Updates on Hospital Presumptive Eligibility

By Liz Hagan

It’s an exciting time for those working on hospital presumptive eligibility (HPE)! Now that 2014 is here, states have started establishing HPE policies, and hospitals have started to put the new option into practice. We have updated our Hospital Presumptive Eligibility Toolkit with information on states’ HPE policies as they have started to roll out around the country. The toolkit now includes:

  • Links to state hospital PE policies and/or hospital PE homepages
  • State performance standards for hospitals using HPE
  • State requirements for providing application assistance to consumers who receive a PE determination
  • State training requirements and links to state training
  • Links to states’ hospital agreements

Last week, CMS also released a number of materials on HPE, including Frequently Asked Questions, a training template, and template forms for hospitals to notify their state Medicaid agency of their intent to make PE determinations. There are a number of notable policy clarifications in the FAQs:

  • Third party eligibility vendors can help hospitals make PE determinations, but the ultimate responsibility for PE determinations lies with the hospital. Previously, CMS indicated that they were considering the use of third parties to assist with PE determinations, and they have now confirmed the appropriate role for third party vendors.
  • Though not a change in policy, CMS has reiterated that:
    • States may not require hospitals to verify residency or immigration status of individuals deemed presumptive eligible; states may require attestations but cannot require additional verification.
    • States cannot require hospitals to make full MAGI-based eligibility determinations in order to determine PE; hospitals must use gross income or a simplified version of MAGI to make PE determinations.
    • States cannot recoup money for services provided during a PE period that resulted from an erroneous determination.
    • States do not need to create a separate PE application; they may use a full Medicaid application for PE determinations as long as it clearly notes which sections are not required to make a PE determination.

We will continue to monitor federal and state developments on HPE and will update the toolkit periodically with new information. If you have questions or have information you think we should share, please contact Liz Hagan (EHagan@enrollamerica.org).

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