Presumptive Eligibility (PE) is a period of temporary medical assistance for certain categories of Medicaid.
Presumptive Eligibility is available to the following medical assistance categories:
- Children's Medicaid (CM), Expanded CM
- Pregnant Women Medical Assistance (MA)
- Family Planning Medical Assistance (FPMA)
- Breast and Cervical Cancer Program (BCCP)
- Former Foster Care Child MA
- Parent/Caretaker Relative MA
- Granite Advantage Health Care Program
Entities and hospitals who are certified by DHHS are referred to as qualified entities (QEs) and qualified hospitals (QHs). These providers are certified to make presumptive eligibility (PE) determinations for a limited period of temporary medical assistance coverage. This temporary PE medical coverage is provided to individuals who have been determined to have met PE eligibility requirements.
Note: Certified QHs, but not certified QEs, can also determine PE for Former Foster Care Child MA.
The PE period begins on the date the individual is determined eligible by the QH/QE. The end date of the PE is the earlier of:
- The date the determination of eligibility, or ineligibility, for full Medicaid is made by DHHS if an application for full Medicaid is filed by the last day of the month following the month in which the determination of PE is made; or
- The last day of the month following the month in which the determination of PE is made if no application for full Medicaid is filed by that date.
Individuals are limited to one (1) PE period per calendar year or, if pregnant, one (1) PE period per pregnancy.
Requirements are based on limited, preliminary, self-attested information provided by the PE applicant on Form 821, Application for Medicaid Presumptive Eligibility (PE) to include:
- The individual meets the categorical requirements for the appropriate medical assistance category;
- The household income does not exceed the income limit for the household size and medical assistance category;
- The individual attests to being a NH resident; and
- The individual attests to US citizenship or acceptable immigration status.
Qualified Entities (QEs) & Qualified Hospitals (QHs)
An entity or hospital that furnishes health care services and is enrolled with DHHS to receive Medicaid payments as a Medicaid provider must do the following if they wish to determine PE:
- Notify DHHS that they wish to determine PE by completing Form 820, Request to Determine Presumptive Eligibility (PE);
- Attend a training on the eligibility criteria for medical assistance categories and score an 85% or higher on the written exam;
- Maintain certification by:
- applying PE eligibility requirements consistently and accurately during each PE determination,
- verifying that the individual is authorized for the PE period, and
- verifying that the individual is not already a Medicaid applicant; and
- Participate in retraining and retesting.
NOTE: A QE or QH may be disqualified from determining PE if DHHS finds that the certified entity or hospital fails to adhere to the requirements of determining PE.
- Contact the DHHS Customer Service Center toll-free at 1-844-ASK-DHHS (1-844-275-3447) (TDD Relay Access: 1-800-735-2964), Monday through Friday, 8:00 a.m. to 4:00 p.m. ET.
- Visit Related Resources for additional eligibility information.