Presumptive Eligibility is a process that allows qualified entities to determine if an individual can receive short-term Medicaid. It provides individuals with temporary Medicaid coverage while KanCare processes their application for Medicaid.
Facilities such as hospitals, clinics, health departments, schools, etc. can become a Qualified Entity. The facility will notify KDHE of its intention to make presumptive eligibility determinations by submitting a statement of interest. They agree to make presumptive eligibility determinations following KDHE policies and procedures. The qualified entity will assist individuals with the process of submitting the Medicaid application. During the medical application process, the qualified entity will help individuals understand and submit requested documents to KanCare. Qualified entities will be paid the Medicaid reimbursement rates while consumers are receiving Presumptive Eligibility Coverage.
To learn more about becoming a Qualified Entity, select the "Becoming a Qualified Entity" in the Links & Resources section below.
General Eligibility Requirements
General Eligibility Requirements can be defined as specific conditions which must be met for a consumer to be eligible for medical benefits.
Qualified entities can make presumptive eligibility determinations for Pregnant Women, Children, Former Foster Care, Breast or Cervical Cancer (BCC) patients currently receiving treatment, parents, and other caretakers. These consumers must be a resident of Kansas, a U.S. Citizen, or eligible Non-Citizen, and meet income guidelines.
To learn more about General Eligibility Requirements, select the "PE Specialist Training Documents & Materials” in the following sections.
Becoming a PE Qualified Entity
Medicaid providers must be trained and certified by the KDHE Division of Health Care Finance (KDHE-DHCF) prior to making Presumptive Eligibility (PE) determinations. In order to become certified, the Medicaid provider must fulfill the following requirements:
- Complete and submit a Presumptive Eligibility Statement of Interest to KDHE-DHCF.
- A Memorandum of Understanding (MOU) contract must be drafted, agreed to and signed by the entity’s CEO or executive director and the KDHE Secretary. An implementation plan will be agreed to and followed.
- Each Entity must designate staff to complete the KanCare Presumptive Eligibility Training in order to conduct PE determinations at their facilities.
Qualified Entity Responsibilities
Presumptive Eligibility (PE) determinations are based on the self-attestation of the applicants. Entities are not allowed to require or request any documentation for verification during the PE application process.
PE specialists at the Qualified Entity are expected to do the following:
- Review KMMS to ensure that applicants do not have active Medicaid coverage
- Interview applicants to complete the PE application
- Provide applicants with the eligibility results of their determination
- Assist applicants in completing a KanCare application for ongoing coverage
- Act as the facilitator for the consumer, receive and follow-up on correspondence requests made by the Clearinghouse
- Track PE determinations completed at the entity
Forms & Documents for Providers
Training Documents and Materials
Below is a list of documents that Presumptive Eligibility (PE) specialists at Qualified Entities can use for training and reference.
PowerPoint
Presumptive Eligibility Policy & Procedure (effective 02/21/2025) - Presentation that provides all of the fundamentals- What PE is, who is eligible, how to enroll applicants, and the business process from start to finish.
Charts
Below are helpful charts for new and existing PE specialists that can be utilized during the PE application process.
Forms
Below are forms PE specialists will utilize while assisting applicants apply for coverage.
Flyers
