PROVIDERS

The Health Care Authority’s mission is: We ensure that New Mexicans attain their highest level of health by providing whole-person, cost-effective, accessible, and high-quality health care and safety-net services.

Presumptive Eligibility Determiners

Presumptive Eligibility (PE)
Presumptive Eligibility (PE) is short-term (60 days or less) Medicaid coverage for children up to age 19, pregnant women, parent caretakers, other adults, breast and cervical cancer, former foster care individuals and/or other adults who live in New Mexico and are a US Citizen, US National or eligible immigrant.
PE is effective from the date of the eligibility determination until the last day of the following month, or if an on-going Medicaid application is submitted along with the PE, the PE will continue until the on-going application has been processed. The goal of PE coverage is to provide immediate access to medical care provided through Medicaid and to ensure that the client has access to application assistance and possible ongoing Medicaid coverage.

Presumptive Eligibility Determiners (PEDs)
In New Mexico we have Presumptive Eligibility Determiners (PEDs) throughout the state, who assist individuals with the submission of PE applications and on-going Medicaid applications. The PEDs can also assist individuals with other applications like SNAP, CASH assistance, LIHEAP and program renewal applications. PEDs are trained and certified by the Health Care Authority (HCA), Medical Assistance Division (MAD) PE Program staff to perform application assistance and to make presumptive eligibility determinations.
PEDs screen for Medicaid eligibility based on self-attestation. When screened correctly, applicants will most likely be approved for presumptive eligibility (emergency Medicaid) and for ongoing Medicaid coverage. When an ongoing Medicaid application is submitted, PE will continue until final determination has been made for ongoing Medicaid eligibility. An approved ongoing application may result in 12 months of Medicaid eligibility for children; coverage for pregnant women (which includes 2 months of post-partum care).

How to Become a Certified New Mexico Medicaid Presumptive Eligibility Determiner
To become a Presumptive Eligibility Determiner, the Medical Assistance Division (MAD) approves the entity you work with is able to participate in our PED Program.
Entities who may participate in the PE program must be:

A qualified hospital that participates as a provider under the Medicaid state plan or a Medicaid 1115 demonstration waiver who notifies the Medicaid agency of its election to make presumptive eligibility determinations and agrees to make PE determinations consistent with state policies and procedures
An entity or provider that has not been disqualified by the Medicaid agency for failure to make PE determinations in accordance with applicable state policies and procedures or for failure to meet any standards that may have been established by the Medicaid agency
A federally qualified health center (FQHC), an Indian health service (IHS) facility, a state of New Mexico agency, a school, or a head start agency or a primary care provider who is contracted with at least one HCA contracted MCO; or
Correctional facilities (state prisons and county jails), health facilities operated by the Indian health service, a tribe, or tribal organization or an urban Indian organization; or
Clinics, behavioral health organizations, community organizations, 3rd party contractors and Department of Health Employees.

Upon approval for our PE program, you will be required to complete a series of computer-based training sessions to become certified. Training sessions are currently scheduled for employees of entities who are approved to participate in the New Mexico Medicaid Presumptive Eligibility Program. During the individual’s certification to become a PED,training will include an informational overview of Medicaid policy, eligibility, enrollment, the Presumptive Eligibility application process, and available resources. Trainees must take a program comprehension test after completing the computer-based training and have a passing test score of 90% or higher to become a certified PED. If you do not pass the exam, you will have a second chance to take the PE training and pass the exam. Upon immediate request, you have two options on how you want to take the next training course based on your learning needs. Option one, is to take the computer-based retake training. Option two, is attending a live two-day webinar training session online with a live instructor that is held once a month. All trainings are administered though the Learning Management System within YesNM. Individuals must create a PED Applicant account on the YESNM-PE portal– The applicant will then be directed to create an application on the Provider and Presumptive Eligibility Determiner Enrollment System. The PE Program staff will review the application request, and the individual will receive an email either accepting or denying the request. For additional instructions on submitting an application to become a certified PED, please email the PED Box:

HCA.PEDeterminers@HCA.NM.GOV

How to become PE Determiner
Process Overview