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Presumptive Eligibility (PE) for Pregnant Women

In Kentucky, 15 percent of pregnant women fail to receive critical prenatal care until after their first trimester. Regular prenatal care is proven to reduce many health risks to both mother and child. Early detection and management of potentially high-risk pregnancies can also make a significant impact on reducing the overall cost of delivering health care to the financially needy citizens of Kentucky. More than 30 states have adopted presumptive eligibility as a way to assure immediate access to prenatal care.

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What is Presumptive Eligibility?

Presumptive Eligibility (PE) is a program that enables eligible pregnant women to receive prenatal care through Medicaid for up to 60 days while their eligibility for full Medicaid benefits is determined.

This program is designed to improve pregnant women's access to outpatient prenatal services. Enrolled providers and their office staff complete a simple application to determine whether a pregnant woman qualifies for presumptive eligibility for Medicaid. Providers are assured payment for those early prenatal services provided and help the woman obtain pharmacy and other prenatal benefits immediately.

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Eligibility Criteria

Who is eligible?

Presumptive eligibility may be granted to a woman if she meets the following criteria:

  • Is pregnant;
  • Is a Kentucky resident;
  • Meets income guidelines established in 907 KAR 20:100;
  • Does not currently have a pending Medicaid application on file with the Department for Community Based Services (DCBS);
  • Is not currently enrolled in Medicaid;
  • Has not been previously granted presumptive eligibility for the current pregnancy; and
  • Is not an inmate of a public institution.

Once I am eligible when will my PE begin?

Presumptive eligibility shall begin on the date on which a qualified provider determines that a woman is presumptively eligible based on the criteria listed above.

Women who are granted presumptive eligibility by a qualified provider receive designated benefits for up to 60 days. During this period she is asked to go to her local DCBS Office to determine her eligibility for full Medicaid benefits.

When does my PE end?

The presumptive eligibility period shall end:

  • on the day preceding the date the presumptively-eligible woman is granted full eligibility in the Medicaid Program by DCBS;
  • or the last day of the month following the month in which a qualified provider made the presumptive eligibility determination
    1. If a presumed eligible woman does not apply for the full Medicaid benefit package, or
    2. Applies for and is found ineligible for the full Medicaid benefit package.

Note: Only one presumptive eligibility period shall be granted for each episode of pregnancy.

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Benefit Information

The following services may be provided by any enrolled Medicaid provider, following current Medicaid coverage rules. These services include:

  • primary care services provided by family practitioners, general practitioners, pediatricians, internists, obstetricians/gynecologists, advanced registered nurse practitioners, nurse midwives and physician assistants;
  • services provided by primary care centers and rural health clinics;
  • services provided by local health departments; laboratory services;
  • X-ray services, including ultrasounds; dental services; emergency room services; prescription drugs; and transportation.

Note: Services delivered in an in-patient setting are not covered under presumptive eligibility.

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Regulations and Publications
 

Regulations

Publications

 

If you have questions
 

Presumptive Eligibility Help Desk for certification of pregnant women and general questions:
(866) 818-0073

Provider Relations for billing questions:
(800) 807-1232

EDS Technical Support for system problems:
(800) 205-4696

Contact us by email: CHFS DMS Webmaster

 


Last Updated 4/3/2014
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