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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 (Portal), 24 hours a day, seven days a week. The qualified provider receives a real-time response as to whether the individual is eligible for PE based on the data entered on the application, such as the individual's demographic information, family size and household income.

Individuals can apply for PE for all members of their family. The QP must complete a separate application for each individual for whom PE coverage is being sought. An individual is allowed to receive PE coverage only once per rolling 12-month period or per pregnancy.

Individuals approved for PE receive temporary coverage reimbursed on a fee-for-service basis. This PE coverage continues until one of the following occurs:

  • The individual 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.

Note: 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 through 18)
  • Adults (ages 19 through 64) without Medicare
  • Parents/Caretakers
  • Former Foster Care Children (ages 18 through 25)
  • 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. For a quick reference to PE requirements, benefits, copay amounts and more, see the IHCP Presumptive Eligibility (PE) Standards document.

The following table outlines coverage for qualifying individuals in these categories during their PE period.

Table 1 – PE Benefit Plan Coverage

PE Aid CategoryPE Benefit Plan NameCoverage Description
Infants

Children

Parents/Caretakers

Former Foster Care Children

Presumptive Eligibility –
Package A Standard Plan

Coverage mirrors
Package A – Standard Plan

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 the Pregnant Women aid category (PEPW coverage) only.

Table 2 – PE Providers and Determinations

Eligible ProviderProvider Type, SpecialtyPE Aid Category/Coverage 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/PEPW only
General practitioner Type 31, specialty 318 Pregnant Women/PEPW only
Obstetrician/gynecologist Type 31, specialty 328 Pregnant Women/PEPW only
General internist Type 31, specialty 344 Pregnant Women/PEPW only
General pediatrician Type 31, specialty 345 Pregnant Women/PEPW 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/PEPW only
Family planning clinic Type 08, specialty 083 Pregnant Women/PEPW only
Clinical nurse specialist Type 09, specialty 093 Pregnant Women/PEPW only
Certified nurse midwife Type 09, specialty 095 Pregnant Women/PEPW 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 so choose. Unless these providers are certified for the full PE process, they are limited to making PE determinations for individuals who are pregnant (PEPW benefit plan assignment) only.

To be eligible, the IHCP-enrolled entity must:

  • Complete and submit PE or PEPW QP eligibility attestations through the PE enrollment process on the IHCP Provider Healthcare Portal.
  • Participate in PE QP training, including training in the Portal PE process.
  • Enroll qualifying individuals in the PE process as described in the Presumptive Eligibility module.
  • Guide individuals in the process for completing and submitting the Indiana Application for Health Coverage paperwork to the FSSA.

More Information

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

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