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Presumptive Eligibility (PE)

Presumptive Eligibility (PE) is a process that offers short-term coverage of services.  The program is available to children, parents/caretakers, and other adults.  The goal of the program is to make sure you have immediate access to health care.  Your short-term coverage will end if you do not complete a Medicaid application.

Below are many answers to popular questions:

Who can get PE coverage?

You can get PE coverage if you are not currently receiving Indiana Medicaid coverage.  The following groups of individuals may qualify for PE:

  • Parents/Caretakers
  • Infants
  • Children
  • Adults
  • Pregnant Women
  • Former Foster Children

You must live in Indiana, and your family income must be below a certain amount.  In order to continue your coverage, you will need to complete a full application as soon as possible.

Why should I submit a Medicaid application?

Approval for PE is NOT the same as being approved for Medicaid.  Your PE coverage is only temporary while you submit a Medicaid application and your Medicaid application is pending.  Your PE will end if you do not apply for Medicaid by end of the next month.

It is very important that you respond promptly to all requests from us regarding your Medicaid application .  If you do not respond to our questions, you will not be eligible for Medicaid coverage, and you will be responsible for paying all of your health care costs.

How does the PE process work?

You will be asked a few questions at the hospital or clinic.  You should be prepared to provide the following information:

  • Name;
  • Home address;
  • Phone number;
  • Date of birth;
  • Social Security Number;
  • Family size; and
  • Amount of monthly/annual income.

You will also be asked a few additional questions to make sure you qualify for the correct coverage.

What is covered?

Your temporary coverage will depend upon your aid category:

  • If you qualify as a Parent/Caretaker, Infant, Child, or Former Foster Child, you will be eligible for all services covered under Hoosier Healthwise Package A.  If you would like more information about the services covered, you should refer to What Is Covered By Hoosier Healthwise.
  • If you qualify as a Pregnant Woman, you will be eligible for doctor visits, tests, lab work, and other care for your pregnancy.  You will also have coverage for dental care, prescription drugs, and transportation services to doctor appointments. This will not cover labor and delivery costs, you must apply for Medicaid.
  • If you qualify for Family Planning coverage, you will only be eligible for services covered by the Family Planning Eligibility Program.  These services include family planning visits, laboratory tests, pap smears, condoms, and birth control.  If you would like more information about the services covered, you should refer to the Family Planning Eligibility Program.
  • If you qualify as an Adult, you will be eligible for services covered under the HIP Basic Plan.  You will be required to pay copays for all services.  If you'd like to learn more about the services covered under HIP Basic, you should refer to the Healthy Indiana Plan website.

What is "fast track"?

If you qualify under the Adult category, the hospital or clinic will ask you to select a health plan.  You will be presumptively eligible for the Healthy Indiana Plan (HIP).  Your health plan will send you a letter in the mail requesting a $10 "fast track" payment to get your full coverage effective faster.  If you pay this $10 and complete your Medicaid application, your full coverage with HIP will begin sooner without a gap in coverage.  While this payment is optional, you are encouraged to pay it so that you can begin receiving your full benefits sooner.  If you would like more information about HIP, you should refer to the Healthy Indiana Plan website.

How can I complete the full application?

The PE application is NOT a full Medicaid application; it provides only temporary coverage.  You should complete a full application as soon as possible to make sure you do not lose any benefits.  You can submit a full application in a number of ways:

  • At the provider where you were found presumptively eligible;
  • Online;
  • Over the phone at 1-800-403-0864; or
  • At a Division of Family Resources (DFR) local office.

You can find answers to even more questions under the Frequently Asked Questions page.