1 Individuals Eligible for Family Planning Services - Pres

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

Medicaid and CHIP Program (MACPro)
S59a - Individuals Eligible for Family Planning
Services - Presumptive Eligibility RU PRA
Document
Version 1.0
08/20/2017

Document Number: 229-QSSI-MACPro-R5.1-S59a-D
Contract Number: HHSM-500-2007-00024I: HHSM-500-T0014

CMS XLC

Table of Contents

Table of Contents
1. S59a - Individuals Eligible for Family Planning Services - Presumptive
Eligibility Screenshots ............................................................................................ 1
1.1
1.2
1.3
1.4
1.5
1.6

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

List of Figures
Figure 1: Package Header .............................................................................................. 1
Figure 2: Section A .......................................................................................................... 1
Figure 3: Section B – Screenshot 1 ................................................................................. 2
Figure 4: Section B – Screenshot 2 ................................................................................. 2
Figure 5 : Section C and Section D ................................................................................. 3
Figure 6 : Section E ......................................................................................................... 3

List of Tables
No table of figures entries found.

S59a - Individuals Eligible for Family Planning Services - Presumptive Eligibility RU PRA Document Version
1.0
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08/20/2017

CMS XLC

Package Header

1. S59a - Individuals Eligible for Family Planning Services
- Presumptive Eligibility Screenshots
1.1

Package Header

Figure 1: Package Header

1.2

A. Presumptive Eligibility Period

Figure 2: Section A

S59a - Individuals Eligible for Family Planning Services - Presumptive Eligibility RU PRA Document Version
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1.3

B. Application for Presumptive Eligibility – Screenshot 1.

B. Application for Presumptive Eligibility – Screenshot 1.

Figure 3: Section B – Screenshot 1

1.4

B. Application for Presumptive Eligibility – Screenshot 2

Figure 4: Section B – Screenshot 2

S59a - Individuals Eligible for Family Planning Services - Presumptive Eligibility RU PRA Document Version
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08/20/2017

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1.5

C. Presumptive Eligibility Determination and D. Qualified Entities

C. Presumptive Eligibility Determination and D. Qualified Entities

Figure 5 : Section C and Section D

1.6

E. Additional Information (optional)

Figure 6 : Section E

S59a - Individuals Eligible for Family Planning Services - Presumptive Eligibility RU PRA Document Version
1.0
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08/20/2017