Presumptive Eligibility for Pregnant Individuals

The Presumptive Eligibility (PE) program provides low income pregnant individuals with immediate, temporary MC coverage, limited to ambulatory prenatal care, while their regular MC (or CalWORKs) application is pending.

The intent of the PE program is to enable pregnant individuals to begin prenatal care as soon as possible. Early prenatal care helps reduce the rate of infant mortality and low birth weight babies.

A pregnant individual eligible for PE is certified for the month of application and the following month. She is instructed by the provider to apply for regular MC (or CalWORKs) before the end of her PE period.

Eligibility Criteria

Who is Eligible

Any California resident who believes that they are pregnant qualifies for PE.
Family income must be at or below 213% of the Federal Poverty Level (FPL).
- “Family income” means gross income of the applicant and/or spouse. If under 21, unmarried and living with her parents, the parents’ income also counts.
- The client's statement regarding family income is sufficient to determine eligibility. Verification of income is not required.
There are no other eligibility requirements. There are no property limits for PE.

Note: Applicants who have an MC or CalWORKs application pending, but whose eligibility has not yet been determined, may apply for PE.

Period of Eligibility

The enrollment period begins on the day in which the individual is determined eligible for the PE4PW program. If the individual does not submit an MC application prior to the PE end date, PE ends on the last day of the following month in which the individual was determined eligible. If the individual does submit an MC application prior to the PE end date, PE coverage ends on the day in which MC eligibility is approved or denied.

Note: It is critical that EWs take immediate and timely action to complete the eligibility determination before the PE period expires.

Minor Consent

PE does not include Minor Consent services. A minor's need for confidentiality is not protected under the PE program.

A minor under 21 years, applying for PE and living with her parent(s) must provide information on her total family income to the best of her knowledge. If the minor does not want her parents to know she is applying for MC, or is unable to provide her family income, the PE provider cannot offer her PE. The provider would instead refer her to a Social Services Agency district office or outstationed clinic to apply for MC under the Minor Consent Program.

PE Covered Services

PE benefits for pregnant individuals cover most outpatient prenatal services including those provided on an outpatient basis at a hospital emergency room for:

Vaginal bleeding
Prescription needs
Dental benefits
Laboratory services determined by the physician to be pregnancy related, and
Therapeutic abortion or termination of pregnancy.

Note: The above is not a comprehensive list of PE services. Clients who have questions regarding covered services should be directed to their provider.

PE does NOT cover:

Sterilization
Family Planning
Hospitalization
Labor and delivery
Some laboratory services
Medical and dental services unrelated to pregnancy.

PE Enrollment

The California Medicaid Management Information Systems’ (CA-MMIS) Online Portal for Qualified Providers (QPs) was established to assist in the Presumptive Eligibility for Pregnant Women (PE4PW) Program to assist applicants applying for PE. When the PE4PW application has been submitted through the Online Portal, an electronic data match of the applicant’s information determines if the applicant is currently receiving MC benefits through the MC Eligibility Data System (MEDS). If the applicant is not currently receiving benefits from MC, MEDS will provide a response to the system with an immediate PE4PW eligibility determination in real time.

If the applicant is determined eligible for PE4PW, the client will be assigned aid code 7G and the QP will print out the eligibility determination and the Immediate Need Eligibility Document. The client must present the Immediate Need Eligibility Document to MC providers for service during the PE4PW eligibility period. PE4PW clients do not receive a plastic BIC. A BIC will only be sent to the client if she applies for and is subsequently determined eligible for MC benefits.

Note: Applicants with a negative pregnancy test result or otherwise found to be not pregnant by the QP will not receive an Immediate Need Eligibility Document. MEDS will place the applicant in aid code 7F.

PE4PW QPs are required to provide clients of the program with an MC application. PE4PW clients must submit a completed application no later than the last day of the month following the month in which PE4PW was granted. When the application is submitted during the PE4PW period, PE4PW coverage can be extended pending the MC determination (approval or denial).

Santa Clara County QPs

A list of QPs for Santa Clara County is located under the MC Reference Materials page of the Program Bureau Intranet.

MEDS

MEDS will be programmed to automatically terminate all PE4PW benefits for clients who reach the
60-day limit unless MEDS has a record of a pending IAP application. If MEDS shows a pending HX-18 transaction (Covered California application) or EW-18 transaction (county application), MEDS will not automatically terminate PE4PW benefits until a determination has been given to the application with either an HX-20 or EW-20.

Aid Codes

The following are the aid codes for the PE4PW program.

Aid Code	Who Qualifies
7F	Valid for pregnancy test, initial visit, and services linked with the initial visit. Individuals placed in 7F have pregnancy test results that are negative or have been found not to be pregnant by the QP.
7G	Valid for specific prenatal care services. Individuals placed in 7G have self-attested to the pregnancy or have a pregnancy test result that is positive. QP issues a paper Immediate Need Eligibility Document.

The following chart provides an overview of the PE and Medi-Cal (or CalWORKs) application process:

PE and Medi-Cal Application Process

Pregnant Individual
1. Obtains medical care, and does not have MC or other health insurance for prenatal care.
PE Provider
1. Explains the PE program.
2. Gives patient the PE Patient Fact Sheet.
3. Gives patient the MC 263 PE Pregnancy packet.
4. Completes PE determination (income screening using the Federal Poverty Level chart and pregnancy testing).
5. Issues a PE Immediate Need Eligibility Document to the eligible patient.
6. Bills MC for services.
Pregnant Individual Who Is PE Eligible
1. Receives an Immediate Need Eligibility Document from the QP, which is good for outpatient prenatal care only.
2. Is advised to apply for MC at a district office/outstationed clinic to get ongoing coverage including labor and delivery before the end of her eligibility for PE.
PE Recipient
1. Applies for MC (or CalWORKs).
CST at Social Services
1. Processes client's request for MC (or CalWORKs), following normal procedures.
2. Screens the pregnant individual for immediate need, following district office procedures.
EW
1. Determines if MC eligibility will be cleared before the end of the initial PE period. The PE recipient is eligible for PE for as long as her MC (or CalWORKs) application is pending.
2. Processes application for MC (or CalWORKs).
3. Advises client to stop using her PE card when her regular no SOC MC BIC is received.
4. No further action for PE is required when MC is denied or SOC MC is approved.

Retroactive Coverage

Some individuals may have received health care services that were not covered under the PE program, or prior to their application for PE or MC. EWs must inquire about the need for retroactive coverage for medical bills incurred in the three months prior to the date of application.

Non-County Resident

Occasionally, a pregnant individual may be determined eligible for PE in this county, but is not a county resident. If a PE applicant applies for MC (or CalWORKs), but is determined not to be a resident of Santa Clara County, the EW must take a courtesy application and send the information to the applicant's county of residence for an eligibility determination.

Immediate Need Eligibility Document Replacement

If a PE recipient requests a replacement for a lost, stolen or destroyed Immediate Need Eligibility Document, EWs should refer her back to the provider who gave her the original document.