Presumptive Eligibility FAQs

Q. How can I confirm that I will be reimbursed for a member's presumptive eligibility service?

The eligibility verification letter clearly indicates the date a member's coverage begins and ends and the plan to which the member belongs, if applicable. This letter serves as the member's identification card. In addition, a member's eligibility is available in real time and should be viewable in the Portal at the time the verification letter is printed and sent. If the member is eligible under the PE Adult aid category or through the Presumptive Eligibility for Pregnant Women (PEPW) process, providers should contact the managed care entity (MCE) listed on the letter with coverage and reimbursement questions.

Q. Where can a PE member receive services?

The member is not limited to receiving services only from the provider location where he or she was determined presumptively eligible. Most presumptively eligible members can receive services covered under their benefit plan from any IHCP-enrolled provider. Members eligible under the PE Adult aid category or through the PEPW process must receive services from providers enrolled with the member's MCE network.

Q. What if a member's eligibility for services is denied via a pharmacy's point-of-sale system?

It may take up to three days for a member's eligibility status to be visible in all eligibility systems, particularly in the eligibility systems of the managed care pharmacy benefit managers. During that time, the member is eligible to receive services. The eligibility verification letter clearly indicates the date a member's coverage begins and ends, and serves as a member's identification card. If a member is enrolled with an MCE and the pharmacy provider is unsure of the member's status, the provider should contact the MCE listed on the eligibility verification letter for guidance.