Working with Your State Medicaid Agency

Section Highlights

Working with Your State

State Medicaid agencies are required to develop policies and procedures for how hospital-based PE will work. All states were required to submit a Medicaid State Plan Amendment (SPA) by March 31, 2014 that describes how the new hospital PE option will work in the state. The SPA template that states were required to use can be found here. The template includes details about populations for which presumptive eligibility determinations can be made, whether hospitals are required to assist individuals in the completion of the full application, and the length of presumptive eligibility periods. More details about states’ choices on the template are available in a related implementation guide.

The SPA that a state submits to CMS will provide hospitals with guidance on how presumptive eligibility will work in their state, although hospitals need not wait for their state to submit the SPA to begin the conversation. In states where hospital PE policies are still being developed, hospitals can work with their Medicaid agencies to create meaningful policies. Enroll America’s fact sheet, Promising State Approaches for Using Hospital Presumptive Eligibility, provides examples of specific HPE policies that hospitals may want to encourage their state to consider. States are permitted to change their HPE policies, so hospitals may also find it useful to work with their state to make adaptations to any existing policies.

Topics to Work on with Your State Medicaid Agency

Notification and State Agreements

  • How does the state prefer that hospitals notify them of intent to make presumptive eligibility determinations?
  • Are other state agencies involved in authorizing a hospital to make PE determinations?
  • Does the hospital have to create and submit a PE proposal or does the state provide an agreement or memorandum of understanding that the hospital must submit?

Making Determinations and Follow-Up

  • Who in the hospital, if anyone, is required to take training on PE in order to be able to make PE determinations?
  • Is the state adding additional groups or populations to the list of people (see: Federal Law and Regulations for the standard list of groups covered) who can be determined presumptive eligible?
  • Is the state using an online application or a paper application?
    • If using paper, what is the process for submitting applications? Does the state intend to eventually offer the HPE application online?
  • Is the state using a specific PE application or the full Medicaid application (Note: States sing the full Medicaid application for PE must denote which questions are required for PE)?
    • What information must be collected on a presumptive eligibility application?
  • After a presumptive eligibility determination has been made, what information must the hospital provide to the state to ensure payment for services provided?
  • What identification or documentation will be issued to the patient as proof of temporary Medicaid enrollment?
    • Will the state send notifications to providers or pharmacists about this temporary identification?
  • Is an individual limited in the number of presumptive eligibility periods they can have in a certain time period (e.g. a person can only be determined presumptively eligible one time per year)?

Performance Standards

  • What standards — if any — will the state require the hospital to meet with respect to:
    • The proportion of individuals who receive a presumptive eligibility determination and submit a full application by the end of the temporary eligibility period
    • The proportion of individuals who receive a presumptive eligibility determination and are determined eligible for Medicaid
  • Will hospitals be required to assist applicants with the full Medicaid application?
    • If so, what does a hospital need to do to fulfill this requirement?
  • Will there be a trial period for performance standards (which can be assessed and reevaluated if needed)?
    • Will standards change/ramp up over time?

Disqualification Policies

  • How often will the state review a hospital’s performance and assess its qualifications to continue conducting presumptive eligibility?
  • How will a state notify a hospital if it is in violation of any policies and procedures?
    • Will the state issue guidance around the training it will offer and/or the process and amount of time a hospital will be given to take corrective active before the hospital is disqualified?
    • If a hospital is disqualified, what steps does it need to take to reinstate its ability to make presumptive eligibility determinations?

Working with Other Hospitals in Your State

It may be beneficial to work with other hospitals in your state as part of approaching the Medicaid agency. This is especially true if some hospitals in your state are already using presumptive eligibility for children and/or pregnant women. See our map for more information about which states have already elected to use presumptive eligibility.

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