1 Presumptive Eligibility for Children under Age 19

Centers for Medicare & Medicaid
Services
CMS eXpedited Life Cycle (XLC)

Medicaid and CHIP Program (MACPro)
S16 - Presumptive Eligibility for Children under
Age 19 RU PRA Document
Version 1.0
08/16/2017

Document Number: 179-QSSI-MACPro-R5.1-S16-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S16 - Presumptive Eligibility for Children under Age 19 Screenshots ................ 1
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Package Header ............................................................................................. 1
A. Presumptive Eligibility Income Standard, B. Presumptive Eligibility Age
Limit and C. Presumptive Eligibility Period ...................................................... 2
D. Application for Presumptive Eligibility–Part 1.............................................. 3
D. Application for Presumptive Eligibility–Part 2 and E. Presumptive Eligibility
Determination .................................................................................................. 4
F. Qualified Entities ......................................................................................... 4
G. Additional Information (optional) ................................................................. 5

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A, Section B and Section C ................................................................. 2
Figure 3: Section D-Part 1 ............................................................................................... 3
Figure 4: Section D-Part 2 and Section E........................................................................ 4
Figure 5: Section F .......................................................................................................... 4
Figure 6: Section G ......................................................................................................... 5

List of Tables
No table of figures entries found.

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
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Package Header

1. S16 - Presumptive Eligibility for Children under Age 19
Screenshots
1.1

Package Header

Figure 1: Package Header

S16 - Presumptive Eligibility for Children under Age 19 RU PRA Document Version
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A. Presumptive Eligibility Income Standard, B. Presumptive Eligibility Age Limit and C. Presumptive Eligibility Period

A. Presumptive Eligibility Income Standard, B. Presumptive
Eligibility Age Limit and C. Presumptive Eligibility Period

Figure 2: Section A, Section B and Section C

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1.3

D. Application for Presumptive Eligibility–Part 1

D. Application for Presumptive Eligibility–Part 1

Figure 3: Section D-Part 1

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D. Application for Presumptive Eligibility–Part 2 and E. Presumptive Eligibility Determination

D. Application for Presumptive Eligibility–Part 2 and E.
Presumptive Eligibility Determination

Figure 4: Section D-Part 2 and Section E

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F. Qualified Entities

Figure 5: Section F

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G. Additional Information (optional)

G. Additional Information (optional)

Figure 6: Section G

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