Hospital Presumptive Eligibility

State of Maine Department of Health and Human Services Revised April 2021

Hospital Presumptive Eligibility PROVIDER HANDBOOK

A guidance document for qualified providers who make presumptive

MaineCare eligibility determinations.

Table of Contents

1. About the Hospital Presumptive Eligibility Process ........................................................................ 1 1.1 Introduction ..................................................................................................................................................... 1 1.2 Becoming a Qualified Provider ................................................................................................................. 1

2. HPE Overview ....................................................................................................................................... 2 2.1 Who can apply? .............................................................................................................................................. 2 2.2 Covered services ............................................................................................................................................ 2 2.3 The HPE Period ............................................................................................................................................... 2 2.4 The HPE Period Examples ........................................................................................................................... 3

3. Determining Eligibility ........................................................................................................................ 4 3.1 Coverage Categories .................................................................................................................................... 4 3.2 Coverage Categories Examples ................................................................................................................ 5 3.3 General Requirements ................................................................................................................................. 6 3.4 Applicant Attestation ................................................................................................................................... 7 3.5 The HPE Application ..................................................................................................................................... 8 3.6 Household Size Examples ........................................................................................................................... 9 3.7 Household Income Examples .................................................................................................................. 12

4. Noticing .............................................................................................................................................. 13 4.1 The Approval Notice (HPE-Card) ........................................................................................................... 13 4.2 The Denial Notice ........................................................................................................................................ 13

5. Bringing It All Together .................................................................................................................... 14 5.1 Examples ......................................................................................................................................................... 14

6. Accountability .................................................................................................................................... 20 6.1 Provider Accountability ............................................................................................................................. 20 6.2 OFI Accountability ....................................................................................................................................... 21 6.3 Applicant Accountability ........................................................................................................................... 21

7. Tools .................................................................................................................................................... 22 7.1 HPE Checklist ................................................................................................................................................. 22 7.2 Quick Guide to Income Eligibility .......................................................................................................... 23 7.3 Provider Portal Guide ................................................................................................................................. 26 7.4 Citizenship and Immigration Status for HPE...................................................................................... 27 7.5 Terms and Definitions ................................................................................................................................ 29

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INTRODUCTION

Hospital Presumptive Eligibility, or “HPE,” is short-term (60 days or less) Medicaid coverage for individuals within certain eligibility categories. The process allows qualified providers, or “QPs,” to make a simplified eligibility determination for individuals within these categories to receive temporary health coverage under MaineCare. The benefits of HPE include:

• Timely access to necessary health care services • Immediate temporary medical coverage while full eligibility

is being determined • Pathway to longer-term Medicaid coverage

THE HOSPITAL PRESUMPTIVE ELIGIBILITY PROCESS

Becoming a Qualified Provider

Qualified Providers

Providers must become qualified before they can make HPE determinations. Providers do this by meeting the following requirements:

• Be enrolled and participating as a MaineCare provider;

• Complete a Hospital Presumptive Eligibility Agreement;

• Agree to make determinations consistent with OFI policies and procedures; &

• Meet established quality standards

Provider Enrollment

Hospitals that would like to make presumptive eligibility determinations must indicate their interest by completing a Memorandum of Understanding (MOU) with the Office for Family Independence (OFI).

Qualified Representatives

To be a qualified hospital representative with the ability to determine eligibility on behalf of the provider, the representative must:

• Be employed by a qualified hospital; • Complete training provided by OFI; & • Make determinations consistent with

OFI policies and procedures

In this guide, “you” refers to a qualified HPE staff member employed by a qualified provider.

HPE Training Every hospital employee who will make HPE determinations must complete on-line HPE training and pass a knowledge test prior to any determinations being made. A list of all approved hospitals that have successfully completed training is available https://www.maine.gov/dhhs/ofi/hpe-training

https://www.maine.gov/dhhs/ofi/hpe-training

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HPE OVERVIEW

Who can apply? Any individual seeking immediate medical coverage may apply for Hospital Presumptive Eligibility (HPE). A person does not need to be a patient at a hospital or seeking medical services to apply. Applicants must meet certain general requirements to gain eligibility for HPE.

