) (a) to (e), Stats.(1s) HOSPITAL REQUIREMENTS. A hospital qualified to make determinations of presumptive eligibility for pregnant women, and women diagnosed with breast or cervical cancer or precancerous conditions shall meet all of the following requirements: (a) Be certified for MA as a general hospital under s. DHS 105.07.(b) Notify the state Medicaid agency of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations consistent with state policies and procedures.(c) Have not been disqualified by the department for failure to make presumptive eligibility determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the department.(2) DUTIES AND RESPONSIBILITIES. (a) A qualified provider or hospital shall ascertain presumptive MA eligibility for a pregnant woman or a woman diagnosed with breast or cervical cancer or precancerous conditions by: 1. Determining on the basis of preliminary information that the applicant's household or individual information meets the applicable non-financial requirements set by the department.2. Determining on the basis of preliminary information that the applicant's household or individual income meets the applicable income limits set by the department.(b) The provider or hospital shall inform the applicant, in writing, of the determination of presumptive eligibility.(bm) In the event that the provider or hospital determines that the applicant is presumptively eligible, the provider or applicant shall explain to the applicant that the presumptive eligibility is for a temporary enrollment period and to file an application for MA eligibility with the county department of social services.(c) Within 5 working days following the date on which the determination was made, the provider or hospital shall in writing notify the department of the applicant's presumptive eligibility.(d) In the event that the provider or hospital determines that the applicant is not presumptively eligible, the provider or hospital shall inform the applicant that he or she may file an application for MA eligibility at the county department of social services.Wis. Admin. Code Department of Health Services DHS 103.11
Cr. Register, February, 1988, No. 386, 3-1-88; correction in (1) (a) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.Amended by, CR 23-046: am. (title), (1) (title), renum. (1) (intro.) to (1) and am., renum. (1) (a) to (d) to be (1e) (a) to (d) and am., cr. (1e) (intro.), (1m), (1s), am. (2) (a), (b), cr. (2) (bm), am. (2) (c), (d); correction in (title) made under s. 13.92 (4) (b) 2, Stats., corrections in (1e) (b) (intro.), (c) (intro.), 5. made under s. 35.17, Stats., and corrections in (1e) (c) 1., 3., 4., (1m) made under s. 13.92 (4) (b) 7, Stats., Register April 29 No. 820, eff. 5/1/2024