Presumptive Eligibility Application PROVIDER INSTRUCTIONS DETACH THIS INSTRUCTION SHEET. THESE INSTRUCTIONS WILL GUIDE YOU THROUGH THE PRESUMPTIVE ELIGIBILITY (PE) PROCESS: FORMS and materials needed to determine PE: 1.003 MA 332 - PE Application 2.003 Provider Instructions 3.003 Desk Guide to Tax Household Size, of the Presumptive Eligibility for Pregnant Women Medical Assistance (MA) Bulletin 4.003 2014 Income Limit for Pregnant Women of the Presumptive Eligibility for Pregnant Women MA Bulletin or subsequent Federal Poverty Level (FPL) updates. 5.003 PA 600HC - Application for Health Care Coverage - if applicant wants to apply for ongoing MA. WHEN APPLICATION SHOULD BE MADE a patient with a self-attested pregnancy requests assistance in paying the medical expenses associated with her pregnancy. The provider must encourage and assist the PE applicant in completing the Application for Health Care Coverage (PA 600HC) if the applicant wants to apply for ongoing MA. The provider must inform the PE applicant that applying for ongoing MA is not withdraw the ongoing MA application. PLEASE NOTE: Only one period of PE is permitted per individual per pregnancy. ELIGIBILITY DETERMINATION must assist the applicant in completing the designated sections of the PA 600HC. The CAO will contact the applicant to request day of the month following the month the PE determination is made, or the date ongoing eligibility is determined, whichever is earlier. The CAO will send a notice of eligibility to the provider and the applicant for PE. INSTRUCTIONS FOR COMPLETING THE MA 332 Please follow the instructions for completing the PE Application. The CAO will not be able to process the PE Application if the PART A - TO BE COMPLETED BY THE APPLICANT AND REVIEWED BY THE QUALIFIED PROVIDER. The provider may assist the applicant in completing this section if necessary. PE APPLICANT NAME: ADDRESS:003 Applicant222s home address DATE OF BIRTH: Applicant222s date of birth COUNTY OF RESIDENCE: County where the applicant resides SOCIAL SECURITY NUMBER: Applicant222s Social Security number is optional for PE PHONE NUMBER: Number where the applicant can be contacted (including area code) INCOME: Applicant222s income source, type, frequency and gross amount before deductions. HOUSEHOLD: List all of applicant222s tax household members, their date of birth, sex and income. See Desk Guide to Tax Household Size, of the Presumptive Eligibility for Pregnant Women MA Bulletin. i American LegalNet, Inc. www.FormsWorkFlow.com Presumptive Eligibility Application002 INSTRUCTIONS FOR COMPLETING THE MA 332 (continued) QUESTION 1: If the applicant answers yes to this question, check the appropriate block in Part B, #4 and refer to instructions 223FOR THE INELIGIBLE APPLICANT.224 Ask to see the applicant222s MA ACCESS card. Check the Eligibility may bill for covered services. QUESTION 2: If the applicant answers no to this question, check the appropriate block in Part B, #4 and refer to instructions 223FOR THE INELIGIBLE APPLICANT.224 Refer the applicant to the CAO in her county of residence for assistance. QUESTION 3: no to this question, check the appropriate block in Part B, #4 and refer to instructions 223FOR THE INELIGIBLE APPLICANT.224 Refer the applicant to the CAO in her county of residence for assistance. QUESTION 4: a. If yes, list the total monthly tax deductions. SIGNATURE: Applicant or applicant222s representative must sign the application form. DATE: Date the application was completed. PART B - TO BE COMPLETED BY THE QUALIFIED PROVIDER. QUESTION 1:003 If no, check #4 and the appropriate reason line and follow instructions in the section 223FOR THE INELIGIBLE APPLICANT.224 QUESTION 2:003 Indicate the expected delivery date. INCOME ELIGIBILITY To determine if the applicant is income eligible, complete the 223Comparison of Household Income to Income Limit224 chart. Take the applicant222s gross monthly income indicated in Part A, #5, and subtract the tax deductions indicated in Part A, #6. From the percent disregard and FPL monthly income limit, see 2014 Income