What services are covered? In general, HPE provides similar coverage for services covered under regular MaineCare.

Exception: Pregnant women are covered only for ambulatory prenatal care. Labor and delivery are not covered. For a pregnant woman applying while in labor, the hospital should also submit a full MaineCare application.

For more information about covered services under MaineCare, contact MaineCare Member Services at: 1-800-977-6740.

How long does coverage last? The “HPE period” refers to the duration of coverage (the length of time that HPE lasts, which consists of a “begin” and “end” date), and the frequency of coverage (how often an individual can receiv HPE).

HPE Begin Date: The HPE period begins on the date the HPE determination is made. HPE cannot be backdated, regardless of the reason. Starting on the date that the individual is found eligible for HPE, they will be able to receive coverage up until their end date, which is no more than 60 days. During this time, it is the individual’s responsibility, with assistance from the qualified provider, to apply for full MaineCare to avoid a break in health care coverage.

HPE End Date: HPE coverage ends when one of the following circumstances happens, whichever is earliest:

• If the individual does not file a full application with OFI, the HPE period ends on the last day of the month following the HPE determination (the “second month”)

• If the individual does file a full application with OFI before the last day of the second month, HPE ends on the date the eligibility determination is made for regular coverage

Frequency: The frequency of coverage, or how often an individual can receive HPE, depends on the coverage category.

• A pregnant woman may have one HPE period during each pregnancy. • All other individuals are only allowed one period of HPE coverage in any 12-month

period, calculated from the first day of the most recent previous period of HPE.

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Examples

What is Anna’s HPE Begin Date?

March 20, 2021

Anna does file a full MaineCare application. She is

determined eligible for full MaineCare on April 9th, 2021. What is her HPE End Date?

April 9, 2021

If Anna had not filed a full MaineCare application, what

would her HPE End Date have been?

April 30, 2021

Is Jessica eligible for HPE?

Yes, Jessica is eligible. She falls under the exception for

pregnant women. These individuals can receive HPE

once per pregnancy.

What is Jessica’s start date?

April 1, 2021

Jessica does file a full MaineCare application. She is

determined eligible for full MaineCare on April 12th. What

is her HPE End Date?

April 12, 2021

How to Determine the HPE Period

Example 1: You receive Anna’s HPE application on March 20, 2021. She has not received HPE in the past 12 months. She is determined eligible for HPE on March 20, 2021.

Example 2: You receive Jessica’s application on April 1, 2021 She is pregnant. Her last HPE period occurred during her previous pregnancy, with a start date of June 1, 2020.

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DETERMINING ELIGIBILITY

For an individual to be eligible for Hospital Presumptive Eligibility, or “HPE,” he or she must meet certain general requirements.

Coverage Category

For eligibility to exist, the individual must first have an HPE coverage category. Individuals in the following categories may be eligible if they meet the category criteria:

Parents and

Caretaker Relatives Individuals living with and caring for a related child under age 18

Infants under 1 year of age

Infants under age 1 who were not born to a mother receiving full MaineCare on their date of birth

Children age 1 through 18 Children between the ages of 1 and 18 years old (up to 19th birthday)

Children age 19 or 20 Individuals age 19 or 20 who are not eligible in another coverage category

Pregnant Women Individuals who are pregnant or are within their post-partum period. The post- partum period begins on the date the pregnancy ends, extends 60 days, and then ends on the day of the month in which the 60-day period ends.

Expansion Adults Individuals age 19 through 64 (up to 65th birthday) who are not eligible for Medicare, and do not fall into any other coverage category

Former Foster

Children

Individuals age 19 through 26 (up to 26th birthday) who were in foster care at age 18 and received Medicaid in Maine until they aged out of foster care on or after their 18th birthday. Must not be eligible in another coverage category (exception: Expansion Adults).

Limited Family Planning Services

Coverage for men and women of any age for family planning and reproductive related services. Pregnant individuals are not eligible for this benefit.

Women in Treatment for Breast or Cervical

Cancer

Women who are under the age of 65 and who are in treatment for breast or cervical cancer

Each coverage category is subject to different income standards when determining eligibility for HPE.

