Presumptive Eligibility for Pregnant Women Frequently Asked Questions
What is Presumptive Eligibility for Pregnant Women (PE for Pregnant Women)?
The PE for Pregnant Women program allows Qualified Providers (QPs) to grant immediate, temporary Medi-Cal coverage for ambulatory prenatal care and prescription drugs for conditions related to pregnancy to low-income, pregnant patients, pending their formal Medi-Cal application.
What is a Qualified Provider (QP)?
A QP is a Medi-Cal provider who participates as a PE for Pregnant Women provider under Title 42 United States Code, Section 1396r-1 (Section 1920 of Title XIX of the Social Security Act).
What is the authority for implementing the PE for Pregnant Women program?
Assembly Bill 501 (Chapter 1127, Statutes of 1992) implemented the PE for Pregnant Women program. Welfare and Institutions Code (W&I Code) 14148.7 authorized the Department of Health Care Services (DHCS) to provide PE benefits to pregnant women as allowed in Section 1920 of the Social Security Act.
When was the PE for Pregnant Women program originated?
The program originated in November 1993.
What is changing in the PE for Pregnant Women program?
Currently, QPs enroll individuals in the program using a manual paper application process. During the first quarter of 2017, the recipient enrollment process will be automated. Providers who meet the eligibility requirements as governed by the PE for Pregnant Women program can enroll individuals through an electronic process.
What are the requirements to become a QP for the PE for Pregnant Women program?
- Be Medi-Cal providers in good standing
- Be authorized to render prenatal services
- Complete the Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility and Pregnant Women (PE4PW) Program (MC 311) form
- Agree to the terms and conditions established by DHCS
- Ensure staff complete the PE for Pregnant Women training program
Are existing QPs exempt from submitting an MC 311 form when PE for Pregnant Women automates?
No. However, existing QPs will have six months from the implementation date of PE for Pregnant Women automation to submit an MC 311 to the DHCS Fiscal Intermediary (FI) before access to the online PE for Pregnant Women application is disabled. DHCS sent letters in mid-November 2016 to existing QPs notifying them of requirements.
Who is responsible for submitting the MC 311?
The provider is responsible for having trained staff submit the MC 311 form.
Where should the MC 311 be sent?
The MC 311 must be submitted hard copy to the FI, at the address stated on the MC 311 form. The form will be available for download on the Medi-Cal website when PE for Pregnant Women automation goes live. Providers are encouraged to check these FAQs periodically for updates.
How does a QP enroll an applicant into the PE for Pregnant Women program electronically?
QPs can enroll an applicant into the PE for Pregnant Women program by accessing the Medi-Cal website, and clicking the “Transactions” tab to enter their National Provider Identifier and Provider Identification Number. Once logged in, QPs can click on the PE for Pregnant Women link to launch the recipient enrollment process.
11. Who is potentially eligible for PE for Pregnant Women?
To qualify applicants must:
- Have income below the monthly limit for household size
- Be a California resident
- Not be currently recieving coverage through Medi-Cal
- If pregnant, not have had a PE enrollment period during the current pregnancy
What is the basis for a PE for Pregnant Women determination?
The PE determination is based on the applicant's self-attestation of income, household size and state residency provided on the Presumptive Eligibility for Pregnant Women Program Application (MC 263) form.
How long does it take to receive the PE determination?
The QP will receive the PE determination in real-time after the applicant information is entered into the PE for Pregnant Women Application Web Portal.
When does the PE for Pregnant Women enrollment period begin and end?
The enrollment period begins on the day in which the individual is determined eligible for the PE for Pregnant Women program.
The enrollment period ends either:
If an individual does not submit an insurance affordability application prior to the PE end date, PE ends on the last day of the following month in which the individual was determined eligibile for PE.
- For example, if an individual is determined eligibile on March 3, 2017, PE coverage ends on April 30, 2017.
If an individual submits an insurance affordability application prior to the PE end date, PE coverage ends on the day in which the eligibility determination is made based on the insurance affordability application (approved or denied).
- For example, if an individual was determined eligible on July 3, 2017, and submitted an insurance affordability application prior to the PE end date of August 31, 2017, and a determination was made on August 25, 2017, PE coverage ends on August 25, 2017.
Important Note: PE eligibility cannot be backdated regardless of the reason. Individuals must apply for full scope Medi-Cal and mark the box on the application that indicates the individual had medical expenses in the last three months and needs help to pay.
Providers can verify eligibility by using the Automated Eligibility Verification System, a Point of Service device or the Medi-Cal website.
Where can individuals receive more information about insurance affordability programs?
Individuals can call Covered California toll-free at 1-800-300-1506 (TTY: 1-888-889-4500). Information is also available on the Covered California website.
How long does it take to gain access to the PE for Pregnant Women Application Web Portal as a QP to conduct transactions?
No more than 24 hours.
What if the PE for Pregnant Women application is approved and no coverage is found when eligibility is checked?
Providers are encouraged to contact the Telephone Service Center at 1-800-541-5555 and provide the necessary recipient information for further research.
Is a Social Security Number needed to apply for the PE for Pregnant Women program?
It is highly recommended that a Social Security number is provided. The SSN is optional on the Presumptive Eligibility for Pregnant Women Program Application (MC263).
Can duplicate Benefits Identification Cards be printed at a later date for an approved patient?
No. It is recommended that the patient’s eligibility be verified at the time of service.