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Hospital Presumptive Eligibility

Hospital Presumptive Eligibility. AHCCCS Training July 2014. Training Objectives. HPE Overview Eligible Populations Eligibility Period and Benefits Hospital Qualifications Becoming an HPE Provider The HPE Application Program Integrity. HPE Overview.

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Hospital Presumptive Eligibility

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  1. Hospital Presumptive Eligibility AHCCCS Training July 2014

  2. Training Objectives • HPE Overview • Eligible Populations • Eligibility Period and Benefits • Hospital Qualifications • Becoming an HPE Provider • The HPE Application • Program Integrity Reaching across Arizona to provide comprehensive quality health care for those in need

  3. HPE Overview • HPE is a process under the Affordable Care Act to connect eligible people to Medicaid • Participating in HPE is optional for hospitals • Hospitals must follow federal and state requirements and performance standards • States have discretion how to operate HPE to ensure appropriate PE determinations are made Reaching across Arizona to provide comprehensive quality health care for those in need

  4. Eligible Populations • Pregnant women (up to 150% FPL) • Infants (up to 147% FPL); children 1-5 (up to 141% FPL); and children 6-19 (up to 133% FPL) • Parents and caretaker relatives (up to 106% FPL) • Non-disabled adults, 19-64 w/o Medicare (up to 133% FPL) • Children who were in foster care at age 18 and aged out are considered eligible up to their 26th birthday • Individuals qualifying under the Breast and Cervical Cancer Treatment Program for those hospitals that are also qualified to perform breast and cervical cancer screenings by the Arizona Department of Health Services under the Well Woman Health Check Program Reaching across Arizona to provide comprehensive quality health care for those in need

  5. Eligibility Criteria • Not currently enrolled in Medicaid • Attest to household size and income • Attest to citizenship/ qualified immigrant status, state residency requirements • Unable or does not have all verification needed to complete a HEAplus application • Cannot have been enrolled via HPE within the last twenty four months Reaching across Arizona to provide comprehensive quality health care for those in need

  6. Eligibility Period • Begins the day HPE determination made • If customer completes a full Medicaid application, HPE ends the day the Medicaid determination is made • If no Medicaid application filed, HPE ends the last day of the month following HPE determination • HPE is only allowed once every 24 months Reaching across Arizona to provide comprehensive quality health care for those in need

  7. HPE Benefits • Benefits are the same as those provided under Medicaid • Federal regulations limit HPE benefits for pregnant women to ambulatory pre-natal care only (no inpatient, non-prenatal care) • Arizona is seeking a waiver to allow pregnant women in HPE to receive full benefits Reaching across Arizona to provide comprehensive quality health care for those in need

  8. Hospital Qualifications • Licensed by ADHS or is a federally operated hospital, including I.H.S. and tribally operated 638 hospitals • Is an active AHCCCS registered provider • Has a HEAplussubscription agreement in place • Is trained as a HEAplus subscriber • Agrees to be listed on AHCCCS website as authorized site for application assistance • Provides application assistance for anyone living in AZ, not just those in need of hospital services Reaching across Arizona to provide comprehensive quality health care for those in need

  9. Hospital Qualifications Con’t • Operates within the state of Arizona • Notifies AHCCCS of HPE election and agrees to abide by State policies • Has not been disqualified by the agency to conduct HPE determinations • Ensures 90% of applicants made eligible via HPE complete full AHCCCS application before end of HPE eligibility period • Ensures 95% of persons made HPE eligible who complete a regular Medicaid application are determined eligible by the State Reaching across Arizona to provide comprehensive quality health care for those in need

  10. Becoming an HPE Provider • Register with AHCCCS • Complete HEAplus Subscription Agreement • Sign the HPE Policy Agreement • Complete initial and ongoing training • If you meet these criteria, email HEAAHCCCS@azahcccs.gov Reaching across Arizona to provide comprehensive quality health care for those in need

  11. The HPE Application • Requires information about: • Gross income • Household members • Citizenship and residency (signature) • OIG will review all HPE determinations • The HPE application cannot be approved if applicant is over income or does not meet citizenship/residency requirements. Reaching across Arizona to provide comprehensive quality health care for those in need

