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Medicaid PE Citizen Application

During the COVID-19 State of Emergency, individuals who do not have medical insurance that pays for doctors, pharmacy, and hospital visits should complete this application to request Presumptive Eligibility under the Kentucky Medicaid program. Presumptive Eligibility Medicaid is temporary and ends on 12/31/2020 unless you submit an application for regular Medicaid.


An application must be submitted for each individual needing Medicaid coverage. By completing this application, you are attesting to the fact that you do not have medical insurance that covers doctors, pharmacy, or hospital visits.

Personal Information

Complete the following personal information data fields. All fields are required.


Today's Date:
*
Last Name:
*
First Name:
*
Date of Birth:
*
Gender
*
Race (Choose All That Apply):





* 
Social Security Number:
*
Marital Status:
*
Telephone Number (Include Area Code):
*
Email Address:
*
Street Address:
*
 
City:
*
Zip Code:
*
Household Information

The following household information will help us know if others within your household are in need of Medicaid services.


Number of people in your family (count unborn if anyone is pregnant):
*

For each member of your family, include: Family Member Name, Income Amount and How Often:
*

Total family income (income should be counted before taxes are taken out):
*
Other Information

Preferred Method of Notifications:
*

By signing and submitting, I am requesting Medicaid coverage:
*
Next Steps

Once your application has been processed, you will receive notice based on your contact preference with your Medicaid ID. Your Presumptive Eligibility Medicaid is temporary and ends on 12/31/2020 unless you submit an application for regular Medicaid.


An application must be submitted for each individual needing Medicaid coverage.

 
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