In instances where individuals fall into more than one coverage category, choose the category with the highest income limit or the category that provides the best coverage. For example, a 19-year-old pregnant woman could fall into the coverage category of “Children age 19 or 20” or “Pregnant Women.” She will gain eligibility through Pregnant Women, which has a much higher income guideline than Children age 19 or 20.

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Examples

How to Determine Coverage Category

The following examples are included to assist representatives in determining coverage categories for HPE applications.

Example 1: Robert (56) and Jerome (55) are married. They have two adult children who live outside of the home.

Individual Coverage Category Robert Expansion Adults Jerome Expansion Adults

Example 2: Marjan (26) lives with her boyfriend Ben (28), and she is three months pregnant.

Individual Coverage Category Marjan Pregnant Women

Ben Expansion Adults

Example 3: Bryan (39) is married and lives with his spouse, Aimee (33), and his twin children, Aidan and Alex (3), from his previous relationship.

Individual Coverage Category Bryan Parent and Caretaker Relatives Aimee Expansion Adults Aidan Children age 1 through 18 Alex Children age 1 through 18

Example 4: Pavel (40) lives with his girlfriend, Rohan (40). They have a mutual child together, Annie (8 months). Rohan also has a daughter, Jai (19), from a previous relationship.

Individual Coverage Category Pavel Parent and Caretaker Relatives Rohan Parent and Caretaker Relatives Annie Infants under 1 year of age

Jai Children age 19 or 20

Example 5: Christine (24) is married to Amir (26). They have one mutual child together, Mohammed (3). Christine is seeking the Limited Family Planning benefit.

Individual Coverage Category Christine Limited Family Planning Services

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Maine Residency

The applicant must be a Maine resident. They must have a Maine home address.

U.S. Citizenship

The applicant must be a U.S. citizen, a qualified non-citizen, or a qualified immigrant. See page 27 for qualifying immigration statuses.

Coverage Category

The applicant must meet a specific coverage category. See page 4 regarding coverage categories.

General Requirements

Eligibility for HPE is based on several other requirements that are both non-financial and financial.

Non-financial Requirements:

HPE Period

The applicant must not be enrolled within the time-frame restrictions. See page 2 regarding the HPE period.

MaineCare Member

The applicant must not be receiving full MaineCare. Use the MaineCare Health Online Portal to check MaineCare status.

Income Limit

The applicant must meet financial requirements.

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Financial Requirements:

The applicant must meet specific financial requirements. Income requirements for HPE are based on a percentage of the Federal Poverty Level, or “FPL,” which is the minimum amount of income a person or family needs for necessities. Each coverage category has different FPL requirements that an individual must meet to become eligible. These FPLs may change every year, so it’s essential to make sure you are always using the most recent HPE Worksheets to determine eligibility.

Income Limits:

Coverage Category FPL Parents and Caretaker Relatives 100% Infants under 1 year of age 191% Children age 1 through 18 157% Children age 19 or 20 156% Pregnant Women 209% Expansion Adults 133% Former Foster Children No income limit Limited Family Planning Services 209% Women in Treatment for Breast or Cervical Cancer 250%

Each coverage category is subject to different income standards. For example, an infant is eligible for HPE coverage if his or her household income is at or below 191% of the Federal Poverty Guideline. A pregnant woman is eligible for HPE coverage if her household income is at or below 209% of the FPL. This means that, depending on each family member’s eligibility group, some members of a family may be eligible for HPE while others are not eligible, even though the family members have the same household income and household size.

You will learn how to determine countable income and how to calculate total household income in the following section.

Applicant Attestation

Hospital staff may not request documentation to verify any information provided by an HPE applicant. Eligibility for HPE is based solely on the applicant’s (or applicant’s authorized representative’s) attestation.

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The HPE Application The Hospital Presumptive Eligibility application, or “HPE-App,” is completed by the individual seeking medical coverage with your assistance. Questions on the application range from identifying information, to family size and household income.

