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What It Is

​Presumptive eligibility enables eligible pregnant women to receive prenatal care through Medicaid for up to 60 days while their eligibility for full Medicaid benefits is determined.

This program helps improve pregnant women's access to outpatient prenatal services. Enrolled providers complete a simple application on behalf of the pregnant patient to get the process started. Providers are assured payment for early prenatal services and help the woman obtain pharmacy and other prenatal benefits immediately.

Services

The following services may be provided by any enrolled Medicaid provider, following current Medicaid coverage rules:

  • primary care by family practitioners, general practitioners, pediatricians, internists, obstetricians/gynecologists, advanced registered nurse practitioners, nurse midwives and physician assistants;
  • services by primary care centers and rural health clinics;
  • services by local health departments; laboratory services;
  • X-rays and ultrasounds; dental services; emergency room services; prescription drugs; transportation.

Note: Services delivered in an in-patient setting are not covered under presumptive eligibility.

Eligibility

Presumptive eligibility may be granted to a pregnant woman who:

  • Is a Kentucky resident;
  • Meets income guidelines in 907 KAR 20:100;
  • Does not have a current pending Medicaid application on file with the Department for Community Based Services (DCBS)
  • Is not enrolled currently in Medicaid;
  • Has not been granted presumptive eligibility previously for the current pregnancy; and
  • Is not an inmate of a public institution.

Once I am eligible when will my PE begin?

Presumptive eligibility begins on the date a qualified provider determines a woman is presumptively eligible based on the criteria above.

Women granted presumptive eligibility by a qualified provider receive designated benefits for a maximum of 60 days. During this period women are asked to contact their local DCBS Office to determine eligibility for full Medicaid benefits.

When does my PE end?

The presumptive eligibility period ends:

  • on the day before the date the woman is granted full eligibility in the Medicaid program by DCBS; or
  • on the last day of the month after the month a qualified provider made the presumptive eligibility determination
    1. If a presumed eligible woman does not apply for the full Medicaid benefit package, or
    2. Applies for and is found ineligible for the full Medicaid benefits.

Note: Only one presumptive eligibility period is granted for each episode of pregnancy.

Provider Information