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Presumptive Eligibility

Overview

Presumptive eligibility (PE) is a process that offers short-term coverage of health care services for those with limited incomes who are not currently receiving Medicaid. The goal of PE is to make sure that those who appear eligible, based on basic information, have immediate access to health care. Your short-term coverage will end if you do not complete an Indiana Application for Health Coverage or are found to be ineligible based upon your full application.

Below are many answers to popular questions:

Who Can Get PE Coverage?

You can get PE coverage if you are not currently receiving Indiana Medicaid coverage. The following groups of individuals may qualify for PE:

  • Parents/Caretakers
  • Infants
  • Children
  • Adults
  • Pregnant Women
  • Former Foster Children

You must live in Indiana, and your family income must be below a certain amount. In order to continue your coverage beyond the temporary PE timeframe, you will need to complete a full Indiana Application for Health Coverage as soon as possible.

How Much Income Can I Have And Qualify For PE?

The income requirements for temporary PE coverage are the same as those for Medicaid coverage. The amount of income you can make depends upon how many people are in your family. See the Eligibility Guide for current guidelines.

How does the PE Process Work?

You will be asked a few questions at the hospital, clinic, or doctor's office. You should be prepared to provide the following information:

  • Name
  • Home address
  • Phone number
  • Date of birth
  • Social Security number
  • Family size
  • Amount of monthly/annual income

You will also be asked a few additional questions to identify the coverage for which you qualify. Based on the information you provide, a PE determination will be made immediately, and an eligibility letter is generated. The letter has a start and end date for your coverage until your full Indiana Application for Health Coverage is submitted and processed.

How Does This Process Differ for Pregnant Women?

If you are pregnant and qualify for PE coverage, you may be asked to select a health plan during the application process. The intent is for you to receive prenatal care as quickly as possible.

How Does This Process Differ For Adults?

If you are found presumptively eligible for the Healthy Indiana Plan (HIP), the hospital or clinic will ask you to select a health plan Your health plan will send you a letter in the mail requesting a $10 "fast track" payment to get your full coverage effective faster. If you pay this $10 and complete your Indiana Application for Health Coverage, your full coverage with HIP will begin sooner without a gap in coverage. While this payment is optional, you are encouraged to pay it so that you can begin receiving your full benefits sooner. If you would like more information about HIP, you should refer to the Healthy Indiana Plan website.

What is Covered During Presumptive Eligibility

Your temporary coverage will depend upon your situation:

  • If you qualify as a parent/caretaker, infant, child, or former foster child, you will be eligible for all services covered under Hoosier Healthwise Package A. If you would like more information about the services covered, you should refer to What Is Covered By Hoosier Healthwise.
  • If you qualify as a pregnant woman, you will be eligible for doctor visits, tests, lab work, and other care for your pregnancy. You will also have coverage for prescription drugs, and transportation services to doctor appointments. This will not cover labor and delivery costs.
  • If you qualify for family planning coverage, you will only be eligible for services covered by the Family Planning Eligibility Program. These services include family planning visits, laboratory tests, pap smears, condoms, and birth control. If you would like more information about the services covered, you should refer to the Family Planning Eligibility Program.
  • If you qualify for HIP, you will be eligible for services covered under the HIP Basic Plan. You will be required to pay copays for all services. If you'd like to learn more about the services covered under HIP Basic, you should refer to the Healthy Indiana Plan website.

I Have PE, But What's Next?

Approval for PE is NOT the same as being approved for Medicaid. Your PE coverage is only temporary while you submit a Medicaid application and your Medicaid application is pending. Your PE will end if you do not apply for Medicaid by end of the next month.

It is very important that you respond promptly to all requests regarding your Medicaid application. If you do not respond to our questions and requests for documentation, your application will not be processed. You will not be eligible for Medicaid coverage, and you will be responsible for paying all of your health care costs after your PE period has ended.

How Can I Complete the Full Application?

The PE application is NOT a full Medicaid application; it provides only temporary coverage. You should complete a full application as soon as possible to make sure you do not lose any benefits. You can submit a full application in a number of ways:

  • At the provider where you were found presumptively eligible
  • Online
  • Over the phone at 1-800-403-0864
  • At a Division of Family Resources (DFR) local office.

Who Can Participate?

PEPW is for pregnant women who are not currently receiving Medicaid. In addition, your family income must be below a certain amount. If you are pregnant and think you will need help from Medicaid, you should contact your doctor or clinic and ask for help applying for PEPW and Medicaid.

PEPW is not for women who already have Medicaid or who do not live in Indiana.

Why Should I Submit a Medicaid Application?

Approval for Presumptive Eligibility for Pregnant Women (PEPW) is NOT the same as being approved for Medicaid. Your PEPW coverage is only temporary while you submit a Medicaid application and your Medicaid application is pending. Your PEPW will be discontinued if you do not apply for Medicaid by the last day of the month following the month your PEPW was established.

It is very important that you respond promptly to all requests from the State regarding your Medicaid application process following your submission of a Medicaid application. If you do not apply and respond, you will not be eligible for Medicaid coverage, and you will be responsible for paying all of your labor and delivery costs.

Many health care services are not covered under PEPW. If you do not begin the Medicaid application process, you will lose your PEPW and be responsible for the cost of the care when you are admitted to the hospital, including labor and delivery, and any services that are not for your pregnancy or for the health of your baby. The costs of your continuing prenatal care, as well as labor and delivery, will only be covered if your Medicaid application is submitted and approved.

For your health and the health of your baby, take the next step and complete the Medicaid application process right away. The same doctor's office or clinic that helped you with your PEPW determination can help in filling out and submitting your Medicaid application.

How Much Income Can I Have and Still Qualify?

This depends on how many people are in your family. Count yourself, your unborn baby, your spouse, and the children who live with you. If you are under 19, count yourself, your unborn baby, your parents, and siblings if they live with you. These income guidelines are effective March 1, 2015.

Family Size:

Maximum Monthly Income:

Maximum Annual Income:

2

$2,828

$33,931

3

$3,566

$42,792

4

$4,305

$51,653

5

$5,043

$60,513

How Can I Find a Designated Clinic or Doctor in my Area?

Please call us at 1-800-889-9949. You may also visit use the Provider Search for a list of locations near you.

Note: When searching for a provider, you have the option to search only the providers in your area who are approved PEPW providers. This will help you to determine where you should go for services.

Presumptive Eligibility for Pregnant Women Brochure

Take this information with you! You can print out the attached PEPW brochure and have all of the critical PEPW process information to take with you.

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