Eligibility Online Manual

M1811 Presumptive Eligibility (PE)

Purpose:  This section will assist in determining eligibility for Presumptive Eligibility.

Current Policy Effective Date:  February 14, 2022

Date Last Reviewed:  July 19, 2024

Previous Policy:  October 1, 2016


1.    Presumptive Eligibility Determinations Are Made By Qualified Providers Or Qualified Hospitals

Qualified Providers can process PE applications for the Pregnant Woman program only.

Qualified Hospitals can process PE applications for the following programs:

2.    Applicants Must Meet All Eligibility Criteria Set For The Full Medicaid Program

Applicants must meet all eligibility criteria for the full Medicaid program but no verifications are required.

3.    Benefits Begin The Day The PE Application Was Submitted If Determined Eligible

4.    There Are No Retroactive Benefits For PE

5.    Clients May Lose Benefits

Benefits will close on the last day of the month after the PE approval, if no full Medicaid application is received.

PE benefits will close when a determination is made on the full Medicaid application, if one is received.

 6.      PE Periods Are Limited

One PE benefit period is allowed per pregnancy.

One PE benefit period is allowed per year for all other PE groups.

7.     The Medicaid Streamlined Application Is Required To Obtain Full Medicaid.

Reference:   42 CFR 435.110

                      42 CFR 435.907

                      1902 (a) (47) and 1920 of the Act


Clarifying Information:

1.    All information gathered for PE is based on self-declaration, information is not verified.

2.    Qualified Hospitals must meet standards established by the state.

3.    A corrective action plan will be established for Qualified Hospitals who do not meet the standards established by the state.

4.    PE for pregnant woman only covers ambulatory outpatient services.  All other PE groups have the same coverage as their full Medicaid program.


Worker Responsibilities: