Presumptive Eligibility (PE)

The Presumptive Eligibility for Pregnant Women program enables eligible women to receive prenatal care early in their pregnancies. Low-income pregnant women are determined presumptively eligible for Hoosier Healthwise through a simplified application process. The PE application is submitted by a qualified provider (QP).

Women found to be presumptively eligible have coverage for outpatient prenatal services while the application and determination process for Hoosier Healthwise is being completed. PE does not cover hospice, long-term care, inpatient care, labor and delivery services, abortion services, postpartum services, and services unrelated to the pregnancy or birth outcome. These services, if determined to be pregnancy-related, may be covered retroactively if the woman is later determined eligible for Hoosier Healthwise benefits.

A woman's PE period begins on the date a QP determines the woman is presumptively eligible. The PE period ends when the Indiana Division of Family Resources (DFR) has completed its eligibility determination process and determines the woman approved or denied for Hoosier Healthwise. PE benefits also end if:

  • The woman's pregnancy ends at any time while she is on PE
  • The woman does not have a Hoosier Healthwise application on file with the DFR on the last day of the month following when she was determined to be presumptively eligible
  • The woman fails to cooperate with the DFR to complete the Hoosier Healthwise application process

It is very important that women who enroll in PE take all the necessary steps to become fully eligible. This helps ensure that no gap in coverage occurs.

PE is different from "pending" Medicaid, because providers are eligible for reimbursement at the time services are rendered, versus waiting for retroactive coverage. Pregnant women found to be presumptively eligible have coverage for their first prenatal visit to a QP.

To be eligible for PE, women must meet the following criteria:

  • Be pregnant as determined by a professionally administered pregnancy test by a licensed practitioner. (Note: Home-administered or over-the-counter pregnancy tests do not meet this requirement.)
  • Not be a current Medicaid member
  • Be an Indiana resident; an Indiana address must be provided on the application
  • Be a U.S. citizen or a qualified noncitizen. The applicant must be a citizen of the United States or a qualifying immigrant with one of the immigration statuses listed below:
    • Lawful permanent resident immigrant living lawfully in the U.S. for five years or longer
    • Refugee
    • Individual granted asylum by the immigration office
    • Deportation withheld by order from an immigration judge
    • Amerasian from Vietnam
    • Veteran of U.S. Armed Forces with honorable discharge
  • Not be currently incarcerated
  • Have gross family income (before any taxes or deductions) at or below 200 percent of the federal poverty level (see table below.)

Family Size and Income Requirements for PE

Family Size Monthly Income Annual Income
2 $2,429 $29,148
3 $3,052 $36,624
4 $3,675 $44,100
5 $4,299 $51,588
6 $4,922 $59,064
7 $5,545 $66,540
8 $6,169 $74,028
Add $624 per month for each additional person Add $7,476 per year for each additional person

Note: The 2009 income standards listed in the table above were in effect at the time of publication. The federal government extended the 2009 income standards and, at the time of publication of this page, no new guidelines were available. If new guidelines become available, the PE application on Web interChange will be updated and a banner page article will be published with updated information.

More Information

Detailed information about PE can be found in the Qualified Provider Presumptive Eligibility Manual.