Ind. Admin. Code tit. 405, r. 10-4-11 – Presumptive eligibility

Sec. 11. (a) An individual may apply for presumptive eligibility under the plan. A qualified presumptive eligibility provider shall determine whether an individual is eligible for a presumptive eligibility period.

(b) An individual who is determined presumptively eligible for the plan shall receive coverage under the fee-for-service model comparable to HIP Basic, including applicable copayments.

(c) A presumptively eligible individual who does not file an Indiana application for health coverage shall receive the presumptive eligibility benefits described in subsection (b) until the last day of the month following the month in which the determination of presumptive eligibility was made.

(d) A presumptively eligible individual whose application for health coverage has been filed and approved by the division shall receive the presumptive eligibility benefits described in subsection (b), until one (1) of the following occurs, as applicable:

(1) Presumptively eligible adult members are enrolled in HIP Basic effective the first day of the month following approval of the members full Indiana health coverage program application. These members continue to have the potential to buy in to HIP Plus benefits by making a POWER account contribution within sixty (60) days of HIP enrollment.
(2) Presumptively eligible adult members who make a POWER account payment within sixty (60) days from the date of determination shall be enrolled in HIP Plus effective the first day of the month after payment is received.
(3) Presumptively eligible adult members who do not make a POWER account payment within sixty (60) days and have household income equal to or less than one hundred percent (100%) of the FPL, shall be enrolled in HIP Basic effective the first day of the month following approval of the members full Indiana health coverage program application. These members are not eligible to buy in to HIP Plus until eligibility redetermination.

(e) A presumptively eligible individual whose Indiana application for health coverage has been filed, but not approved by the division, shall receive the presumptive eligibility benefits described in subsection (b), until the day on which a decision is made on that application.

(f) An individual whose presumptive eligibility period ends in accordance with subsections (c), (d)(2), and (e) shall not be enrolled in the plan and may reapply.

(g) An individual shall only be approved for one (1) period of presumptive eligibility within a twelve (12) month period beginning on the date that a qualified presumptive eligibility provider makes an affirmative presumptive eligibility determination.

(Office of the Secretary of Family and Social Services; 405 IAC 10-4-11; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA; filed Jan 19, 2018, 8:42 a.m.: 20180214-IR-405170484FRA; errata filed Feb 22, 2018, 9:36 a.m.: 20180307-IR-405180114ACA; filed Mar 18, 2019, 2:27 p.m.: 20190417-IR-405180371FRA; readopted filed Oct 16, 2024, 11:20 a.m.: 20241113-IR-405230817RFA)