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. The eligibility groups and qualified provider types are listed below.
|Qualified Providers (QPs)*||
*QPs for PE for low-income pregnant women only. Other QPs can make PE determinations for all applicable eligibility groups.
NOTE: A presumptive eligibility process exists for inmates. For more information see the Presumptive Eligibility for Inmates web 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 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, and only once per pregnancy.
The individual receives temporary coverage reimbursed on a fee-for-service basis, except for individuals qualifying under the PE Adult category. These individuals are enrolled with a managed care entity (MCE) selected during the PE application process. Qualifying individuals are covered under the following benefit plans during their PE period:
- Presumptively eligible infants, children, parents/caretakers, and former foster care children are covered under the Presumptive Eligibility - Package A Standard Plan benefit plan.
- Presumptively eligible pregnant women are covered for ambulatory prenatal care benefits under the Presumptive Eligibility for Pregnant Women benefit plan.
- Individuals presumptively eligible for family planning services only are covered under the Presumptive Eligibility Family Planning Services Only benefit plan.
- Presumptively eligible adults are covered under the Presumptive Eligibility - Adult benefit plan (which mirrors the HIP Basic benefit plan) and have copayment obligations.
After enrollment, the individual maintains 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 time lines.
Enrolling as a Qualified Provider
Hospitals, CMHCs, RHCs, FQHCs, and local health departments are eligible to enroll as PE QPs to make PE determinations for all applicable eligibility groups. Advanced practice nurse practitioners, family/general practitioners, certified nurse midwives, general internists, OB-GYNs, general pediatricians, medical clinics, and family planning clinics are eligible to make PE determinations for low-income 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 PE QPs receive training in the Portal. During the training, the entities also receive a printed copy of the PE Process Guide.
More information on the PE process is available via the following links:
- Presumptive Eligibility Presentation
- IHCP Presumptive Eligibility (PE) Standards
- Presumptive Eligibility FAQs web page
- Presumptive Eligibility provider reference module
- Sample PE adult approval letter
- Sample PE child approval letter
- Sample PE for pregnant women approval letter
- Sample PE denial letter