You are responsible for making immediate eligibility determinations once an HPE-App has been completed and signed. To make an accurate HPE determination, you will evaluate the information on the application and apply the HPE-specific rules. You will use the HPE-Worksheet and other tools to help you apply these rules when determining what income is counted, how household size is determined, etc. Only one HPE application is required for a family. A separate HPE-Worksheet is required for each individual applying for HPE.

Determining eligibility is a four-step process:

1) Determine the person’s household size 2) Determine the person’s individual income 3) Determine the person’s household income 4) Compare the person’s household size and household income to the income limit for their

particular coverage category

STEP 1: Household Size

Eligibility for HPE is based on an individual’s income as a percentage of the FPL. To determine a person’s percentage of the FPL, you must know the individual’s HPE household size. A household size includes all of the individuals in the home who are required to be in it. There are specific family relationships that are tied together, which make certain individuals financially responsible for each other.

The household size determination must be done for each applicant requesting coverage on the HPE application. Count the following people as part of the applicant’s household*:

If the applicant is under age 19, their household includes (if living with):

If the applicant is age 19 or older, their household includes (if living with):

The individual The individual’s children If pregnant, the number of unborn

children of the individual The individual’s spouse Parent(s) or step-parent(s) Any sibling under the age of 19

The individual If pregnant, the number of unborn

children of the individual The individual’s spouse Children or step-children under the age

of 19

*Former Foster Care and Limited Family Planning Coverages are always household sizes of 1, which includes only the individual.

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Examples

How to Determine Household Size

The following examples are included to assist representatives in determining household size for HPE applications.

Example 1: Robert (56) and Jerome (55) are married. They have two adult children who live outside of the home.

Individual Household Size Robert 2 (himself and his spouse) Jerome 2 (himself and his spouse)

Example 2: Marjan (26) lives with her boyfriend Ben (28), and she is three months pregnant with one child.

Individual Household Size Marjan 2 (herself and her unborn child)

Ben 1 (himself)

Example 3: Bryan (39) is married and lives with his spouse, Aimee (33), and his twin children, Aidan and Alex (3), from his previous relationship.

Individual Household Size Bryan 4 (himself, his spouse, his children) Aimee 4 (herself, her spouse, her step-children) Aidan 4 (himself, his father, his step-mother, his sibling) Alex 4 (himself, his father, his step-mother, his sibling)

Example 4: Pavel (40) lives with his girlfriend, Rohan (40). They have a mutual child together, Annie (8 months). Rohan also has a daughter, Jai (19), from a previous relationship.

Individual Household Size Pavel 2 (himself, his child Annie) Rohan 2 (herself, her child Annie) Annie 3 (herself, her mother, her father)

Jai 1 (herself)

Example 5: Christine (24) is married to Amir (26). They have one mutual child together, Mohammed (3). Christine is seeking the Limited Family Planning benefit.

Individual Household Size

Christine 1 (herself; Limited Family Planning is always a household size of 1)

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STEP 2: Determine Individual Income

Some types of income are not counted when determining eligibility.

Countable Income Non-Countable Income

Wages/tips Unemployment Pensions and annuities Income from businesses or personal

services Self-employment Military retirements/pensions Interest Alimony* Social Security benefits (excluding SSI) Foreign earned

Child support Supplemental Security Income (SSI) Workers’ compensation Veteran’s benefits Scholarships, awards, or fellowship grants

used for educational expenses (except room and board)

American Indian or Alaska Native Tribal income

*Alimony is only counted if the agreement was executed prior to Jan 1, 2019.

Income is based on pre-tax income (not take-home pay). If a gross amount is not provided, you may ask about the hourly rate of pay and number of hours worked per week or pay period.

If income is not reported as a monthly amount, you must convert the income to a monthly amount. You will need to know how often the individual is paid, how many hours per week they work, and their hourly rate. Use the following formulas to convert pay to a monthly amount:

If the individual is paid… then…

Weekly Multiply gross pay by 4.3

Bi-weekly Multiply gross pay by 2.15

Twice a month Multiply gross pay by 2

Monthly No calculation needed

Annually Divide gross pay by 12

As an additional tool to the HPE-Worksheet, refer to the “Quick Guide to Income Eligibility” document to help you calculate income and household size. This is found on page 23 of this Handbook.

