Presumptive Eligibility for Pregnant Women
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Welcome to the Presumptive Eligibility (PE) for pregnant women web site. This site provides access to information and forms related to PE for pregnant women.
The PE for pregnant women program allows Qualified Providers (QP) 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.
Information For Women Interested In This Program
The PE for pregnant women program is designed for low-income California residents who believe they are pregnant and who do not have health insurance or Medi-Cal coverage for prenatal care.
Find a Qualified Provider to Enroll - On this page, you will find a list of PE providers by county.
Information For Providers
A Qualified Provider is allowed to grant immediate, temporary Medi-Cal coverage and care to pregnant patients pending their formal Medi-Cal application.
Changes were made to the Presumptive Eligibility (PE) for Pregnant Women program. Revisions to the program’s application, supplemental forms and manual are in review. These changes are immediately applicable to women seeking PE for Pregnant Women program eligibility.
Applicants can have Other Health Insurance
The question on the MC 263 PE for Pregnancy - Application for Presumptive Eligibility Only page will only ask if the applicant has Medi-Cal.
Medical verification of pregnancy is not necessary
The MC 263 - PE for Pregnancy Provider Instructions, number 5 will not require the provider to ask for medical verification of pregnancy for purposes of enrollment into the PE for Pregnant Women program. The provider may conduct a pregnancy test only if the beneficiary request one.
Proof of a full Medi-Cal application is not needed to get PE extensions. Self-attestation is accepted
Providers should accept the beneficiary’s self-attestation that she has submitted an application for Medi-Cal or insurance affordability programs. Qualified providers should extend the PE coverage until a full eligibility determination is made.
Do not count child support or cash gifts as income in determining eligibility
Providers shall disregard child support income or cash gifts in determining household income.
The Federal Poverty Level (FPL) has increased
The FPL for the PE for Pregnant Women program is 213%. You can obtain the new FPL on the PE for Pregnant Women program here (PDF).
Presumptive Eligibility for Pregnant Women Program Automation
Announcing upcoming changes in the PE for Pregnant Program.
The Department of Health Care Services (DHCS) will implement the CA-MMIS Health Enterprise (HE) Portal for qualified providers in the Presumptive Eligibility for Pregnant Women (PE4PW) program to assist applicants applying for Presumptive Eligibility. This implementation is targeted for October 31, 2015. There will be a 90 day transition period for existing providers and their staffs to move to the new CA-MMIS HE Portal and DHCS will provide training and support to assist existing providers in the transition process. DHCS wants to assure that all existing providers successfully move to the new system before shutting down the manual process.
DHCS will provide transitioning providers resources, such as Computer Based Training modules, Frequently Asked Questions (FAQs), provider readiness checklists, and more to assist the move to the HE Portal. These resources will be made available to help ensure providers are kept up-to-date and have the information they require to get started on HE. The resources will also be available to all new Medi-Cal providers who will be PE providers in the future.
Providers are encouraged to watch for HE updates in the NewsFlash area on the Medi-Cal website, and subscribe to the Medi-Cal Subscription Service (MCSS) to receive timely notifications related to HE by completing the MCSS Subscriber Form on the Medi-Cal website.
Some the requirements and changes for PE4PW are:
- Current Qualified Providers (QPs) of the program will have to go through training to continue participation in the program.
- Providers wishing to become a QP will be able to request enrollment through an on-line application.
- Beneficiaries will continue to apply for benefits in person at QPs offices.
- QPs will use a new electronic web portal for eligibility determinations.
- PE Eligibility determinations will happen in real time.
- QPs will be able to do electronic claims.
DHCS looks forward to collaborating with its provider community to embrace and realize the benefits of the new system in 2015 and beyond.