  12. Submitting HPE Applications • Step 1: Start application in HEAplus • Step 2: Try to complete a full application first • Step 3: If the applicant is unable to complete a full application, use HPE as the backup • Step 4: Schedule a follow-up appointment to complete the full AHCCCS application • Step 5: Provide an HPE eligibility determination letter on hospital letterhead with instructions to complete AHCCCS application (next slide) • Step 6: Submit HPE application online to AHCCCS Reaching across Arizona to provide comprehensive quality health care for those in need

  13. The HPE Determination Letter • Hospital provides HPE determination letter explaining whether applicant is eligible • Letter must explain: • If denied, no appeal rights are available. • If approved, identify the • HPE time period, including exact date applicant made eligible • Need to complete full application • Appointment time to complete full AHCCCS application Reaching across Arizona to provide comprehensive quality health care for those in need

  14. Reimbursement • All claims for HPE services will be submitted to AHCCCS and reimbursed on a fee-for-service basis at AHCCCS rates • No payments for completing HPE determinations • No payments for completing AHCCCS applications • Can not charge applicants to apply for HPE or assist with AHCCCS applications Reaching across Arizona to provide comprehensive quality health care for those in need

  15. Program Integrity • HPE is a powerful tool- hospital staff have authority to determine eligibility for Medicaid • AHCCCS has a fiduciary duty to ensure taxpayer funds are appropriately spent • The Office of Inspector General (OIG) will monitor and identify trends in order to conduct additional investigations and take necessary corrective action, as needed Reaching across Arizona to provide comprehensive quality health care for those in need

  16. Program Integrity Reporting • All HPE participating hospitals must submit quarterly reports with the following: • Number of HPE applications by: • Specific hospital facility • Name of the Hospital worker who approved the HPE application • Approvals by • Eligibility category • Income • Denials • Reason for denial • Medical Need – e.g., did applicant come in through ED, IP, OP, walk in/not a patient Reaching across Arizona to provide comprehensive quality health care for those in need

  17. Program Integrity Reporting Con’t • Number of follow up appointments scheduled to complete a regular application for benefits • Number of missed appointments • Number of HPE applicants for whom follow up appointment was not scheduled and reason why • Number of HEAplus applications for individuals determined presumptively eligible that were completed before the end of the PE period • Number of individuals made eligible via HPE for whom no Medicaid application was completed Reaching across Arizona to provide comprehensive quality health care for those in need

  18. Program Integrity Reporting Con’t • Number of individuals made eligible using HPE who were later denied for full Medicaid coverage. • Number of HPE approved applications, which the OIG later determined to not meet eligibility. • Total payments made for services provided to individuals eligible via HPE. • Annual Report: • Due January 31 • Includes same elements in quarterly report aggregated for calendar year • Submitted to the OIG Reaching across Arizona to provide comprehensive quality health care for those in need

  19. Program Integrity Con’t • OIG will perform regular on-site audits of HPE qualified hospitals • OIG will inspect records, policies and procedures, documentation and compliance with HPE requirements • Annual audits will also be conducted by an independent third party • All findings will be reported and posted to the AHCCCS website • If OIG audit results in open investigations for Medicaid fraud, waste, or abuse, the qualified hospital could be subject to disciplinary action Reaching across Arizona to provide comprehensive quality health care for those in need

  20. Hospital Disqualification • Federal regulations allow states to disqualify hospitals from participating in HPE for failure to meet standards: • 90% of all individuals made presumptively eligible must complete a regular application before the end of their HPE period • 95% of all applicants made presumptively eligible that complete a regular Medicaid application must be found eligible for full Medicaid benefits Reaching across Arizona to provide comprehensive quality health care for those in need

  21. Hospital Disqualification Con’t • Qualified hospitals not meeting the above-stated standards will be placed on a corrective action plan (CAP) and will be given one calendar year from the date the CAP to come into compliance • 12 month grace period beginning the first month the hospital is granted permission for HPE participation before disqualifications will be made • Hospital will be disqualified if after completion of the CAP and additional training, the State determines the hospital is not capable of making HPE determinations in compliance with standards Reaching across Arizona to provide comprehensive quality health care for those in need

  22. Questions? Reaching across Arizona to provide comprehensive quality health care for those in need

  23. Thank You. Reaching across Arizona to provide comprehensive quality health care for those in need

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