Presumptive Eligibility Process

The presumptive eligibility (PE) process allows community mental health centers (CMHCs), rural health clinics (RHCs), federally qualified health centers (FQHCs), and local health departments 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. Once enrolled, the individual maintains PE coverage until one of the following occurs:

  • A member 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. 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 POWER Account contributions. This approach allows them to avoid a gap in coverage, as long as they meet required application and payment time lines.

An individual is allowed to receive PE coverage only once per rolling 12-month period.

Groups eligible for PE include:

  • Low-income infants and children
  • Low-income parents or caretakers
  • Low-income adults
  • Former foster care children
  • Low-income pregnant women
  • Individuals seeking family planning services only

Member Enrollment Process

An individual seeking presumptive eligibility works with a qualified provider to complete a PE application. The PE application is available through Web interChange 24 hours a day, seven days a week. The CMHC, RHC, FQHC, or local health department receives a real-time response as to whether the individual is eligible for PE. Information requested on the application includes an individual's demographic information, family size, and household income.

Individuals complete a PE application for each member in their families, regardless of a person's need for services when he or she applies. Each individual who desires to apply through the PE process must have his or her own application for enrollment. Once enrolled, the individual remains active in the PE program until the last day of the month following his or her month of enrollment or until a determination is made on his or her completed Indiana Application for Health Coverage. The individual receives temporary coverage reimbursed on a fee-for-service or managed care basis, appropriate to the aid category under which he or she qualifies, as follows:

  • Presumptively eligible infants, children, parents/caretakers, and former foster care children are covered under the Standard Plan (Package A)
  • Presumptively eligible pregnant women are covered for ambulatory prenatal care benefits under Package P
  • Individuals presumptively eligible for the Family Planning Eligibility Program are covered for family planning benefits
  • Presumptively eligible adults are covered under the HIP Basic benefit plan and have copayment obligations. Individuals eligible for PE Adult receive services through a managed care entity (MCE) selected during the PE application process.

PE Adult Fast Track

Adults determined to be presumptively eligible for HIP can use the Fast Track application process to expedite their official enrollment in HIP. All PE Adult members receive a letter with an invoice for $10 from their MCE to facilitate the Fast Track process. After payment of this invoice is submitted, a full Indiana Application for Health Coverage filed, and official eligibility approved, the individual's HIP enrollment can be fully effective on the first day of the month following the PE period. The $10 payment is then credited toward the member's required POWER Account contribution. Once a PE Adult member has elected to use the Fast Track process, he or she will not be able to change to a different MCE.

Enrolling as a Qualified Provider

CMHCs, RHCs, FQHCs, and local health departments are eligible to enroll as PE qualified providers (QPs). To be eligible, a CMHC, RHC, FQHC, or local health department must:

  • Participate as a provider under the Indiana State Plan or under a demonstration program under Section 1115 of the Social Security Act.
  • Notify the FSSA of the provider's intention to make presumptive eligibility determinations.
  • Agree to make presumptive eligibility determinations consistent with state policies and procedures.
  • Guide individuals in the process for completing and submitting the Indiana Application for Health Coverage paperwork to the FSSA.
  • Complete and submit PE QP eligibility attestations through the PE enrollment process on Web interChange.

CMHCs, RHCs, FQHCs, and local health departments that wish to enroll as PE QPs are provided Web interChange training. During the Web interChange training session, the CMHC, RHC, FQHC, or local health department also receive a printed copy of the Hospital PE/PE Process Guide.

More Information

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