Provider Contact Information for Presumptive Eligibility (PE)

Federal Poverty Level (FPL) Chart for PE

FPL Chart for Presumptive Eligibility

Effective April 1, 2008 through March 31, 2009
Number of Persons In the family	200 Percent Monthy Income	200 Percent Monthy Income
2	$ 2,334	$ 28,000
3	$ 2,934	$ 35,200
4	$ 3,534	$ 42,400
5	$ 4,134	$ 49,600
6	$ 4,734	$ 56,800
7	$ 5,334	$ 64,000
8	$ 5,934	$ 71,200
9	$ 6,534	$ 78,400
10	$ 7,134	$ 85,600
For each additional family member add:	$ 600	$7,200

INSTRUCTIONS TO DETERMINE IF APPLICANT QUALIFIES FOR PE SERVICES

Remember: the unborn child is counted as a member of the family.
1. Find the PE applicant’s total family income and family size as it is stated on the Provider Use Only section of the MC 263 PREMED 1 - Application For Presumptive Eligibility Only.
2. Compare the applicant’s income and family size to the 2008-2009 Federal Poverty Level Chart above.

EXAMPLES

A. A pregnant women who lives alone requests PE services. Her monthly income is $2,000. The mother and her unborn child would be counted as a two-person (2) family household. Comparing her income of $2,000 to the chart’s income for a family size of two ($2,334), she would qualify for PE services.
B. A pregnant woman with two children requests PE services. Her annual income is $42,000. The mother, her unborn child, and her two children would be counted as a four-person (4) family household. Comparing her annual income of $43,000 to the chart’s annual income for a family of four ($42,400), she would not qualify for PE services. The provider should help the patient complete a Medi-Cal application, and encourage her to submit the application to her local county welfare office.

If you have questions regarding this chart or the program, contact the PE Support Unit, California Department of Health Care Services, 1501 Capital Avenue, Bldg #171, MS-4607, Sacramento, CA 95814, 1-800-824-0088, Fax 1-800-409-1498.

For Presumptive Eligibility Providers

How to order Presumptive Eligiblity (PE) for pregnant women forms
These forms are used to ENROLL YOUR ELIGIBLE PATIENTS in the PE for Pregnant Women Program	These forms are used to DETERMINE YOUR PATIENT'S ELIGIBILITY for the PE for Pregnant Women Program
MC 263 - PE Applications (These forms may not be duplicated. You must order them from the PE Support Unit.) four part form: PREMED,PREMED 1, PREMED 2 (two copies) (specify English/Spanish) Please allow 2-8 weeks for delivery *Federal Poverty Level (FPL) for PE - Income Screening Chart FAX or mail a completed MC 285 to: California Department of Health Care Services (DHCS) Presumptive Eligibility (PE) Support Unit, MS - 4607 P.O. Box 997417 Sacramento, CA 95899-7417 Fax 1-800-409-1498 If you do not have form MC 285, contact the PE Support unit at the address listed above, and one will be mailed or faxed to you. Or call the PE Support Unit for questions regarding these forms: 1-800-824-0088	MC 263 S-R - State of California Residency (specify English/Spanish) MC 264 - PE patient Fact Sheet (specify English/Spanish) MC 265 - Patient Directions for PE Application (specify English/Spanish) MC 266 - directions for Medi-Cal Application (specify English/Spanish) MC 267 - Explanation of Ineligibility for PE PUB 68 - Medi-Cal What it Means to you These forms are used to REPORT ELIGIBLE PATIENTS to the California Department of Health Care Services MC 283 - Weekly PE enrollment Summary To FAX or mail a completed DHS 2031 to: California Department of Health Care Services Warehouse - Forms Processing 1037 North Market Boulevard, Suite #9 Sacramento, CA 95834 FAX: 916-928-1326 If you do not have the DHS 2031, order it by faxing your business letterhead to: California Department of Health Care Services Warehouse - Forms Processing 1037 North Market Boulevard, Suite #9 Sacramento, CA 95834 FAX: 916-928-1326 DHCS Warehouse Forms Questions: 916-928-9217
*Download these forms at: http://www.dhcs.ca.gov/formsandpubs/forms/Pages/MCEBbyNumber.aspx or visit Presumptive Eligibility (PE) for Pregnant Women

Other Important PE Contacts

PE Billing questions:

Electronic Data Systems (EDS) OB Hotline - 1(800) 257-6900

Medi-Cal Provider Enrollment - (916) 323-1945

Medi-Cal Provider Updates - 1(800) 541-5555

PE Training - 1 (800) 541-5555

DHCS Warehouse PE Forms - (916) 928-9217

PE Application – MC 263 questions - 1 (800) 824-0088

Presumptive Eligibility (PE) Support Unit
1501 Capitol Avenue, MS 4607
Sacramento, CA 95814
1 (800) 824-0088
FAX: 1 (800) 409-1498

Presumptive Eligibility Analyst

Cynthia Cannon - (916) 552-9499