1. (Applicant) Completes Healthy Start Application (Medicaid Presumptive Eligibility) (Form 3089) at the qualified provider's office.
  2. (Provider) Completes Section III of Form 3089.
  3. (Provider) Unless the pregnant woman wants to apply for cash, SNAP, or assistance for her spouse, completes Form 2378MC and forwards it to the HFS Central All Kids Unit
  4. (Provider) If the pregnant woman wants to apply for cash, SNAP, or assistance for her spouse, calls the DHS Family Community Resource Center to schedule an appointment for an application interview. The interview must be before the last day of the month following the month of the MPE determination.
    1. Completes Notice of Instructions to Pregnant Applicant (Form 3090). The notice has general information and the appointment date for the application interview.
    2. Reviews the Checklist For the Applicant on reverse side of Form 3090 with the applicant.
    3. Tells the pregnant woman what documents to take with her to the appointment at the DHS Family Community Resource Center.
    4. Writes DHS in the upper right-hand corner of Form 3089.
    5. Distribute Form 3090: 
      • original to the woman,
      • copy in the provider's case file, and
      • copy to the Family Community Resource Center.

        NOTE: The provider must complete all the above actions on the same day that they find the woman qualifies for the MPE program.

  5. Distributes Form 3089:

    • original and one copy to the HFS Central All Kids Unit or DHS Family Community Resource Center, and
    • copy in file.

      NOTE: Form 3089 may be faxed or mailed. If faxed, the MPE provider must mail the original to the DHS Family Community Resource Center or HFS Central All Kids Unit within 5 workdays. 

  6. (FCRC/All Kids Unit) Receives Form 3089 and Form 3090 within 5 workdays from the date the provider found the woman MPE eligible.
  7. (FCRC/All Kids Unit) Contacts the Regional Office when there are continuing problems with a provider missing the deadlines.