Presumptive Eligibility

The presumptive eligibility process includes two programs: Hospital Presumptive Eligibility (HPE) and Presumptive Eligibility (PE). With the expansion of the presumptive eligibility process to include new provider types and specialties, the process is now referred to as Presumptive Eligibility (PE).

Presumptive eligibility (PE) and Hospital Presumptive eligibility (HPE) allow an individual to be quickly determined eligible for certain Medicaid programs on a temporary basis. Indiana Health Coverage Programs recently expanded PE programs in the state, allowing more individuals to be found eligible and for additional provider types to perform PE determinations. More about this expansion can be found in IHCP Bulletins BT201513 and BT201514.

PE is intended to help individuals that may be eligible for coverage who are facing acute health care issues and is not intended to be a primary method of enrollment into the Healthy Indiana Plan (HIP) or Medicaid.

An individual may become PE eligible when he or she visits a provider who has enrolled to be a Qualified Provider (QP) and answers a short list of eligibility questions including age, income, pregnancy status, and residency status. This information is quickly assessed and a determination regarding their eligibility for coverage is made. Individuals who are found eligible have coverage starting that same day. They are given a PE Acceptance letter that serves as their proof of coverage. Because this coverage is temporary, they do not get a membership card. The letter includes critical information for providers:

  • Name
  • Date PE coverage starts and stops
  • PE ID number that starts with “600”
  • The benefit package for the member
  • A Managed Care Entity and Phone number – if they are in the PE Adult category

A member’s PE status will be identified on the Eligibility Verification System (EVS) using benefit category and aid category for which the member qualifies, for example: Package A-PE Infants.

Presumptive Eligibility (PE) PE is available to children, parents/caretakers and other adults. The goal of the program is to make sure the member has immediate access to healthcare. Short-term coverage will end if the member does not complete a Medicaid application. As of April 1, 2015, federally qualified health centers (FQHCs), rural health centers (RHCs), community mental health centers (CMHCs) and local county health departments may also enroll as qualified providers (QPs).

Learn more about PE (PDF)

Hospital Presumptive Eligibility (HPE)
Hospital Presumptive Eligibility (HPE) is a program created by the Affordable Care Act in which hospital participation is optional. Any hospital qualified by the state to take HPE applications is able to make temporary Medicaid determinations based on questions asked by the hospital worker to the applicant. This includes contracted staff of the hospital assisting in the HPE application, regardless of whether the individual is seeking medical care at the time of the application.

The implementation of the new Healthy Indiana Plan (HIP) program also creates an HPE for adults category for applicants. HPE coverage is short-term coverage limited to 60 days. Once an individual is enrolled and receiving HPE services, MHS will encourage the member to complete the Indiana application for health coverage.

As of January 1, 2014, acute care hospitals enrolled as HPE qualified providers may assist qualifying individuals in certain aid categories to receive temporary coverage until eligibility for the Indiana Health Coverage Programs (IHCP) is officially determined by the Indiana Family and Social Services Administration (FSSA). As of April 1, 2015, free-standing psychiatric hospitals may also enroll as qualified providers.

Learn more about HPE (PDF)

Hospital Presumptive Eligibility Qualified Provider Manual (PDF)

Once a member is found eligible for PE, they are fully eligible for all services covered by their PE aid category. Their coverage is temporary and they are directed to apply for full coverage before the end of the following month. An individual may only get PE coverage once per calendar year or per pregnancy.

Eligibility and Providing Service to PE Members

The PE determination is a real time, immediate process. However, it may take several days for the member’s information to be fully visible in all provider eligibility systems. This is especially true for members who fall into the PE Adult category and are served via managed care.

When you can expect to see members in different systems:

  • Within 1 business day of PE eligibility: you can verify a member’s eligibility utilizing the eligibility verification system or Provider Healthcare Portal. Member will be fully visible in Catamaran pharmacy benefits manager.
  • Within 3 days of PE eligibility: member will be visible in the appropriate managed care entity system.
  • Within 5-7 days of PE eligibility: member will be visible in the managed care entity’s pharmacy benefits manager systems.

During this time, members are fully eligible for service but some providers may not accept the PE letter as proof of coverage and will not provide services until the person can be identified by the eligibility verification system or a managed care entity. The state and MHS continue efforts to educate providers, including pharmacies, that the letter is proof of coverage. If possible, members should wait to seek pharmacy services.

MHS wants to provide the best experience possible for our members. However, a member must be identified in EVS or Provider Healthcare Portal as an MHS member to receive services.  If a member is in need of prescription coverage or medical services and is identified as an MHS member in EVS, but does not appear in the MHS provider portal  call MHS for assistance at 1-877-647-4848. As long as the member has their PE Acceptance letter, providers can be assured that covered services rendered during the PE period will be paid.

