Medicaid Presumptive Eligibility

Children and learners attending public school, private school, charter school, preschool programs, and childcare programs may need healthcare and not have insurance to seek the appropriate care. School nurses can assist families with accessing the necessary application to access Iowa’s medicaid program.

Medicaid Qualified Entity (QE) 

The school nurse, in a Medicaid approved provider school (meaning a school that holds a national provider identifier), may become a QE to make the presumptive determination about a child's Medicaid eligibility based on the family's income self declaration statement to assist the child in receiving immediate medical care from a community or school based health center licensed healthcare provider.

Once registered as a Qualified Entity (QE), the QE ensures with their organization that emails from HHS will not be blocked by their organization's firewall. Emails will be the primary source of communications between the QEs and HHS.

Presumptive eligibility (PE) 

Presumptive eligibility provides Medicaid for a limited time while a formal Medicaid eligibility determination is being made by the Iowa Department of Health and Human Services (HHS). The goal of the presumptive eligibility process is to offer immediate health care coverage to people likely to be Medicaid eligible, before there has been a full Medicaid determination. Based on a household’s statements regarding their circumstances and income, a qualified entity (QE) can enter the applicant’s information into the Medicaid Presumptive Eligibility Portal (MPEP). If determined to be eligible, the applicant will have temporary Medicaid eligibility during the presumptive eligibility period. A “qualified entity” or QE is generally defined as an enrolled Iowa Medicaid provider who is certified by HHS and is authorized to make presumptive eligibility determinations. A provider who meets the QE requirements must agree to the terms and conditions in an electronically maintained Memorandum of Understanding (MOU).

Presumptive Eligibility refers to a government program that offers immediate health services access by providing temporary health insurance through Medicaid or Children’s Health Insurance Program (CHIP). A presumptive provider is an organization that approves PE determinations, is authorized by the state agency and who may not delegate their PE authority to another entity, subcontractor or agent. In the state of Iowa, Iowa HHS is considered the presumptive provider. A qualified entity (QE) is an individual authorized to determine presumptive eligibility under the supervision and authority of the presumptive provider. 

School nurses who would like to become a QE should reach out to their school leadership and Iowa Health and Human Services.