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STEP 3: Determine Household Income

Household income is the combined pre-tax income (not take-home pay) of all included family members. To determine the applicant’s household income, you must complete the following steps first:

1) Determine who must be included in the applicant’s household (page 8) 2) Determine whether any of these people have countable income (page 10) 3) Then add the countable income of every individual in the applicant’s

home. The sum of this is the applicant’s household income.

If the applicant is seeking the Limited Family Planning benefit, only the income of the individual seeking coverage is counted. Former Foster Care coverage does not have an income test.

Whose income counts?

You must use the chart below to determine whose income counts towards the total household income.

For example, if an individual is an unmarried 15-year-old, the income that is counted in their household includes (see the red box):

• Any countable income from the 15-year-old • Any countable income from the 15-year-old’s parent(s), step-parent(s) or caretaker relative(s)

After you have determined the applicant’s household income, you can determine whether the applicant is eligible for HPE. This is done in Step 4: Comparing Income to the FPL.

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Examples

How to Determine Household Income

The following examples are included to assist representatives in determining household income for HPE applications.

Example 1: Robert (56) and Jerome (55) are married. Robert earns $300 biweekly at his job, Jerome earns $100 monthly; he is a self-employed artist.

Individual Household Income Robert $745 ($300 x 2.15 = $645, + $100 = $745) Jerome $745 ($300 x 2.15 = $645, + $100 = $745)

Example 2: Marjan (26) lives with her boyfriend Ben (28), and she is three months pregnant with one child. Marjan is receiving Workers’ Compensation of $400 monthly. Ben earns $410 weekly at his job.

Individual Household Income Marjan $0

Ben $1,763 ($410 x 4.3 = $1,763)

Example 3: Bryan (39) is married and lives with his spouse, Aimee (33), and his twin children, Aidan and Alex (3), from his previous relationship. They earn a total of $950 per month as farmers. Bryan receives $500 in child support from his ex-partner for Aidan and Alex.

Individual Household Income Bryan $950 Aimee $950 Aidan $950 Alex $950

Example 4: Pavel (40) lives with his girlfriend, Rohan (40). They have a mutual child together, Annie (8 months). Rohan also has a daughter, Jai (19), from a previous relationship. Pavel receives $1,200 in Veteran’s benefits. Rohan is paid $900 biweekly from her job. Jai also works and is paid $100 weekly.

Individual Household Income Pavel $0 Rohan $1,935 Annie $1,935

Jai $430

Example 5: Christine (24) is married to Amir (26). They have one mutual child together, Mohammed (3). Christine is seeking the Limited Family Planning benefit. Amir grosses $65,000 annually at his job.

Individual Household Income Christine $0

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STEP 4: Compare

Using the most-current FPL Chart, compare the individual’s total monthly household income to the individual’s coverage category and household size. If the individual’s income is less than or equal to the income limit, the individual is presumptively eligible. As a reminder, only hospital staff from a qualified hospital who have successfully completed the HPE online training curriculum are allowed to make HPE determinations. A qualified hospital is not permitted to subcontract this function to a third- party contractor, volunteer, or untrained employee.

NOTICING

At the time of eligibility determination, you must give the individual immediate written notice of whether he or she is approved or denied coverage.

The Approval Notice (HPE-Card)

If the individual is determined to be presumptively eligible, you must complete the Hospital Presumptive Eligibility Card, or “HPE-Card.” The HPE-Card can be used by individuals as proof of coverage to obtain MaineCare covered services. The HPE-Card also serves as their notice that this benefit is temporary, and the date coverage will end.

You must submit a copy of the HPE-Card to OFI by mail, fax, or email within five working days from the date of the determination. The Department will not pay claims for individuals determined presumptively eligible if the hospital does not notify OFI of the determination within those five working days.

