All Medicaid Programs |
Obsolete Policy |
Effective Date: November 1, 2019 - May 31, 2020
PE allows eligible individuals to receive temporary medical assistance while eligibility is being determined for ongoing medical coverage. Unless otherwise stated, Medicaid eligibility rules apply. Additional program requirements can be found in the BYB and HPE Training Manuals.
Program Types
PE is divided into two programs: Baby Your Baby (BYB) and Hospital Presumptive Eligibility (HPE). Both programs are administered by PE providers as outlined below:
BYB is administered by qualified health care providers. BYB providers determine eligibility for Pregnant Women (PW) medical assistance.
HPE is administered by qualified hospitals. HPE providers determine eligibility for the following medical assistance programs in order of hierarchy:
Child 0-5 (CM 0-5)
Child 6-18 (CM 6-18)
Parent Caretaker Relative (PCR)
Pregnant Women (PW)
Former Foster Care (FFC)
Adult Expansion
Eligibility Requirements
Eligibility is based on an individual’s statement. Do not request verification from an individual applying for PE.
In addition to meeting residency and citizenship/alien status requirements in section 200, an individual must meet the following:
Gross household income at or below the income limit for the specific medical assistance program (Table VII)
Not currently covered on Medicaid, CHIP, UPP or Medicaid with a spenddown, even if the spenddown has not been met.
Not been denied for Medicaid, CHIP or UPP, within the past 30 days, unless the household circumstances have changed.
For PW, a woman must be pregnant at the time of application.
A woman can only receive PW once per pregnancy.
Except for PW, an individual can only receive HPE once per calendar year.
Medical Support Enforcement is not required for PE programs.
The following are circumstances when the eligibility agency can override a PE provider’s decision:
An individual is currently receiving Medicaid, CHIP, UPP or Medicaid with a spenddown, even if the spenddown has not been paid.
The form 40 is submitted after the ongoing medical determination (approval or denial) has been made.