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Hospital Presumptive Eligibility (HPE) Program Frequently Asked Questions

  1. What is Hospital Presumptive Eligibility (PE)?

    Hospital PE provides temporary, no Share of Cost Medi-Cal benefits during a presumptive period to individuals determined eligible by a qualified hospital on the basis of preliminary patient information.

  2. What is the authority for implementing the Hospital PE Program?

    On July 5, 2013, the Centers for Medicare & Medicaid Services (CMS) released Part 2 of the Medicaid final rule regulations to implement various provisions of the Patient Protection and Affordable Care Act (ACA). Title 42 of the Code of Federal Regulations, Section 435.1110, established the Hospital PE Program.

  3. What is a “qualified hospital?”

    A qualified hospital is a hospital that participates as a Hospital PE provider under the state plan or under the authority of the Section 1115 Medicaid demonstration waiver. The qualified hospital must be licensed.

  4. How does a hospital become a qualified hospital for purposes of participating in the Hospital PE Program?

    The hospital must:

    • Notify the Department of Health Care Services (DHCS) of its election to participate in the Hospital PE Program.
    • Agree to the terms and conditions established by DHCS
    • Ensure hospital staff completes the Hospital PE training program

    Instructions will be provided detailing how and when hospitals shall notify DHCS of its election to partake in the Hospital PE Program.

  5. When was the Hospital PE Program implemented?

    The Hospital PE Program was implemented January 1, 2014.

  6. Who is responsible for submitting the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022)?

    The qualified hospital will be responsible for having trained staff submit the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022) online. The Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022) may not be submitted in a paper format

  7. How does a hospital submit the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022)?

    Qualified Hospital PE providers will login via the Transactions tab of the Medi-Cal website and submit applications under the Hospital Presumptive Eligibility tab. The hospital’s National Provider Identifier (NPI) and Provider Identification Number (PIN) are required to log on.

    Note:

    The Hospital Presumptive Eligibility Medi-Cal Application (DHCS 7022) transaction submission process is scheduled to be updated in mid to late 2015. It is imperative that Hospital PE providers monitor the ACA Hospital PE Program page of the Medi-Cal website for future articles and materials regarding this anticipated update.

  8. Who is potentially eligible for Hospital PE?

    To qualify for Hospital PE, individuals must:

    • Have income below the monthly limit for household size.
    • Be a California resident.
    • Not be currently receiving coverage through Medi-Cal.
    • If not pregnant, have not already received the maximum PE enrollment period benefits from a Medi-Cal PE program with in the past 12 months of applying.
    • If pregnant, not have had a PE enrollment period during the current pregnancy.

    Additionally, individuals must be in one of the groups in the table below:

    Hospital PE Groups PE Enrollment Periods Permitted
    Individuals 18 through 25 years of age who were in foster care at 18 years of age (no income limit) One PE enrollment period within the past 12 months
    Children 19 years of age or younger Two PE enrollment periods within the past 12 months
    Parents and caretaker relatives One PE enrollment period within the past 12 months
    Adults 19 through 64 years of age, who are not pregnant, not enrolled in Medicare and not eligible for any other group stated above. One PE enrollment period within the past 12 months
    Pregnant women One PE enrollment period, per pregnancy
  9. What is the Hospital PE determination based on?

    The Hospital PE determination is based on the applicant’s self-attestation of income, household size and state residency provided on the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022).

  10. How long does it take to receive the Hospital PE determination?

    The hospital will receive the Hospital PE determination in real-time after the applicant information is entered into the Hospital PE Application Web Portal.

  11. When does the Hospital PE enrollment period begin and end?

    The Hospital PE enrollment period begins on the day in which the individual is determined eligible for Hospital PE.

    The Hospital PE enrollment period ends either:

    • If an individual does not submit an insurance affordability application prior to the PE end date, PE ends on the last day of the following month in which the individual was determined eligible for PE.
      • For example, if an individual is determined eligible for Hospital PE on July 3, 2015, PE coverage ends on August 31, 2015.
    • If an individual submits an insurance affordability application prior to the PE end date, PE coverage ends on the day in which the eligibility determination is made based on the insurance affordability application (approved or denied).
      • For example, if an individual was determined eligible for Hospital PE on July 3, 2015, and submitted an insurance affordability application prior to the PE end date, and a determination was made on August 25, 2015, PE coverage ends on August 25, 2015.

    Important Note: PE eligibility can’t be backdated regardless of the reason. Individuals must apply for full scope Medi-Cal and mark the box on the application that indicates the individual had medical expenses in the last three months and needs help to pay.

    Providers can verify eligibility by using the Automated Eligibility Verification System (AEVS), a Point of Service device or the Medi-Cal website.

  12. Where can individuals receive more information about insurance affordability programs?

    Individuals can call Covered California toll-free at 1-800-300-1506 (TTY: 1-888-889-4500). Information is also available online at www.coveredca.com.

  13. How long does it take to gain access to the Hospital PE Application Web Portal as a qualified Hospital PE provider in order to conduct transactions?

    No more than 24 hours.

  14. What if a Hospital PE application is approved and no coverage is found when eligibility is checked?

    Providers are encouraged to contact the Telephone Service Center at 1-800-541-5555 and provide the necessary recipient for further research.

  15. What is the Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification Form (DHCS 7011)?

    The Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification Form (DHCS 7011) is verification of Hospital PE providers designated contractors, third party vendors, and/or sub-contractors permitted to assist individuals with their Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022) information.

  16. When will the Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification Form (DHCS 7011) be available?

    Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification Form (DHCS 7011) will be available by June 22, 2015.

  17. What are the provider's responsibilities concerning the Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification (DHCS 7011)?
    • Hospital PE providers must oversee Hospital PE Intake Advisors responsibilities to ensure accountability and confidentiality.
    • Hospital PE Intake Advisors are not permitted to access or use the Hospital PE Application Web Portal.
    • Hospital PE Intake Advisors are not permitted to make Hospital PE eligibility determinations.
    • Hospital PE Intake Advisors must ensure confidentiality.
    • Hospital PE provider employees cannot delegate the authority to determine presumptive eligibility to another entity." (See 42 CFR 435.1102(b)(2)(VI).
    • Regulations 42 CFR 435.1102(b)(2)(VI) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application.
  18. Is a Social Security Number needed to apply for Hospital Presumptive Eligibility?

    Although it is highly recommended that a Social Security number is provided, the SSN is optional on the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022).

  19. Can duplicate Benefits Identification Cards be printed at a later date for an approved patient?

    No, it is recommended that the patient’s eligibility be verified at the time of service.