Hospital Presumptive Eligibility AHCCCS Training July 2014.

Hospital Presumptive Eligibility

AHCCCS TrainingJuly 2014

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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

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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


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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


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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


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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


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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


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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 HEAplus subscription 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


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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


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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

[email protected]


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The HPE Application • Requires information about:

o Gross incomeo Household memberso 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.


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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


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The HPE Determination Letter• Hospital provides HPE determination

letter explaining whether applicant is eligible

• Letter must explain:o If denied, no appeal rights are available.o If approved, identify the

HPE time period, including exact date applicant made eligible

Need to complete full application Appointment time to complete full AHCCCS

applicationReaching across Arizona to provide comprehensive quality health care for those in need

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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


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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


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Program Integrity Reporting• All HPE participating hospitals must submit

quarterly reports with the following:• Number of HPE applications by:

o Specific hospital facilityo Name of the Hospital worker who approved the HPE

applicationo Approvals by

Eligibility category Income

o Denials Reason for denial

o Medical Need – e.g., did applicant come in through ED, IP, OP, walk in/not a patient


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Program Integrity Reporting Con’t• Number of follow up appointments

scheduled to complete a regular application for benefitso Number of missed appointmentso 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


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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:

o Due January 31o Includes same elements in quarterly report

aggregated for calendar yearo Submitted to the OIG


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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


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Hospital Disqualification• Federal regulations allow states to

disqualify hospitals from participating in HPE for failure to meet standards:o 90% of all individuals made

presumptively eligible must complete a regular application before the end of their HPE period

o 95% of all applicants made presumptively eligible that complete a regular Medicaid application must be found eligible for full Medicaid benefitsReaching across Arizona to provide comprehensive

quality health care for those in need

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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


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Questions?


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Thank You.


Hospital Presumptive Eligibility AHCCCS Training July 2014.

Documents

hpe determination hpe

hpe overview hpe

hpe provider

hpe benefits benefits

need slide

day hpe determination

foster care

medicaid application