Presumptive Eligibility for Pregnancy (PEP)

Effective October 1, 2025, Presumptive Eligibility for Pregnancy (PEP) allows pregnant women who meet requirements to receive temporary Maternity coverage through the Alabama Medicaid Agency (Medicaid). This coverage begins immediately once a qualified provider makes the determination.

PEP was authorized by Senate Bill 102 (Act 2025-204), passed during the 2025 legislative session.

When PEP Coverage Begins and Ends

PEP coverage starts on the day a qualified provider determines eligibility and ends on the earliest of:

  • The date Medicaid makes a decision on the woman's full application, or
  • The last day of the month following the month in which PEP determination wasm ade (if no Medicaid application is filed), or
  • No later thank the 60th day after the PEP determination
Who Can Determine Eligibility for PEP?

Qualified providers include:

  • Hospitals
  • Federally Qualified Health Centers (FQHCs)
  • Rural Health Centers (RHCs)
  • County Health Departments
  • Physicians
  • Certified Nurse Midwives
  • Certified Registered Nurse Pracitioners
  • Physician Assistants
Eligibility Requirements

A pregnant woman may be determined presumptively eligible if:

  • She provides proof of pregnancy
  • She provides monthly household income documentation
  • Her household income does not exceed Medicaid's MAGI income limits for pregnant women

Qualified providers may determine a pregnant woman to be presumptively eligible for coverage for ambulatory prenatal care under Medicaid if they determine on the basis of preliminary information that household income does not exceed the modified adjusted gross income (MAGI) limit for the eligibility of pregnant women which is in effect under the state Medicaid plan.

Eligibility income Guidelines:  Medicaid Income Limits

How Providers Enroll Patients in PEP

Provider Responsibilities:

  • Determine PEP eligibility based on pregnancy status and income.
  • Notify Medicaid of your determination within 5 business days. (Include details on how to notify Medicaid: TBD)
  • Inform patients that they must complete a full Medicaid application no later than the last day of the following month that PEP coverage began.
  • Encourage patients to apply for Maternity Care coverage right away to avoid a gap in coverage. Patients can apply online at: https://insurealabama.adph.state.al.us/
PEP Coverage

Covered Services:

  • Professional claims
  • Outpatient claims
  • Pharmacy claims

Not Covered:

  • Inpatient hospital claims
  • Dental claims

Important:  Claims must include a pregnancy diagnosis.

Note:  PEP recipients will not be assigned to an ACHN and will not be required to get an ACHN referral.

Resources
  • PEP Application - Coming Soon
  • Frequently Asked Questions - Coming Soon
  • Alabama Medicaid Agency Application (print for patients)
  • Patient Handout - Coming Soon
  • Social Media Post - Coming Soon
Training for Providers

Only qualified providers may make PEP eligibility determinations. Completion of Alabama Medicaid Agency training is required.

To request training or to ask questions, email PEP@medicaid.alabama.gov.

 

 

 

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