Presumptive eligibility for Medicaid

On March 16, 2020, Gov. Ralph DLG Torres declared a State of Public Health Emergency for the CNMI due to the imminent threat of COVID-19. Due to the PHE, the Commonwealth Medicaid Agency designated the Commonwealth Healthcare Corp. as a qualified entity to make presumptive eligibility determinations for all uninsured individuals and individuals whose attested gross income does not exceed 180% of the SSI federal benefit rate. The effective date is when CHCC makes a presumptive eligibility determination that a patient meets qualifications, which is not earlier than March 18, 2020, for the uninsured and April 1, 2020, for those meeting the income eligibility. The CHCC is Medicaid’s primary provider of all medical and public health services, both inpatient and outpatient (Public Law 21-28).

It is important to note that as long as the PHE is declared and in existence, presumptive eligibility will be available and we are encouraging the community to access the care they need as it is unknown to when this declaration will end.

What is presumptive eligibility?

Presumptive Eligibility is an expedited process of enrolling eligible residents into the CNMI Medicaid program. It allows patients to have their care covered while waiting for their application to be fully processed.

Who can apply?

PE is not limited to patients. The CHCC is assisting with PE determinations for family members of patients as well.

What are the requirements?

Eligibility for CNMI residents is based primarily on age, household size, and income.

What are the covered services under PE?

PE eligible individuals receive the same benefits as a standard covered enrollee in the Medicaid program. Some examples include, inpatient and outpatient services, prescribed drugs, dental services, physical therapy, and more. PE does not apply to services received prior to the Public Health Emergency.

How long is Presumptive Eligibility effective?

PE is a temporary coverage provided by Medicaid for those who are currently uninsured. PE coverage lasts until the earlier of the end of the PHE, or if a full Medicaid application is submitted prior to the end of the PE period, the date an eligibility determination is made on that application.

Are there any co-pays required for PE clients?

No, just like standard enrollees of the CNMI Medicaid program, there are no co-pays required if you are determined eligible for PE.

How long will coverage last?

PE coverage ends at either at the end of the Public Health Emergency or if a full Medicaid application is submitted prior to the end of the PE period, the date when an eligibility determination is made on that application, whichever is earlier.

Do I need to provide verifications?

No, there will not be any supporting documents needed, except for proof of identification.

Will this cover any of my bills for services received prior to the PHE?

No, this will not cover any medical expenses incurred prior to the PHE. Although, we are able to assist with payment plans, if needed.

If I’m determined as PE-eligible but I have outstanding bills prior to the eligibility date, will that affect my ability to access services as CHCC?

No. PE Determination at CHCC is aimed to increase your access to CHCC services during the Public Health Emergency and prior bills will not affect such access.

For more information about the CNMI Medicaid program, call (670) 664-4880. For information about P.L. 21-28, visit http://www.cnmilaw.org/pdf/public_laws/21/pl21-28.pdf. (PR)