Presumptive Eligibility for Pregnant Women

The Presumptive Eligibility for Pregnant Women (PE4PW) 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.

A QP is a Medi-Cal provider who participates as a PE4PW provider under Title 42 United States Code, Section 1396r-1 (Section 1920 of Title XIX of the Social Security Act).

Assembly Bill 501 (Chapter 1127, Statutes of 1992) implemented the PE4PW 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.

The program originated in November 1993.

The automation of the PE4PW program went live April 1, 2017.

Effective, April 1, 2017, Medi-Cal providers wishing to become QPs of the PE4PW program must enroll using the Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility for Pregnant Women (PE4PW) Program (MC 311) (revised 2/2017).

Currently, existing QPs can enroll individuals in the program using a manual paper application process. The recipient enrollment process was automated April 1, 2017. Providers who meet the eligibility requirements as governed by the PE4PW program can enroll individuals through this automated process. The last day that QPs can enroll recipients manually is September 31, 2017.

Providers must:

• 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 PE4PW training program

No. However, current QPs will have six months from the implementation date of PE4PW automation to submit a new MC 311 (revised 2/2017) to the California MMIS Fiscal Intermediary before access to the online PE4PW application is disabled. DHCS sent letters in mid-November 2016 to existing QPs notifying them of requirements.

The provider is responsible for having trained staff submit the MC 311 form.

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 PE4PW automation goes live. Providers are encouraged to check these FAQs periodically for updates.

QPs can enroll an applicant into the PE4PW 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 PE4PW link to launch the recipient enrollment process.

To qualify applicants must:

• Have income below the monthly limit for household size as listed on the Federal Poverty Level Chart in the Presumptive Eligibility for Pregnant Women manual section
• 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

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.

The QP will receive the PE determination in real-time after the applicant information is entered into the PE4PW Application Web Portal.

The enrollment period begins on the day in which the individual is determined eligible for the PE4PW 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 eligible for PE.

For example

, if an individual is determined eligible 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.

Providers can verify eligibility by using the Automated Eligibility Verification System, a Point of Service device or the Medi-Cal website.

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.

No more than 24 hours.

Providers are encouraged to contact the Telephone Service Center at 1-800-541-5555 and provide the necessary recipient information for further research.

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).

No. It is recommended that the patient’s eligibility be verified at the time of service.

As of July 18, 2016, all persons, regardless of gender identity, may request eligibility for pregnancy services when applying for Medi-Cal or other health insurance affordability programs. A doctor must submit a Treatment Authorization Request (TAR) explaining that the services requested are medically necessary. Medi-Cal has 30 days to take action on the TAR. The TAR overrides gender limitations on procedure codes and allows a person with a gender other than female, who is reporting a pregnancy, to receive pregnancy services.

No. Qualified Providers not enrolled to use the electronic enrollment process through the PE4PW Web Portal will not be able to enroll beneficiaries into PE4PW after October 31, 2018.