Medicaid Presumptive Eligibility Moves to Fee-For-Service


December 18, 2018

By: Amanda K. Schipp and Brandon W. Shirley

Indiana Medicaid announced that, effective January 1, 2019, adults determined to be presumptively eligible for Medicaid will receive fee-for-service benefits during the presumptive eligibility (PE) coverage period. This change means that the enhanced benefits and additional flexibilities previously available during the PE coverage period through managed care will no longer be available to PE adults in fee-for-service as summarized below. The full copy of the Indiana Health Coverage Program (IHCP) bulletin is available here.

  • Mental Health Coverage in an Institute for Mental Disease (IMD). Since mental health services in an IMD are only permitted through managed care, this change means that individuals in a mental health crisis will no longer be able to receive PE covered services in an IMD.
  • Pregnancy Benefits. Individuals who become pregnant during their PE coverage period will no longer be able to receive enhanced maternity care through the managed care entity. Instead, these individuals will need to timely report the change to the State so the individual can be transitioned to the PE for Pregnant Women eligibility category in order to access maternity benefits. 
  • Non-Emergency Transportation (NEMT). Fee-for-service patients will no longer have access to these transportation services during their PE coverage since that too is an enhanced benefit offered through managed care. 

Importantly, once individuals complete the application and eligibility process to transition to full Medicaid coverage, the individual will have full access to all of the typical benefits available through managed care. Therefore, it will become even more important to ensure timely completion of the full Medicaid application following the initial PE determination. 

For individuals eligible for the Healthy Indiana Plan, the fast track option is also available to further reduce the time prior to full coverage. Fast track allows an applicant to pay a POWER account contribution at the time of application or any time prior to the state’s eligibility determination. Once the applicant is determined eligible for Medicaid, the individual’s Medicaid eligibility dates back to the first day of the month in which the fast track payment was made, which can be as early as the first day of the month in which the application was filed.

If you have any additional questions about this bulletin or how it impacts you, please contact Amanda K. Schipp (aschipp@kdlegal.com) or Brandon W. Shirley (bshirley@kdlegal.com).