- How can I confirm that I will be reimbursed for a service provided to an individual with presumptive eligibility (PE) coverage?
The Indiana Health Coverage Programs (IHCP) PE acceptance letter indicates the date a member's coverage begins and ends and the plan to which the member belongs, if applicable. See the following examples:
- Sample acceptance letter for PE Adult
- Sample acceptance letter for PE Package A – Standard Plan (for Children)
- Sample acceptance letter for Presumptive Eligibility for Pregnant Women (PEPW)
This letter serves as the member's identification card. In addition, a member's eligibility is updated in real time in the IHCP Eligibility Verification System (EVS) and should be viewable in the IHCP Provider Healthcare Portal at the time the acceptance letter is printed and sent.
- Where can a presumptively eligible member receive services?
PE members are not limited to receiving services only from the provider location where they were determined presumptively eligible. PE members can receive services covered under their PE benefit plan from any IHCP-enrolled provider.
- What if a PE member's eligibility for services is denied via a pharmacy's point-of-sale system?
It may take up to 24 hours for a member's eligibility status to be visible in the eligibility system of the pharmacy benefit manager. During that time, the member is eligible to receive services covered under their PE benefit plan. The PE acceptance letter clearly indicates the date a member's PE coverage begins and ends, and serves as a member's identification card.
- How long does PE coverage last?
PE coverage begins on the day that the applicant is found presumptively eligible by a qualified provider (QP). Coverage lasts until the last day of the month following the month in which PE was determined (for example, if PE is determined March 15, the PE coverage lasts until April 30), or unless the individual files a full IHCP application by that date. If the individual files a full IHCP application by the last day of the month following the month in which PE was determined, then the PE coverage lasts until the full application is either approved or denied:
- If the full application is denied, the individual’s coverage ends on the date the denial is determined.
- If the full application is approved, the individual’s PE coverage ends only when the member is covered by another form of IHCP coverage. This avoids a gap in coverage for the applicant.
- An applicant filed a full IHCP application before the end of the month after PE was determined. Why was PE still end dated even though the application was filed before the end date?
Applications are processed through the Department of Family Resources (DFR), which is on a different system than the one where PE information is stored. It can take a few days for the systems to link when a new application is filed. If a member filed an application and PE was still end dated, please email firstname.lastname@example.org.
- Are applicants required to have proof of demographic, income or family-size qualifications?
No, applicants are not required to have proof for any of the questions on the PE application. The PE application is based entirely on self-attestation, and QPs are not allowed to require any form of verification.
Note: Although verification is not allowed, providers must not enter information they know to be false into the IHCP Portal.
- Who should be contacted if an error was made on a PE application, or if a provider has a question about the application?
- What happens if, after submitting a PE application, a QP later finds out that information provided by the applicant was incorrect, and the correct information would have disqualified the applicant from receiving PE coverage?
If information is later found that differs from what was entered on the PE application, the correct information should be entered when completing the full IHCP application for DFR determination of eligibility. If the FSSA discovers that an individual received PE using incorrect information, the PE will be voided. Providers can ask the FSSA to void PE.