Full MaineCare Applications

After you’ve determined the individual eligible for HPE coverage, you must assist the individual with completing and submitting a full MaineCare application. Individuals may complete the full application in paper format, online, over the phone with OFI representatives, or in-person at their local DHHS office. Individuals must complete and submit the application before the HPE end date. If individuals have questions about the full MaineCare application process, providers can refer them to:

Website: www.maine.gov/mymaineconnection Phone: 1-855-797-4357 Local DHHS office location list: https://www.maine.gov/dhhs/about/contact/offices

The Denial Notice

If the individual is not eligible for HPE, you must complete the Denial Notice that explains the reason for the denial. The individual may not appeal the HPE determination. They may still apply for full MaineCare using one of the options listed above.

http://www.maine.gov/mymaineconnection

https://www.maine.gov/dhhs/about/contact/offices

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Examples

Robert is presumptively eligible. His HPE period will end April 30, 2021. You will create an HPE-Card for him. You will also help Robert complete and submit a full MaineCare application. This is due by the end

of the HPE period.

Bringing It All Together

The following examples are included to assist representatives in determining household eligibility. We will use the HPE-Worksheet to help us determine if the applicants from our previous examples are eligible for HPE.

Example 1: Robert (56) and Jerome (55) are married. Robert earns $300 biweekly at his job, Jerome earns $100 monthly; he is a self-employed artist. They applied for HPE on March 24, 2021. We have determined that they both meet all non-financial requirements. Robert has completed the application for himself and Jerome, and he has attested to their household size and household income.

Hospital Presumptive Eligibility Worksheet

Presumptive eligibility determination for: Robert

☒ The applicant is not currently eligible for MaineCare and has not received Presumptive Eligibility coverage within the last 12 months from the date of application. If pregnant, cannot have received PE coverage for this pregnancy. ☒ The applicant is a U.S. Citizen or Qualified Non-citizen and resident of the state of Maine.

Applicant coverage category (check one): ☐ Parent/Caretaker relative caring for a child under 18 ☐ Child age 19 or 20, not eligible for expansion ☐ Pregnant Women ☐ Former foster child under 26 years of age ☒ Expansion adult between age 19 and 64, no Medicare ☐ Limited Family Planning Services ☐ Infant under 1 year of age ☐ Child age 1 through 18 ☐ Women in Treatment for Breast or Cervical Cancer

If the applicant is pregnant, how many babies are expected?

MAGI Eligibility Calculation (not required for former foster children under age 26) Step Description Amount

1. Individual’s Household Size (from HPE-App) 2

2. Income Limit for the household size & coverage group (see FPL chart) $1,931

3. Total Monthly Household Income (from HPE-App) $745

4. Is Monthly Household Income equal to/less than Income Limit? ☒ Yes ☐ No

Presumptive Eligibility Determination Results ☒ Applicant is presumptively eligible.

Eligibility Start Date: 3/24/2021

Date of Presumptive Eligibility Determination: 3/24/2021

Examples Bringing It All Together

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Jerome is presumptively eligible. His HPE period will end April 30, 2021. You will create an HPE-Card for him. You will also help Jerome complete and submit a full MaineCare application. This is due by the end

of the HPE period.

Example 1 (continued): Robert (56) and Jerome (55) are married. Robert earns $300 biweekly at his job, Jerome earns $100 monthly; he is a self-employed artist. They applied for HPE on March 24, 2021. We have determined that they both meet all non-financial requirements. Robert has completed the application for himself and Jerome, and he has attested to their household size and household income.


Presumptive eligibility determination for: Jerome



If the applicant is pregnant, how many babies are expected?

MAGI Eligibility Calculation (not required for former foster children under age 26) Step Description Amount









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Marjan is presumptively eligible. Her HPE period will end May 31, 2021. You will create an HPE-Card for her. You will also help Marjan complete and submit a full MaineCare application. This is due by the end

of the HPE period.

Example 2: Marjan (26) lives with her boyfriend Ben (28), and she is three months pregnant with one child. Marjan is receiving Workers’ Compensation of $400 monthly. Ben earns $210 weekly at his job. They applied for HPE on April 1, 2021. We have determined that they both meet all non-financial requirements. Marjan completed the application for herself and Ben, and she has attested to their household size and income.


