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 (IHCP Portal), 24 hours a day, seven days a week. The qualified provider (QP) 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.
When applicants themselves are unable to answer PE application questions, such as in situations of unconsciousness or incapacitation, an advocate can be used to file the PE application. An advocate can be the applicant's adult child, spouse, parent/caretaker, case worker and so forth. For any questions regarding whether or not an individual qualifies as an advocate, send an email to presumptiveeligibility@fssa.in.gov.
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 (FFS) 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 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 Category | PE Benefit Plan Name | Coverage Description |
|---|---|---|
Infants Children Parents/Caretakers Former Foster Care Children | Presumptive Eligibility – |
Coverage mirrors Package A – Standard Plan |
Adults | Presumptive Eligibility – Adult | Coverage mirrors HIP Basic |
Pregnant Women | Presumptive Eligibility for | Coverage includes ambulatory |
Family Planning | Presumptive Eligibility | Coverage mirrors |
Enrolling as a Qualified Provider
The following table lists IHCP providers that can apply to become certified as 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 Provider | Provider Type, Specialty | PE 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 IHCP 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:
- Presumptive Eligibility Presentation
- Presumptive Eligibility FAQs
- IHCP Presumptive Eligibility (PE) Standards document
- Presumptive Eligibility provider reference module
- Sample acceptance letter for PE Adult
- Sample acceptance letter for PE Package A – Standard Plan (Children aid category)
- Sample acceptance letter for Presumptive Eligibility for Pregnant Women (PEPW)
- Sample PE denial letter