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Qualified Provider Presumptive Eligibility (PE)

The presumptive eligibility (PE) process allows qualified providers to make PE determinations for certain eligibility groups to receive temporary health coverage under the Indiana Health Coverage Programs (IHCP) until official eligibility is determined.

Note: For information about the PE process for individuals who are incarcerated, see the Presumptive Eligibility for Inmates page.


Presumptive Eligibility Process

An individual seeking presumptive eligibility works with a qualified provider to complete a PE application. The PE application is available through the IHCP Provider Healthcare Portal, 24 hours a day, 7 days a week. The qualified provider receives a real-time response as to whether the individual is eligible for PE. Information requested on the application includes an individual's demographic information, family size, and household income.

Individuals complete a PE application for each member in their families, regardless of a person's need for services when he or she applies. Each individual who desires to apply through the PE process must have his or her own application for enrollment. An individual is allowed to receive PE coverage only once per rolling 12-month period or per pregnancy. The individual receives temporary coverage reimbursed on a fee-for-service basis.

The individual maintains this PE coverage until one of the following occurs:

  • A member has not filed an Indiana Application for Health Coverage by the last day of the month following the month in which the PE period began.
     
  • A determination has been made on the individual's Indiana Application for Health Coverage. Members who qualify under the PE Adult category retain PE after they have been determined conditionally eligible for Healthy Indiana Plan (HIP) coverage pending payment of their Personal Wellness and Responsibility (POWER) Account contributions. This approach allows them to avoid a gap in coverage, as long as they meet required application and payment timelines.

PE Aid Categories and Benefit Plans

Individuals in the following aid categories are eligible for PE coverage:

  • Infants (up to age 1)
  • Children (ages 1–18)
  • Adults (ages 19-64) without Medicare
  • Parents/Caretakers
  • Former Foster Care Children (ages 19-26)
  • Pregnant Women
  • Family Planning (individuals eligible for family planning services only)

For specific requirements within each aid category (including income requirements, where applicable), see the Presumptive Eligibility provider reference module. The following table outlines coverage for qualifying individuals in these categories during their PE period.

PE Aid Category PE Benefit Plan Name Coverage Description
Infants

Presumptive Eligibility –
Package A Standard Plan

Coverage mirrors
Package A – Standard Plan
Children
Parents/Caretakers
Former Foster Care Children

Adults

Presumptive Eligibility – Adult

Coverage and copayment
obligations mirror HIP Basic

Pregnant Women

Presumptive Eligibility for
Pregnant Women (PEPW)

Coverage includes ambulatory
prenatal care only

Family Planning

Presumptive Eligibility
Family Planning Services Only

Coverage mirrors
Family Planning Eligibility Program

 


Enrolling as a Qualified Provider

The following table lists IHCP providers that can apply to become certified as qualified providers (QPs) for the PE process. As indicated, certain specialties are limited to making PE determinations for pregnant women only.

 

Eliigible Provider Provider Type, Specialty PE Determinations
Acute care hospital Type 01, specialty 010 All
Freestanding psychiatric hospital Type 01, specialty 011 All
Family practitioner Type 31, specialty 316 Pregnant women only
General practitioner Type 31, specialty 318 Pregnant women only
Obstetrician / gynecologist Type 31, specialty 328 Pregnant women only
General internist Type 31, specialty 344 Pregnant women only
General pediatrician Type 31, specialty 345 Pregnant women only
Federally qualified health center (FQHC) Type 08, specialty 080 All*
Rural health clinic (RHC) Type 08, specialty 081 All*
Medical clinic Type 08, specialty 082 Pregnant women only
Family planning clinic Type 08, specialty 083 Pregnant women only
Nurse practitioner (other, for example, clinical nurse specialist) Type 09, specialty 093 Pregnant women only
Certified nurse midwife Type 09, specialty 095 Pregnant women only
Community mental health center (CMHC)  Type 11, specialty 111 All*
County health department Type 13, specialty 130 All*

*Note:  FQHCs, RHCs, CMHCs, and county health departments have the option to be certified as PEPW QPs only, if they choose. Unless these providers are certified for the full PE process, they are limited to making PE determinations for pregnant women only.

To be eligible, the entity must:

  • Participate as a provider under the Indiana State Plan or under a demonstration program under Section 1115 of the Social Security Act.
  • Notify the Family and Social Services Administration (FSSA) of the provider's intention to make presumptive eligibility determinations.
  • Agree to make presumptive eligibility determinations consistent with State policies and procedures.
  • Guide individuals in the process for completing and submitting the Indiana Application for Health Coverage paperwork to the FSSA.
  • Complete and submit PE QP eligibility attestations through the PE enrollment process on the Provider Healthcare Portal.

Providers that wish to enroll as QPs for PE or PEPW receive training in the Portal.


More Information

More information on the PE process is available via the following links:

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