Presumptive EligibIlity for Pregnant Women process

The Presumptive Eligibility for Pregnant Women (PEPW) process enables eligible women to receive prenatal care earlier in their pregnancies. Low-income pregnant women have the opportunity to be determined presumptively eligible for Indiana Health Coverage Programs (IHCP) coverage through a simplified application process. Women found presumptively eligible have coverage for ambulatory prenatal services while their applications and eligibility determinations for full IHCP coverage are completed by the Indiana Family and Social Services Administration (FSSA).

PEPW coverage begins on the date a qualified provider (QP) determines the woman is presumptively eligible. The QP assists with the PEPW application by accessing Web interChange. For more information about how to become a qualified provider and about the PEPW and Indiana Application for Health Coverage processes, see the Presumptive Eligibility for Pregnant Women provider reference module.

Enrollment centers that are not qualified providers for PEPW can assist pregnant women by helping women complete and submit the Indiana Application for Health Coverage and by providing referrals to qualified providers. It is critical, however, that only ONE Indiana Application for Health Coverage be submitted for a member.

QPs can submit PEPW applications Monday through Friday, 8 a.m. to 6 p.m. Eastern Time (ET). However, PEPW coverage is activated only after the woman calls the enrollment broker, MAXIMUS, to select a health plan. Enrollment with a health plan must occur before 6 p.m. ET on the same day the PEPW application is completed or the PEPW coverage will not be activated. Women should also be strongly encouraged to select a primary medical provider (PMP) during this same visit so that prenatal care can begin as soon as possible.

PEPW status is different from a "pending" eligibility status. Under a PEPW status, providers can receive reimbursement at the time services are rendered. Under "pending" status, providers must wait for retroactive IHCP coverage to receive reimbursement. Even before the PEPW member selects a PMP, the PEPW member's health plan will allow reimbursement for covered services provided by in-network providers.

The woman's official IHCP eligibility determination is subsequently completed by the FSSA. All Indiana Application for Health Coverage faxes or inquiries should be directed to 1-800-403-0864 or to a local Division of Family Resources (DFR) office. It is very important for women who are determined to be presumptively eligible to take all the necessary steps to become fully eligible. This helps ensure there will be no gap in coverage.

To be eligible under PEPW, women must meet the following criteria.

  • Be pregnant
  • Not be enrolled in the IHCP
  • Be an Indiana resident; an Indiana address must be provided on the application
  • Be a U.S. citizen or a qualified noncitizen with one of the following immigration statuses:
    • 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
  • Meet income eligibility guidelines (see the  PEPW page on the member website at indianamedicaid.com)

Women found eligible under PEPW are covered for Package P services, which include ambulatory pregnancy-related services, such as visits to a doctor for prenatal care, pregnancy-related lab work and prescriptions, and transportation for prenatal care. PEPW 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.

PEPW coverage will be terminated under the following circumstances:

  • The woman does not have an Indiana Application for Health Coverage on file with the FSSA on the last day of the month following the month of the approved PEPW determination.
  • The woman fails to cooperate with the FSSA to complete the Indiana Application for Health Coverage process.

More Information

More information is available via the following links.