Presumptive eligibility determination for: Marjan


Applicant coverage category (check one): ☐ Parent/Caretaker relative caring for a child under 18 ☐ Child age 19 or 20, not eligible for expansion ☒ Pregnant Women ☐ Former foster child under 26 years of age ☐ Expansion adult between age 19 and 64, no Medicare ☐ Limited Family Planning Services ☐ Infant under 1 year of age ☐ Child age 1 through 18 ☐ Women in Treatment for Breast or Cervical Cancer

If the applicant is pregnant, how many babies are expected? 1

MAGI Eligibility Calculation (not required for former foster children under age 26)

Step Description Amount









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Ben is not eligible. You will create an HPE Denial Notice for him. You will explain to Ben that he cannot

appeal this decision.

Example 2 (continued): Marjan (26) lives with her boyfriend Ben (28), and she is three months pregnant with one child. Marjan is receiving Workers’ Compensation of $400 monthly. Ben earns $210 weekly at his job. They applied for HPE on April 1, 2021. We have determined that they both meet all non-financial requirements. Marjan completed the application for herself and Ben, and she has attested to their household size and income.


Presumptive eligibility determination for: Ben



If the applicant is pregnant, how many babies are expected? 0

MAGI Eligibility Calculation (not required for former foster children under age 26)

Step Description Amount



3. Total Monthly Household Income (from HPE-App) $1,763

4. Is Monthly Household Income equal to/less than Income Limit? ☐ Yes ☒ No

Presumptive Eligibility Determination Results ☐ Applicant is presumptively eligible.

Eligibility Start Date: Click or tap to enter a date.

Date of Presumptive Eligibility Determination: Click or tap to enter a date.

☒ Applicant is not presumptively eligible for the following reason: Ben’s income is over the limit


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Abbreviated Examples #3 – 5

Example 3: Bryan (39) is married and lives with his spouse, Aimee (33), and his twin children, Aidan and Alex (3), from his previous relationship. They earn a total of $950 per month as farmers. Bryan receives $500 in child support from his ex-partner for Aidan and Alex. They applied March 28, 2021 and meet all non-financial requirements.

Individual Coverage Category

Household Size

Income Limit

Total household

income

Eligible for HPE?

HPE Period

Bryan

Parent and Caretaker Relatives

4

$2,209

$950

Yes 3/28/21-

4/30/21

Aimee Expansion Adults 4 $2,938 $950 Yes 3/28/21-

4/30/21

Aidan Children age 1 through 18 4 $3,468 $950 Yes 3/28/21-

4/30/21

Alex Children age 1 through 18 4 $3,468 $950 Yes 3/28/21-

4/30/21

Example 4: Pavel (40) lives with his girlfriend, Rohan (40). They have a mutual child together, Annie (8 months). Rohan also has a daughter, Jai (19), from a previous relationship. Pavel receives $1,200 in Veteran’s benefits. Rohan is paid $900 biweekly from her job. Jai also works and is paid $100 weekly. They applied April 30, 2021 and meet all non-financial requirements.


Household Size

Income Limit

Total household

income

Eligible for HPE?

HPE Period

Pavel Parent and Caretaker Relative 2 $1,452 $0 Yes 4/30/21-

5/31/21

Rohan

Parent and Caretaker

Relatives or Expansion Adults

2

$1,452 or

$1,931

$1,935

No, over- income for both

categories

-

Annie Infant under 1 year of age 3 $3,496 $1,935 Yes 4/30/21-

5/31/21

Jai Children age 19 or 20 1 $1,675 $430 Yes 4/30/21-

5/31/21


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Example 5: Christine (24) is married to Amir (26). They have one mutual child together, Mohammed (3). Christine is seeking the Limited Family Planning benefit. Amir grosses $65,000 annually from his job. She applied April 20, 2021 and meets all non-financial requirements.


Household Size

Income Limit

Total household

income

Eligible for HPE?

HPE Period

Christine

Limited Family Planning benefit

1

$2,244

$0

Yes

4/20/21- 5/31/21

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ACCOUNTABILITY

Provider Accountability

Confidentiality

You must safeguard all confidential information from unauthorized disclosure and use. Staff who fail to safeguard confidential information may be subject to both civil and criminal penalties.

The hospital shall implement and maintain administrative, technical, and physical safeguards necessary to protect the confidentiality of the data and to prevent any unauthorized use or access.

