Tip for State-specific PE form

PE coverage is temporary — you MUST submit a full Medicaid application to continue coverage

Tip for State-specific PE form

PE is available for pregnant women, children, and in some states, other adults

Tip for State-specific PE form

Hospitals that are PE providers must screen you for PE before providing non-emergency services

Medicaideasy

Presumptive Eligibility Determination

State-specific PE form · State Medicaid Agencies / Qualified Entities

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Form Details

Total fields: 25
Auto-fillable: 18 (72%)
Time without BeneFill: 20 minutes
Time with BeneFill: 6 minutes
Time saved: 14 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

At a qualified presumptive eligibility (PE) provider

Hospitals, clinics, and community health centers designated as PE providers can determine PE on-site.

🌐

Some states allow PE applications online through their Medicaid portal

Filing Deadline

You must submit a full Medicaid application during the PE period to continue coverage.

Required Attachments

📎 Self-declaration of income and household size (detailed verification is not required for PE)
📎 Basic identification information

Processing Time

Immediate. Coverage begins the day the PE provider determines you are likely eligible.

What Happens Next

You receive temporary Medicaid coverage while your full application is processed. PE coverage typically lasts until the end of the month following the month of the PE determination.

Tips for This Form

✓ PE coverage is temporary — you MUST submit a full Medicaid application to continue coverage
✓ PE is available for pregnant women, children, and in some states, other adults
✓ Hospitals that are PE providers must screen you for PE before providing non-emergency services
✓ PE cannot be denied based solely on immigration status for pregnant women in many states

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Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

HealthCare.gov Marketplace Application

Federal Marketplace Application · CMS / Federal Marketplace

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Emergency Medicaid Application

State-specific (e.g., Form 520) · State Medicaid Agencies

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Medicaid Renewal / Redetermination

State-specific (e.g., CA MC 210 RV) · State Medicaid Agencies

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

QMB / Medicare Savings Program Application

State-specific MSP/QMB form · State Medicaid Agencies

Application for Medicare Savings Programs (QMB, SLMB, QI) that help pay Medicare premiums, deductibles, and copays for low-income Medicare beneficiaries.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies / Qualified Entities or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.