101.05.07 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN (PEP)

Qualified providers/entities are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid. A qualified provider/entity is one that participates as a Medicaid provider, has executed required PEP formal agreements with DOM and agrees to make PEP decisions according to state policies provided to authorized entity staff. PEP is time-limited Medicaid eligibility for pregnant women presumed to be eligible for Medicaid. DOM provides qualified providers/entities with the PEP application form and model notices to use to establish PEP. The provider/entity must provide written notice to the PEP applicant regarding their eligibility for PEP and assist the PEP applicant in completing and submitting the full application for Medicaid before the end of the PEP period. The Division of Medicaid provides training and training material to provider/entity staff assigned to PEP. These individuals are required to pass a knowledge test before becoming certified to authorize PEP decisions. In addition, DOM provides the PEP staff with PEP applications and notices for use in PEP decisions. PEP approvals must be transmitted by the qualified provider/entity to DOM central office staff assigned to PEP within 5 days after the approval decision. DOM assigns a Medicaid ID and places PEP on file. The begin date of PEP is the day the provider/entity approves PEP. The end date of PEP is either the last day of the month following the month the PEP period begins, or the day DOM makes the final decision on the full application, which could either lengthen or shorten the PEP period. If a full Medicaid application is submitted to DOM following the PEP decision, the application is completed by the central office staff member assigned to PEP. If the full application is approved, the regional office is responsible for the case after approval, i.e., at the time of the first renewal or reported change. If the full application is denied, identifying information remains on record with the office in the event the individual reapplies.