Presumptive Eligibility for presum
Pregnant Women 1
This section includes information about the Presumptive Eligibility for Pregnant Women (PE4PW) program.
The PE4PW program allows Qualified Providers (QPs) 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 application for Medi-Cal (and all other health insurance affordability programs). PE4PW is designed for California residents who believe they are pregnant and who appear eligible for and do not have Medi-Cal coverage for prenatal care.
Eligibility Criteria If the patient is a California resident, believes she is pregnant, and does not have Medi-Cal coverage for prenatal care, the QP should inform her that she may be eligible for PE4PW and show her a copy of the Presumptive Eligibility Patient Fact Sheet (MC 264). The QP should explain that this program provides temporary Medi-Cal coverage for ambulatory prenatal care services. The patient must be told that to continue eligibility for these services, she must formally apply for health insurance affordability programs, including Medi-Cal. If she has already applied for health insurance affordability programs but has not yet been determined eligible, she may still apply for PE4PW.
California Residency: The first form the patient must complete is the Statement of California
Form Completion Residency (MC 263-SR). On this form the patient declares whether or not she is a resident of California and plans to continue living in California.
Note: The patient’s declaration of California residency is all that is necessary. Providers must not attempt to obtain proof of
residency. If the patient has questions about Medi-Cal
residency requirements, she must be referred to the county
Health and Human Services Agency. Provider staff should
explain to each patient that program providers are not responsible for verifying California residency. However, the
provider must tell patients the county will require information
about California residency when the patient applies for health insurance affordability programs, including Medi-Cal.
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Refusal to Complete If the patient refuses to complete the Statement of California
Residency Form Residency form, write “refused” in the signature block. If the patient refuses to sign, or declares she is not a resident, you may not offer her PE4PW program benefits. Complete the bottom portion of the Statement of California Residency form, titled “Why You Cannot Get Presumptive Eligibility for Pregnant Women Benefits (Residency),” and give a copy to the patient. Keep the original for your records.
Note: The Statement of California Residency form has no effect on the patient’s potential eligibility for health insurance affordability programs, including Medi-Cal. If the patient thinks she might qualify, she should be encouraged to apply.
PE Application Patients interested in PE4PW should read the Patient Directions for Presumptive Eligibility for Pregnant Women Program Application (MC 265) and the Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (MC 264). After reading the directions, the patient must complete the Application for Presumptive Eligibility for Pregnant Women Program (MC 263). A supply of original applications must be ordered from the Department of Health Care Services’ (DHCS’) vendor. The applications are pre-imprinted with the Qualified Provider’s name, address, provider ID number, and the patient’s PE4PW ID number.
Definitions of Family The following definitions apply when the patient is filling out the
Members and Income Application for Presumptive Eligibility for Pregnant Women Program and when the provider is determining eligibility:
· “Family Members” are persons living in the patient’s household who are either:
- The spouse of the patient,
- The natural, adopted or step-children of the patient,
- The parents of the patient if she is under 21, unmarried and living with her parents; or
- The unborn (also considered a person when determining the patient’s family size and income level).
“Family Income” is the income of the patient and/or her spouse. If she is under 21, unmarried and living with her parents, the income of her parents is also considered “family income.”
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Minors Applying for PE When a minor applies for PE4PW, she must include her family members and gross family income on the application as indicated in “Definitions of Family Members and Income” in this section.
· If the patient is younger than 21, unmarried and living on her own with no children, only her income is counted.
· If the patient is younger than 21 and married, her income and her spouse’s income are counted. Children living in the patient’s household are only included as family members.
· If the patient is younger than 21, unmarried and living with her parents, her income and her parents’ income are counted. Siblings living in the patient’s household are only included as family members.
· If the patient is younger than 21, married and living with her parents, her income, her spouse’s income and her parents’ income are counted. Siblings living in the patient’s household are only included as family members.
· If the patient is younger than 21, unmarried, and does not know her parents’ income or cannot obtain their income because she does not want them to know about her PE4PW program application, she can apply for the Minor Consent Program at her local county social services office. The Minor Consent Program provides basic benefits, including pregnancy-related services, based solely on her income and resources. The minor’s parents are not contacted or included in the determination for Minor Consent Program services. (See the Eligibility: Recipient Identification Cards section in the Part 1 manual and the Minor Consent Program section of the appropriate Part 2 manual for information about the Minor Consent Program.)
Income Screening Once the patient has completed the Application for Presumptive
Guidelines Eligibility for Pregnant Women Program, the provider compares the patient’s family size and gross income from that application to the Poverty Income Guidelines in this section. Income verification is not required; however, the patient must include her income on the PE application.
When determining family size, the unborn child is always counted as a family member. Anyone not defined as a family member should not be counted. (Refer to “Definitions of Family Members and Income” in this section for more information.) For example, a “boyfriend’s” income is not counted, even if he is the father of the unborn child. Only the income of the patient and her spouse (if married) should be counted. If the patient is younger than 21 and living with her parents, her parents’ income also is considered “family income” and must be counted.
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Income Eligibility The Federal Poverty Level (FPL) Chart is used to determine
Guidelines whether an applicant’s gross family income is at or below the PE4PW program income limits. “Gross Income” is defined as income before taxes and other deductions. The applicant’s unborn child is counted as a member of the family; therefore, the guidelines begin with two persons (the mother and her unborn child).
