151-E:18 Presumptive Eligibility. –
I. The commissioner of the department shall establish a presumptive eligibility program to prevent unnecessary and costly institutionalization of individuals who are Medicaid eligible for nursing facility services and choose to receive services in less restrictive settings.
II. Pending verification of application information, the department shall authorize medical assistance in the interval between application and the final Medicaid eligibility determination if the department determines the applicant is likely to be eligible. Presumptive eligibility shall be made available at department district offices, information and referral resource centers, and other qualified providers. The presumptive eligibility period shall not include coverage of home or environmental modifications.
III. Presumptive eligibility authorizations shall be dependent upon a face-to-face clinical assessment of each applicant and review of a completed Medicaid application. The department shall perform the face-to-face clinical assessment within 20 business days of a request for medical assistance. The department shall review the application for presumptive eligibility within 5 business days of completion of the Medicaid application and clinical assessment.
IV. The presumptive eligibility period begins on the date the department determines the applicant likely meets the eligibility criteria and ends on the date eligibility is verified or the individual is determined ineligible.
V. The Medicaid applicant shall acknowledge in writing the uncertainty of continuing service coverage beyond the presumptive eligibility period and the potential for financial responsibility for costs incurred in the event of a determination of Medicaid ineligibility.
VI. If an applicant is determined ineligible for Medicaid, the department shall promptly notify the applicant and the applicant's providers of the finding and the immediate termination of service coverage authorization. In such a case, the department shall use non-Medicaid funds to pay for any waiver services which the applicant has already received. In the event an application was filed with fraudulent intent, the department shall be entitled to reimbursement of funds expended on behalf of the applicant.
VII. The commissioner of the department shall adopt rules, pursuant to RSA 541-A, relative to:
(a) A process to determine presumptive eligibility.
(b) A definition of a qualified provider.
(c) Content and format of forms required under this section.