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MEDICAL SERVICES POLICY MANUAL, SECTION B

B-280 Presumptive Eligibility-Pregnant Woman (PE-PW)

B-280 Presumptive Eligibility-Pregnant Woman (PE-PW) MS Manual 07/01/26

Agencies who have been designated by DHS as Qualified Entities (QE)* may determine women presumptively eligible for PE-PW Health Care based on preliminary information, subject to federal and state requirements, in order that the individual may receive temporary coverage until ongoing eligibility for Health Care is officially determined by DHS. The goal of the PE-PW process is to offer immediate health care coverage to pregnant women likely to be Health Care eligible before there has been a full Health Care eligibility determination. * See the Medical Services Policy Glossary for more information on Qualified Entities for PE-PW. If determined eligible for PE-PW, the individual will have temporary coverage during the PE-PW period. The PE-PW period begins on the day that a QE or DHS determines the individual to be presumptively eligible and will end the date DHS makes the final determination for full Health Care coverage. The individual must be pregnant at the time of the PE-PW coverage being determined and cannot be currently receiving Health Care coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Pregnant women are limited to one PE-PW determination per pregnancy. If a woman is pregnant more than once in a calendar year, they may have more than one presumptive eligibility period in a calendar year due to multiple pregnancies. NOTE: PE-PW coverage is temporary coverage that is restricted to the designated PE-PW period outlined above. Due to this the PE-PW category does not require advance notice in order to end the PE-PW coverage once the final determination for full Health Care is made, no matter the outcome of that final determination.

Qualified Entities (QE), including DHS, are responsible for determining eligibility for PE-PW. The QE will make the PE-PW determination based on the following criteria: • State residency • Income PE-PW Coverage will be determined based off self-attested information and may be approved while information is pending to determine eligibility for an ongoing Health Care coverage. Self-attestation of all household information will be accepted for PE-PW. The income limit for the PE-PW category may be found in Appendix F.

Presumptive Eligibility Pregnant Woman (PE-PW) coverage is limited Medicaid that is restricted to prenatal services and services for conditions that may complicate the pregnancy. These services are further limited to the outpatient setting only.