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Presumptive Eligibility

Pregnant woman and medical staffer

District of Columbia Presumptive Eligibility Medicaid coverage allows certain health care providers to treat an individual who is not enrolled in the Medicaid’s program.

Hospital-Based Presumptive Eligibility

The District of Columbia offers a Hospital Based Presumptive Eligibility (HBPE) program. HBPE will provide individuals with temporary District Medicaid benefits.  In order to be found eligible for HBPE, an individual must submit an application during their stay at a Qualified Hospital. Individuals will be notified immediately of their eligibility determination and provided the DC Health Link application to apply for full Medicaid coverage. 

 

Who is eligible?

You may be eligible for Medicaid under HBPE, if you:

Fall into one of these categories:

  1. Pregnant women with income up to 319% of the Federal Poverty Level (FPL)
  2. Infants and Children under Age 19 with income up to 319% FPL
  3. Individuals age 19-20 with income up to 216% FPL
  4. Parents and Other Caretaker Relatives with income up to 216% FPL
  5. Childless Adult Group (21-64) with income up to 210% FPL
  6. Former Foster Care Children
  7. Certain Individuals Needing Treatment for Breast or Cervical Cancer
    • Are a District resident; and
    • Are a US citizen or have an eligible immigration status

What is covered?

Individuals found eligible for HBPE will be able to receive all Medicaid services covered by the District of Columbia. Pregnant women found eligible under HBPE will only be able to receive prenatal ambulatory care. Coverage for HBPE will begin on the date an eligibility determination is made and will end on the date a full Medicaid eligibility determination is made. If an individual does not file a full Medicaid application then the presumptive eligibility coverage will end on the last day of the month following the original determination.

 

Pregnant Women Presumptive Eligibility

If you are a pregnant woman you may be eligible for pregnant women presumptive eligibility (PWPE) if:

  • Your income is at or below 319% FPL
  • You are a District of Columbia resident
  • You are a US Citizen or have an eligible  immigration status
  • You are pregnant (Medical verification of pregnancy is not necessary)

If you are found eligible for PWPE, then you will be able to receive coverage for prenatal ambulatory care. Coverage for PWPE will begin on the date an eligibility determination is made and will end on the date a full Medicaid eligibility determination is made. If an individual does not file a full Medicaid application then the presumptive eligibility coverage will end on the last day of the month following the original determination.

 

How to apply for Pregnant Women Presumptive Eligibility (PWPE)?

You can now apply for PWPE at any Qualified Entity, which includes:

  • The Economic Security Administration
  • Federally Qualified Health Centers (*Note: These centers cannot determine eligibility.)
    • The list of Federally Qualified Health Centers can be found here: DOH List of Federally Qualified Health Centers
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