PE Billing
Providers should check eligibility prior to rendering services as they would for any Medicaid participant. When utilizing the eligibility verification system or Provider Healthcare Portal, please use the member’s social security number for eligibility verification. If the member has two ID numbers showing as fully eligible for that date of service (one beginning with “600”-the PE ID, and the other beginning with “100”-the RID), bill using the ID beginning with “100”-the RID.

Important Billing Notes

  1. If the member is HPE, they receive HIP Basic benefits with no dental or vision coverage and are required to make a copayment at the time of service for all medial services including doctor visits, hospital stays and pharmacy drugs.
  2. If a hospital admission date is prior to the PE eligibility start date, no portion of that stay will be considered a PE covered service.

Members found eligible for PE are assigned to the following benefit packages. They are able to seek any covered service within their benefit package from any IHCP provider or a provider within their managed care network.

Aid Category

Description

Benefits

FFS/RBMC

HI

PE Infants Package A FFS

HK

PE Children Package A FFS

HA

PE Adult HIP Basic RBMC

HP

PE Parent/Caretaker Package A FFS

HW

PE Pregnant Women Package P FFS

H1

PE Former Foster Care Children Package A FFS

HF

PE Family Planning Family Planning Only FFS

If a member seeks a service that requires a prior authorization or pre-certification, contact MHS Provider Services at 1-877-647-4848. If a member is in fee-for-service, please follow standard prior authorization processes.

Covered Services by Package

Package A – Standard Plan: Members on this plan are able to receive any services covered by the Medicaid program.

Package P- Pregnancy Only: This coverage is limited to ambulatory prenatal care services only. This includes prenatal doctor visits, prescription drugs related to pregnancy, prenatal lab work, and transportation to prenatal visits. It does not cover any services related to labor and delivery.

HPE (HIP Basic) – This covers a wide range of ambulatory patient services, hospitalization, ER, mental health and substance abuse, prescription drugs, labs, preventive care, and rehabilitative care. HIP Basic does not cover dental, vision, non-emergency transportation or MRO services.

Members in this category will have copays for most services due at the point of services ranging from $4-$75 including doctor visits, hospital stays or prescription drug. If the HPE member is younger than 21, they will also be eligible for vision and dental services. HPE members will not be provided a POWER Account during this period.

Family Planning – This is very limited coverage for family planning services only. The following are covered: family planning visits, laboratory tests (if medically indicated as part of the decision-making process regarding contraceptive methods), limited health history and physical exams, pap smears, initial diagnosis of sexually transmitted diseases (STDs) and sexually transmitted infections (STIs), follow-up care for complications associated with contraceptive methods, FDA-approved oral contraceptives, devices and supplies, screening, testing, counseling and referral of members at risk for human immunodeficiency virus (HIV), tubal ligations, hysteroscopy sterilization and vasectomies.

Providers are responsible for verifying eligibility every time a member schedules an appointment and when the member arrives for service. As some HIP members will now be responsible for copays, it is very important for providers to check the eligibility and packages or HIP members to determine if a copay is due at the time of service. Use the Provider Healthcare Portal or the MHS provider portal for package coverage and copayment information.

If an individual is admitted to the hospital and a PE determination is made during their stay, is that stay covered?
Member PE eligibility begins on the date that the PE application is submitted and the approval determination is made. Services delivered prior to this date are not covered services. This also applies to hospital admission dates that pre-date the PE eligibility start date. If a hospital admission date is prior to the PE eligibility start date, no portion of that stay will be considered a PE covered service.

When I check the member’s presumptive eligibility/hospital based presumptive eligibility, I cannot find his or her PE ID in Web interChange. How can I confirm that I will be reimbursed for a 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. If the member is eligible under the PE adult aid category, providers should contact the managed care entity listed on the letter for services that require prior authorization or pre-certification. It will take up to three days from the PE coverage start date for the member to be visible in the MCE system. Each managed care entity has a process in place to provide prior authorization or pre-certification for PE adult members.

Where can a PE member receive services?
The member is not limited to receiving services only from the provider location or hospital where he or she was determined presumptively eligible. Most PE members can receive services covered under their aid category from any Indiana Health Coverage Programs-enrolled provider. PE adult members should seek non-emergency care through their managed care entity network.

What if a member’s eligibility for services is denied via a pharmacy’s point-of-sale system?
It may take several 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 members’ identification card. If a member is enrolled with an managed care entity and the pharmacy provider is unsure of the member’s status, the provider can contact the managed care entity listed on the eligibility verification letter for guidance.