Application for Presumptive Eligibility for Medicaid

Use this form to find out quickly if you qualify for presumptive eligibility for Medicaid

[State

information: State Medicaid program name]

. Presumptive eligibility offers you and your family

immediate access to health care while you apply for regular Medicaid or other health coverage.

To find out if you qualify for regular Medicaid or other health coverage, you must complete

[State

information: State single streamlined application]

. While you wait to learn if you qualify for regular

Medicaid or other health coverage, you can get your health services through presumptive eligibility

for Medicaid.

[State information: State instructions for how to apply for regular Medicaid and other health

coverage, e.g., online or via telephone or paper application.]

Who can qualify

for presumptive

eligibility for

Medicaid?

You can qualify for presumptive eligibility for Medicaid if you meet all of these rules:





Your income is below the monthly limit





You are a U.S. citizen, U.S. national, or eligible immigrant





You do not already have Medicaid





You have not had presumptive eligibility for Medicaid in the [State policy: Applicable

timeframe]. Or, if you are pregnant, you have not had presumptive eligibility for

Medicaid during this pregnancy.





You are in one of the groups that qualifies for presumptive eligibility for Medicaid:

• Children under [State policy: Applicable age]

• Parents and caretaker relatives

• Pregnant women

• [State policy: Other adults age 19-64]

• People under age 26 who were in foster care at age 18 (no income limit)

• [State policy: Women in treatment for breast and cervical cancer]

• [State policy: Women who need family planning services]

• [State policy: Any other populations]

Need help with

your application?

[State information: For example: “Ask your hospital representative or call us

at 1-800-XXX-XXXX. Para obtener una copia de este formulario en Español,

llame 1-800-XXX-XXXX. If you need help in a language other than English, call

1-800-XXX-XXXX and tell the customer service representative the language

you need. We’ll get you help at no cost to you. TTY users should call

1-800-XXX-XXXX.”.]

You can use this form to apply if you are a patient

of the hospital, a patient’s family member, or

a community member.

Tell us about your family

List yourself and the members of your immediate family who live with you. Include your spouse and your

children

under [State policy: Applicable age] if they live with you. Do not list other relatives or friends

even if they live with you.

Tell us about yourself

We ask for this information so that we can contact you about this application.

Name (ﬁrst, middle, last)

Home address (leave blank if you don’t have one)

City State ZIP code

Mailing address (if different from home address)

Phone number (if you have one) Email address (if you have one)

Name

(ﬁrst, middle, last)

Date of

birth

(XX/XX/

XXXX)

Relationship

to you

Applying for

presumptive eligibility

for Medicaid?

(Yes or No)

Already has

Medicaid?

(Yes or No)

[State policy: U.S. Citizen,

U.S. National, or eligible

immigrant?]

(Yes or No)

[State policy:

Resident of State?]

(Yes or No)

Answer for family members who are applying. If a person is not

applying, you do not have to answer these questions for that person.

(Same as above) (Self)

Questions? Ask your hospital representative or call us at 1-800-XXX-XXXX. The call is free.

(TTY: 1-888-XXX-XXXX). You can call [days and hours of operation]. Or visit [web address].

Tell us about your family’s income

Write the total income before taxes are taken out for all family members listed in Section 2.

 Job income For example, wages, salaries, and self-employment income.

Amount $................................................................... How often? (check one)



Weekly



Biweekly



Monthly



Yearly

 Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration

(“SSDI”). Do not include Supplemental Security Income (“SSI payments”) or any child support you receive.

Amount $................................................................... How often? (check one)



Weekly



Biweekly



Monthly



Yearly

Sign this form here

By signing, you are swearing that everything you wrote on this form is true as far as you know.

We will keep your information secure and private.

Your signature: Date:

Other questions

Answer these questions for yourself and your family members listed in Section 2. Your answers will make it

easier to ﬁnd out if you and any family members qualify.

Is anyone pregnant, [State policy: even if she is not applying for presumptive eligibility for Medicaid]?



Yes



If yes, who? .............................................................................................................................................. How many babies does she expect? ...................................................

[State policy: Is anyone who is applying for presumptive eligibility for Medicaid receiving Medicare?]



Yes



If yes, who? .....................................................................................................................................................................................................................................................................................

Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative?



Yes



For example, a grandparent who is the main person taking care of a child.

If yes, who? .....................................................................................................................................................................................................................................................................................

Was anyone who is applying for presumptive eligibility for Medicaid in foster care at age 18 [State policy: Or

applicable older age]?



Yes



If yes, who? .....................................................................................................................................................................................................................................................................................

[State policy: Is anyone who is applying for presumptive eligibility for Medicaid being treated for



Yes



breast or cervical cancer?]

If yes, who? .....................................................................................................................................................................................................................................................................................

Questions? Ask your hospital representative or call us at 1-800-XXX-XXXX. The call is free.

(TTY: 1-888-XXX-XXXX). You can call [days and hours of operation]. Or visit [web address].

If you qualify for presumptive eligibility for Medicaid, what

happens next?

 You will get a notice from the hospital saying you were approved.

 You can start using your presumptive eligibility for Medicaid coverage right away for Medicaid covered

services such as doctor visits, hospital care, and some prescription drugs. You can go to any health care provider

who accepts Medicaid, starting the day you are approved.

• To start using your presumptive eligibility for Medicaid, [State information: State-specific directions. For

example, “The hospital will give you a notice saying you are approved. Use the notice to get services until

you get a card in the mail. The card should arrive within X days.”] If you lose the notice, you can call [State

information: Relevant instructions].

• If the notice says you qualify for presumptive eligibility for Medicaid because you are pregnant, you can get

care at outpatient clinics or other places in the community. Presumptive eligibility for Medicaid will not cover

the cost if you are admitted to a hospital.

• If the notice says you qualify for presumptive eligibility for Medicaid for family planning services, you are only

covered for those services.

 If you do not fill out and send the [State information: State single streamlined application] to see if you qualify for

regular Medicaid or other health coverage, your presumptive eligibility for Medicaid coverage will end on the last

day of the month after the month you are approved.

¨ For example, if you qualified for presumptive eligibility for Medicaid in January, it will end on the last day

of February.

 To see if you qualify for regular Medicaid or other health coverage, [State information: State instructions

for how to apply for regular Medicaid and other health coverage, e.g., online or via telephone or paper

application.]. The hospital will provide you with an application.

If you do not qualify for presumptive eligibility for Medicaid,

what happens next?

You will get a notice from the hospital saying you were not approved. You cannot appeal the hospital’s decision.

BUT, you can still apply for regular Medicaid or other health coverage using the [State information: State single

streamlined application].

Questions? Ask your hospital representative or call us at 1-800-XXX-XXXX. The call is free.

(TTY: 1-888-XXX-XXXX). You can call [days and hours of operation]. Or visit [web address].