Presumptive Eligibility (PE) was designed to identify and provide coverage for individuals who are likely eligible for Medicaid, but are not enrolled. This is not an additional eligibility category; it is a method of determining temporary eligibility. PE determinations are made based on preliminary information, and according to polices and procedures established by the Bureau Medical Services in Chapter 400, Medicaid Eligibility, Section 400.8, Presumptive Eligibility Policy Manual.
Section 1902(a)(47)(B) of the Social Security Act gives qualified hospitals the option to determine an individual to be presumptively eligible and to access Medicaid-covered services while their full Medicaid application is being processed. Sections 1920, 1920A, and 1920B of the Act permits states to identify their State Plan's additional "qualified entities," who are authorized to determine PE.
In 2015 and 2023, the Bureau for Medical Services expanded the PE program to allow additional Medicaid providers and qualified entities the option to enroll as a PE provider. The following entities are permitted to apply to determine PE:
- Qualified Hospitals
- Federally Qualified Health Centers
- Rural Health Clinics
- Comprehensive Community Mental Health Centers
- Free Clinics
- Local Health Departments
- Licensed pharmacists and pharmacy technicians employed by Medicaid enrolled pharmacies
- The Affordable Care Act Navigators and HELP4WV helpline staff employed by First Choice Services
Presumptive Eligibility Enrollment Information
Please contact Elijah Harper, PE Coordinator at 304-558-1700 or elijah.d.harper@wv.gov for application information or questions.