Federal Poverty Level Chart
Effective January 1, 2017, through December 31, 2017
Number of Persons In Family / 213 PercentMonthly Income / 213 Percent
Annual Income
2 / $2,883 / 34,592
3 / $3,625 / $43,495
4 / $4,367 / $52,398
5 / $5,109 / $61,302
6 / $5,851 / $70,205
7 / $6,593 / $79,109
8 / $7,335 / $88,012
9 / $8,077 / $96,915
10 / $8,819 / $105,819
For each additional family member add: / $742 / $8,904
Note: The Federal Poverty Level Chart is adjusted on an annual basis.
Example 1 A pregnant woman is single with two children. Her gross monthly income is $1,200. Her elderly aunt lives with her and receives $550 a month from Social Security.
The pregnant woman and her two children would be counted as a four-person household: Herself, her unborn child and her two children. The aunt and her income would not be counted as part of the family income or family size.
The woman’s monthly income of $1,200 is at or below the gross monthly income for her family size as indicated by the FPL chart; therefore, she meets the income criteria for PE for Pregnant Women.
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Example 2 A pregnant woman lives with her boyfriend (who is the father of the unborn child) and her son from a previous marriage. Her boyfriend has an income of $1,500 a month, and she receives $250 a month in child support for the son and has no other income.
For PE4PW purposes, the number of persons in the pregnant woman’s household is three: The woman, her unborn child and her existing child. Her boyfriend and his income are not counted because he and she are not married. Her $250 a month child support is not counted as income and thus her income is $0. Her income of $0 is at or below the monthly 213 percent amount for her family size and she meets the income criteria for PE4PW. If her pregnancy test is positive or she self-attests to pregnancy, she is eligible.
Pregnancy Test The patient is not required to take a pregnancy test. Patients can
self-attest to pregnancy.
Positive Result If the patient meets the residency and income criteria for PE4PW, and states that she is pregnant or requests a pregnancy test and the result is positive, the patient is eligible to receive the PE for Pregnancy – Proof of Eligibility immediate need card and instructions on applying for health insurance affordability programs, including Medi-Cal.
If the patient does not meet the income criteria, she is ineligible. Issue her a Why You Cannot Get Presumptive Eligibility Benefits form.
Negative Result If the patient requests a pregnancy test and the result is negative, she is not eligible for PE4PW, but the office visit and pregnancy test are still reimbursable. The QP must issue the patient an Explanation of Ineligibility for the Presumptive Eligibility for Pregnant Women Program (MC 267) and report her ineligibility to DHCS in order to bill for the visit. (See “Record Retention” on a following page for instructions.) The patient may apply for health insurance affordability programs, including Medi-Cal, even if she is not eligible for PE4PW.
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Eligibility Limitations Eligibility for PE4PW is limited to once per pregnancy. If PE4PW is granted to a patient and she does not apply for a health insurance affordability plan, including Medi-Cal, or if she is determined to be ineligible for Medi-Cal, she should not be re-evaluated for the PE4PW program during that pregnancy. If she is determined to be ineligible for Medi Cal, providers may arrange for private payments.
When determining eligibility, providers should ensure all items on the Application for Presumptive Eligibility for Pregnant Women Program form are complete and legible. The applicant’s and each family member’s full name, relationship, and the family’s gross monthly income must be included.
PE Card Issuance Qualified Providers must order Application for Presumptive Eligibility for Pregnant Women Program (MC 263) packages in advance. Photocopies may not be used. When PE4PW program eligibility is determined, the Proof of Eligibility immediate need card must be completed with the patient’s name, date of birth, valid month and year, and the “FIRST Good thru” date (the last day of the month following the month in which PE4PW eligibility is determined). The QP and patient must both sign and date the card. The patient must be told that she may use this card for ambulatory prenatal care and pharmacy services rendered by Medi-Cal providers and that she is not eligible for labor and delivery, family planning or inpatient services through the PE4PW program.
Replacement Card If a patient loses her card, she should apply for a replacement with the QP who initially established her eligibility for PE4PW. The provider may issue a replacement card if she has applied for a replacement before the “FIRST Good thru” date or if she states that she has applied for health insurance affordability programs, including Medi-Cal (no verification is required) and she has not received a determination. If the woman states she has not applied for health insurance affordability programs, including Medi-Cal, and she is asking for a replacement after the “FIRST Good thru” date, no replacement card may be issued. This patient should be instructed to apply for health insurance affordability programs, including Medi-Cal.
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The QP must fill in the patient -identifying information on the bottom of the PE for Pregnancy – Proof of Eligibility immediate need card. The word “Replacement” and the 14-digit number from the original PE for Pregnancy – Proof of Eligibility immediate need card must be written on the new PE for Pregnancy – Proof of Eligibility immediate need card and reported to the PE4PW Support Unit on the Weekly Presumptive Eligibility (PE) for Pregnant Women Enrollment Summary. See “Reporting PE” in this section. If the patient has applied for a replacement card before the “FIRST Good thru” date and does not state that she has applied for health insurance affordability programs, including Medi-Cal, the replacement card should have the same “FIRST Good thru” date as the original. If the patient states that she has applied for health insurance affordability programs, including Medi-Cal, put “until Medi-Cal eligibility is determined” as the “SECOND Good thru” date.
Any claims submitted after the patient is issued a replacement card must contain the new 14-digit number.
PE for Pregnancy Packages Qualified Providers should keep a supply of PE for Pregnancy packages (MC 263) that are ordered through DHCS’ contracted vendor using the Forms Order – Presumptive Eligibility (PE) for Pregnant Women Program (MC 285). These packages contain the PE for Pregnancy – Proof of Eligibility form, the Application for Presumptive Eligibility for Pregnant Women and two copies of the
PE for Pregnancy – Medi-Cal Application. The forms are
pre-imprinted with the Qualified Provider’s name, address and patient PE4PW ID numbers.