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 answers to many popular questions:
Who can get PE coverage?
You can get PE coverage if you are not currently receiving Indiana Medicaid coverage. 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 or Healthy Indiana Plan 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.
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 Hoosier Healthwise page.
- If you qualify as a pregnant woman, you will be eligible for doctor visits, tests, lab work and other care for your pregnancy through fee for service. 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 qualify for PE Adults, 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 or the Healthy Indiana Plan. Your PE coverage is only temporary while you submit a full application and while your application is pending. Your PE will end if you do not apply for coverage by end of the next month.
It is very important that you respond promptly to all requests regarding your 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 coverage under the Medicaid program or Healthy Indiana Plan, 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 only provides 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 800-403-0864
- At a Division of Family Resources local office.
Why should I submit a Medicaid application?
Approval for PE is NOT the same as being approved for ongoing health coverage. Your PE coverage is only temporary while you submit an Indiana application for health coverage and while your application is pending. Your PE will be discontinued if you do not apply for coverage by the last day of the month following the month your PE was established.
It is very important that you respond promptly to all requests from the state following your application. If you do not apply and respond, you will not be eligible for coverage, and you will be responsible for paying all of your health care costs.
For pregnant women many health care services are not covered under Presumptive Eligibility for Pregnant Women (PEPW). If you do not begin the application process for full coverage (by submitting the Indiana application for health coverage), you will lose your PEPW and will 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 application is submitted and approved. For your health and the health of your baby, take the next step and complete the Indiana application for health coverage right away. See the PEPW brochure to view all of the critical PEPW process information.
The same doctor's office or clinic that helped you with your PE determination can help in filling out and submitting your application for health coverage.
How much income can I have and still qualify for PEPW?
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, 2022.
Family size: | Maximum monthly income: | Maximum annual income: |
2 | $3,501 | $42,014 |
3 | $4,414 | $52,963 |
4 | $5,325 | $63,900 |
5 | $6,237 | $74,849 |
How can I find a designated clinic or doctor in my area?
Please call us at 800-889-9949. You may also visit use the provider locator for a list of locations near you.