Form Doh 4441 – Fill Out and Use This PDF

1. NAME OF

PRESUMPTIVE SCREENING DATE

Application Site

PARENT/GUARDIAN:

LAST

FIRST

M.I.

/

/

20____

HOME PHONE (INCLUDE AREA CODE)

County of

Residence

Address

(

)

Authorization

Approval

CONTACT/ MESSAGE NUMBER

Number/Name

(

)

2. Child(ren)’s Name(s)

DOB

Sex

Social Security Number

Please read the following to all being

screened: To get Medicaid for

anything other than an emergency, a

person must be a US citizen or be in

satisfactory immigration status. If the

person is undocumented or a

temporary non-immigrant, he or she

can only get Medicaid for the

treatment of an emergency medical

condition, if otherwise eligible.

A. Are all children being screened U.S. citizens? Yes No

B. If no, Satisfactory Immigration Status? Yes No

Please list any children who are not citizens and do not have satisfactory immigration status:

3. HEALTH INSURANCE

Do any children above have or have recently applied for : Medicaid

Yes

Medicare Yes

Child Health Plus Yes

If YES, who:

Place & estimated date of application if not yet active:

Does anyone have other health insurance? Yes No

Name of Subscriber/Policy Holder:

Relationship to Child(ren)

Insurance Company Name:

If

YES

Group/Policy #

Child(ren) Covered:

3.A. Monthly Premium Cost paid by child or parent/guardian

$ __________________________

4. Family Size:

5. a. Household’s monthly gross total income (no deductions) a. $ _____________

Enter # of parent(s) of applying child(ren) who

(Include wages, tips, commissions, social security, child support, alimony,

are living in the household:

_______

unemployment benefits, worker’s compensation, disability payments, etc. Do not include

Note: Pregnant woman = 2 (Preg Woman + Unborn)

wages, grants, or loans of students or any Public Assistance or SSI payments)

Note: Enter 1 if child is not living with a parent but with a

b. Deductions allowed (Monthly)

caretaker relative who will also be applying for MA

(i.e.grandparent, aunt, uncle, adult sibling, etc.)

$90 from earned income only

$ ______________

Enter number of children who live in applying

child’s household who are under age 21

+

_______

Child care expenses from employment

(including applying child)

($175.00 maximum per child age 2 or over;

$200.00 maximum per child under age 2)

_______________

4. a. Total # in HH

_______

$50 per household from child support/alimony received

_______________

6. Compare Net Monthly Income (5c) for Family

Health Insurance premium cost paid by HH (3a)

+ _______________

Size (4a) to Current Monthly Income Levels

(see chart)

Total Deductions……………………………

b. $ _______________

Net Monthly Income is:

9 Less than 133% poverty

Net Monthly Income (a minus b)

5.c. $ ______________

Children age 1 through 5

9 Less than 100% poverty

Is Net Monthly Income Less than appropriate Poverty Level standard?

Children age 6 through 18

YES

Eligible for Presumptive; List Name(s):

9Less than 200% poverty

Infant under age 1

NO Ineligible for Presumptive; List Name(s):

Ineligible for anything other than the treatment of an emergency medical condition; cannot have presumptive eligibility; List Name(s) : If INELIGIBLE, Make referral to State Child Health Plus Program (see number below)

7. QUALIFIED NAME	PHONE NUMBER
PROVIDER
ADDRESS	SIGNATURE

If ELIGIBLE, submit to Appropriate Local Department of Social Services with Medicaid application within 21 days.

If INELIGIBLE, Make referral to State Child Health Plus Program.

Call 1-800-698-4KIDS (1-800-698-4543) or refer to a Facilitated Enroller

____________________________________________________________________________________________________________________

DOH-4441 (01/08) Page 1 of 2

Instructions for Completing PE for Children Screening Form

Section 1:

ƒName: List name of parent(s)/guardian(s) of the applying child(ren)

ƒAddress: List the address where the child(ren) live(s) including house number, street name, apt number, city, and zip code

ƒCounty of Residence: Enter county in which above address is located

ƒPresumptive Screening Date: List today’s date

ƒHome Phone / Contact/Message Number: Enter home, contact/message number

ƒApplication Site: List the name of the Qualified Entity Site

ƒAuthorization Number/Name: Call NYSDOH to obtain authorization number for children who screen eligible. Document the name of the person who provided you with the number.

Section 2:

ƒChild(ren)’s Names: List all children who are being screened for PE for Children

ƒEnter SSN (if known), SSN or proof of application for SSN will have to be provided for full Medicaid determination

ƒA/B: Citizenship/Immigration Status: Check boxes as appropriate. Explain that Medicaid is available to people who are US Citizens or have satisfactory immigration status. Others may receive treatment only for an emergency medical condition. If unsure of the child(ren)’s status, ask if they have any of the following: a Green Card, a Passport, a Visa or any other document that allows them to stay here indefinitely. Also ask if they are working with immigration services to get permanent status.

Section 3:

ƒHealth Insurance: Complete as much information as known. Inquire about recent applications for Child Health Plus, Medicaid, and Family Health Plus. If yes, indicate when and where the application was taken.

Section 4:

ƒFamily Size: Enter numbers to identify number of persons living in the household. If the mother of the applying child is pregnant, count as 2 (mom plus the unborn child). Count the legal spouse and/or father of the child, if they live in the household. Count 1 for Caretaker Relative (if no parents live in the household) and if they will also be applying for Medicaid. Count all of the children under age 21 in the household whether or not they are applying. Do not count persons who receive Temporary Cash Assistance or SSI cash assistance. Total number of household members will be recorded on line 4.a.

Section 5:

ƒIncome: On line 5a. enter the total amount of the monthly gross (before taxes and deductions) household income. Verification is not required for PE. Weekly wages are converted to monthly by multiplying by 4.3333. Do not count grants, loans, student’s wages, Temporary Cash Assistance or SSI Cash Assistance. Enter caretaker relative’s income if they are in the household count and are applying for MA. Enter monthly amounts as allowed in b. Child care expenses may be deducted only if parent/guardian is employed. Only one $50 deduction per household is allowed if anyone (or more than one person) in the HH receives child support payments. Enter the total monthly premium paid out for health insurance premiums. Add deductions and enter on line 5.b. The Net Monthly Income amount, entered on line 5.c., is the figure that results when the total allowable deductions (line 5b) is subtracted from the household gross income (line 5a).

Section 6:

ƒCompare the net monthly income with the income standards chart for the appropriate household size (4.a.) and percentage of the Federal Poverty Level for the age of each child. If the child(ren) is found to be eligible, the corresponding box(es) is checked, the child(ren)’s name(s) is listed and a Presumptive Eligibility Screening Determination letter is given to the applying parent or guardian with the names of the children who are Presumptively Eligible for Medicaid. This letter advises households of next steps to take to apply for ongoing Medicaid. This completed screening form, an accompanying Medicaid application, determination letter and all documentation are forwarded to the appropriate county Local Department of Social Services (LDSS) within 21 days for further review and a determination for ongoing Medicaid.

ƒIf any child applying is ineligible, list the name of the child(ren) that is ineligible and refer to the phone numbers at the bottom of the screening sheet for information on applying for Child Health Plus, and/or refer to the nearest Facilitated Enroller for application assistance. If all children on the screening are ineligible, do not send the PE screening form to the LDSS, but retain copies in a locked, secure area.

Section 7:

Qualified Provider must enter their name, address, telephone number, and sign the bottom of the form.

____________________________________________________________________________________________________________________

DOH-4441 (01/08) Page 2 of 2