1 Individuals above 133% FPL under Age 65 - Presumptive El

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

Medicaid and CHIP Program (MACPro)
S50a - Individuals above 133% FPL under Age 65
- Presumptive Eligibility RU PRA Document
Version 1.0
08/18/2017

Document Number: 221-QSSI-MACPro-R5.1-S50a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility
Screenshots ............................................................................................................. 1
1.1
1.2
1.3
1.4

Package Header ............................................................................................. 1
A. Presumptive Eligibility Period and B. Application for Presumptive Eligibility 2
C. Presumptive Eligibility Determination and D. Qualified Entities .................. 2
E. Additional Information (optional) ................................................................. 3

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A and Section B .................................................................................. 2
Figure 3 : Section C and Section D ................................................................................. 2
Figure 4 : Section E ......................................................................................................... 3

List of Tables
No table of figures entries found.

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
1.0
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08/18/2017

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Package Header

1. S50a - Individuals above 133% FPL under Age 65 Presumptive Eligibility Screenshots
1.1

Package Header

Figure 1: Package Header

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
1.0
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08/18/2017

CMS XLC

1.2

A. Presumptive Eligibility Period and B. Application for Presumptive Eligibility

A. Presumptive Eligibility Period and B. Application for
Presumptive Eligibility

Figure 2: Section A and Section B

1.3

C. Presumptive Eligibility Determination and D. Qualified Entities

Figure 3 : Section C and Section D

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
1.0
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08/18/2017

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1.4

E. Additional Information (optional)

E. Additional Information (optional)

Figure 4 : Section E

S50a - Individuals above 133% FPL under Age 65 - Presumptive Eligibility RU PRA Document Version
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