42 USC 1396r-1a - Presumptive eligibility for children

U.S Code last checked for updates: Apr 24, 2025

§ 1396r–1a.

Presumptive eligibility for children

(a)

In general

(b)

Definitions; regulations

For purposes of this section:

(1)

The term “child” means an individual under 19 years of age.

(2)

The term “presumptive eligibility period” means, with respect to a child, the period that—

(A)

begins with the date on which a qualified entity determines, on the basis of preliminary information, that the family income of the child does not exceed the applicable income level of eligibility under the State plan, and

(B)

ends with (and includes) the earlier of—

(i)

the day on which a determination is made with respect to the eligibility of the child for medical assistance under the State plan, or

(ii)

in the case of a child on whose behalf an application is not filed by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.

(3)

(A)

Subject to subparagraph (B), the term “qualified entity” means any entity that—

(i)

(I)

is eligible for payments under a State plan approved under this subchapter and provides items and services described in subsection (a), (II) is authorized to determine eligibility of a child to participate in a Head Start program under the Head Start Act (42 U.S.C. 9831 et seq.), eligibility of a child to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 [42 U.S.C. 9857 et seq.], eligibility of an infant or child to receive assistance under the special supplemental nutrition program for women, infants, and children (WIC) under section 1786 of this title 1

 So in original. A comma probably should appear after “title”.

eligibility of a child for medical assistance under the State plan under this subchapter, or eligibility of a child for child health assistance under the program funded under subchapter XXI, (III) is an elementary school or secondary school, as such terms are defined in section 8801 of title 20,

(ii)

is determined by the State agency to be capable of making determinations of the type described in paragraph (2).

(B)

The Secretary may issue regulations further limiting those entities that may become qualified entities in order to prevent fraud and abuse and for other reasons.

(C)

Nothing in this section shall be construed as preventing a State from limiting the classes of entities that may become qualified entities, consistent with any limitations imposed under subparagraph (B).

(c)

Application for medical assistance; procedure upon determination of presumptive eligibility

(1)

The State agency shall provide qualified entities with—

(A)

such forms as are necessary for an application to be made on behalf of a child for medical assistance under the State plan, and

(B)

information on how to assist parents, guardians, and other persons in completing and filing such forms.

(2)

A qualified entity that determines under subsection (b)(2) that a child is presumptively eligible for medical assistance under a State plan shall—

(A)

notify the State agency of the determination within 5 working days after the date on which determination is made, and

(B)

inform the parent or custodian of the child at the time the determination is made that an application for medical assistance under the State plan is required to be made by not later than the last day of the month following the month during which the determination is made.

(3)

In the case of a child who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the parent, guardian, or other person shall make application on behalf of the child for medical assistance under such plan by not later than the last day of the month following the month during which the determination is made, which application may be the application used for the receipt of medical assistance by individuals described in section 1396a(l)(1) of this title.

(d)

Treatment of medical assistance

Notwithstanding any other provision of this subchapter, medical assistance for items and services described in subsection (a) that—

(1)

are furnished to a child—

(A)

during a presumptive eligibility period,

(B)

by an entity that is eligible for payments under the State plan; and

(2)

are included in the care and services covered by a State plan;

shall be treated as medical assistance provided by such plan for purposes of section 1396b of this title.

(Aug. 14, 1935, ch. 531, title XIX, § 1920A, as added Pub. L. 105–33, title IV, § 4912(a), Aug. 5, 1997, 111 Stat. 571; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title VI, § 608(r)], Nov. 29, 1999, 113 Stat. 1536, 1501A–397; Pub. L. 106–554, § 1(a)(6) [title VII, § 708], Dec. 21, 2000, 114 Stat. 2763, 2763A–577.)

cite as: 42 USC 1396r-1a