Limits for Pregnant Women, of the Presumptive Eligibility for Pregnant Women MA Bulletin or subsequent FPL updates. Compare the household222s net monthly income to the applicable FPL monthly income limit. QUESTION 3:003 The applicant is presumptively eligible. Check here if the household222s total monthly income is equal to or less than a224 to indicate that a completed PA 600HC is attached. QUESTION 4:003 The applicant is not presumptively eligible. Check here if the household222s total monthly income is greater than CHECK THE APPROPRIATE REASON LINE. Type or print the provider name, address, telephone number and MA ID number. Enter PE begin date. The date should be the same as the date PE eligibility is determined. Sign and date Part B of the application. The application may be signed by the attending physician, clinic director, or designee. FOR THE ELIGIBLE APPLICANT 1. If the applicant is applying for ongoing MA, have the applicant complete all sections of the PA 600HC. 225 Pages 11 - 13: Have applicant read and review the Rights and Responsibilities. 225 Page 13: Have applicant sign and date the application. Note:ii American LegalNet, Inc. www.FormsWorkFlow.com Presumptive Eligibility Application002 INSTRUCTIONS FOR COMPLETING THE MA 332 (continued) 2. Distribute the MA 332 as follows:the applicant222s county of residence. If applying for ongoing MA, staple the MA 332 to the PA 600HC and mail both to the for Pregnant Women MA Bulletin for a link to the appropriate CAO address. FOR THE INELIGIBLE APPLICANT 1. Distribute the MA 332 as follows:applicant resides. iii American LegalNet, Inc. www.FormsWorkFlow.com THIS PAGE 002INTENTIONALLY 002BLANK002 American LegalNet, Inc. www.FormsWorkFlow.com Presumptive Eligibility Application PART A - TO BE COMPLETED BY APPLICANT OR APPLICANT222S REPRESENTATIVE TELL US ABOUT THE PE APPLICANT AND THE APPLICANT222S TAX HOUSEHOLD MEMBERS PE APPLICANT LAST NAME FIRST NAME M.I. ADDRESS DATE OF BIRTH COUNTY OF RESIDENCE SOCIAL SECURITY NUMBER (OPTIONAL) TELEPHONE NUMBER PE APPLICANT222S TYPE AND SOURCE OF INCOME* HOW OFTEN IS INCOME RECEIVED? (WEEKLY, BIWEEKLY, MONTHLY) GROSS AMOUNT OF INCOME (AMOUNT BEFORE TAXES AND DEDUCTIONS) LIST PE APPLICANT222S TAX HOUSEHOLD MEMBERS002 NAME (First, middle initial, last) Date of Does this person have income? Type of income and source* How often is the income received (Weekly, biweekly, monthly)? Gross amount of income (Amount before deductions and taxes) How is this person related to the PE applicant? Person 2 Person 3 Person 4 Person 5 Person 6 * Income includes wages, salaries, tips, commissions, bonuses, self-employment, alimony, Social Security* other than SSI, Unemployment Compensation, lump individual has no other income.002 If you have additional household members, please list them on a separate sheet of paper and attach to the MA 332.002 QUESTIONS FOR THE PE APPLICANT: 1. Do you have a current Medical Assistance (MA) ACCESS Card? Yes No 2. Are you a resident of Pennsylvania? Yes No Yes No Yes No a. If yes, does the tax household have any of the following tax deductions on their Federal Tax Form 1040? 225 Student loan interest deduction 225 Educator expenses 225 Job-related moving expenses 225 Health savings account deduction 225 Alimony paid 225 IRA deduction 225 Penalty on early withdrawal of savings 225 Tuition and fees 225 Certain business expenses of reservists, 225 Deductible part of self-employment tax performing artists and free-basis 225 Self-employed health insurance deduction Type: Amount: Type: Amount: Type: Amount: Type: Amount: To the best of my knowledge, the above information is correct. SIGNATURE - APPLICANT OR REPRESENTATIVE DATE Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Presumptive Eligibility Application PART B - TO BE COMPLETED BY QUALIFIED PROVIDER 1. Is applicant pregnant? Yes No 2. Expected date of delivery: COMPARISON OF HOUSEHOLD INCOME TO INCOME LIMIT (Use applicable annual FPL.) (include unborn child(ren)) Gross Monthly Income -Tax Deductions Monthly Income After Deductions -5% FPL Disregard* Net Income F