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
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
- Be pregnant
- Not be enrolled in the IHCP
- Be an Indiana resident; an Indiana address must be provided on
- 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
- 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
PEPW coverage will be terminated under the following
- 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 is available via the following links.