Performance Standards

Qualified hospitals are required to meet performance standards. These standards are designed to measure how well qualified hospitals are meeting the main objective of Hospital Presumptive Eligibility – which is connecting individuals to ongoing health care coverage. You will be expected to maintain a level of accuracy consistent with the following:

• Full MaineCare Applications: a completed full MaineCare application must be submitted to OFI before the end of the HPE period for no less than 80% of the applicants granted presumptive eligibility.

To meet this standard, hospitals must adopt practices that ensure that individuals who are approved for HPE have the help necessary to submit complete applications. Compliance of this will be reviewed twice per year. Hospitals not meeting this standard will be notified in writing, and corrective action will be required.

Corrective Actions

OFI is required to take corrective action up to and including disqualification of participating hospitals that are not making (or found to be incapable of making) HPE determinations according to state policy and procedure. OFI will issue a corrective action notice to a qualified hospital if the hospital violates HPE policy or procedure. The corrective action plan includes:

1. Mandatory Training: The first time a hospital fails to meet performance standards, all applicable hospital staff must participate in mandatory online HPE training.

2. Disqualification: If, within the subsequent 24-month period, the hospital again fails to meet performance standards, the hospital will be disqualified from making presumptive eligibility

CONFIDENTIAL INFORMATION INCLUDES:

• Identifying information, such as names, addresses, Social Security Numbers, date of birth, etc.

• Information used to determine eligibility, such as income

• Information about benefits and medical services provided

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determinations for 12 months. Disqualification does not affect the hospital’s status as a MaineCare provider.

3. Requalification: To requalify after the 12-month period, the hospital must: a. Participate as a Medicaid provider b. Notify OFI in writing of its intention to make HPE determinations c. Agree to make determinations consistent with OFI policies and procedures d. Accept mandatory online training

OFI Accountability

Upon receipt of approved HPE determinations, staff at OFI will:

• Confirm the hospital is qualified to make HPE determinations • Confirm the person who made the determination is a qualified hospital representative

o Illegible or incomplete applications will be returned to the hospital for correction. • When all criteria have been met, OFI will:

o Accept the hospital’s determination. HPE decisions will not be reversed, nor HPE eligibility terminated, retroactively.

o Enter the individual(s) into the eligibility system with the appropriate start and end dates.

Applicant Accountability

When applying for HPE and full MaineCare, the applicant is responsible for providing true and accurate information. If approved for HPE, the applicant is responsible, with the assistance of the qualified hospital, to pursue ongoing eligibility by submitting a full MaineCare application before the last day of the calendar month following the month of their HPE determination. If denied for HPE, the applicant has the option to complete the full MaineCare application for full eligibility determination.

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Hospital Presumptive Eligibility Checklist

Hospitals are responsible for identifying individuals who may be eligible for Hospital Presumptive Eligibility. Once you have identified an individual who may be eligible for coverage, you must complete the following steps:

General Requirements

� The person has a coverage category � The person is a resident of Maine � The person is a U.S. Citizen or qualified non-citizen � The person has income below the HPE income limit for their household size and coverage

category

Check Provider Portal

� The person has not received HPE within the HPE time frame restrictions � The person is not currently enrolled in MaineCare

Application

� The person has completed and signed the application (or has designated another person, such as a family member or authorized representative, to sign the HPE-App on their behalf)

� You have completed the HPE-Worksheet for each individual requesting HPE coverage

Processing an Approval

� You have created HPE-Cards for all individuals approved for HPE � You have submitted a copy of the HPE-Card to OFI by mail, fax, or email within five working

days from the date of determination. Email is preferred: [email protected] � You have assisted the individual with completing and submitting a full MaineCare application

Processing a Denial

� You have issued the person an HPE Denial Notice

mailto:[email protected]

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Quick Guide to Income Eligibility (March 2021)

Instructions for Hospitals: Refer to the following table when making Hospital Presumptive Eligibility determinations based on the information required in the HPE application.

Determine the household size for each applicant Count the monthly gross income (before taxes) of everyone included in the household size for

the specific program If the applicant’s income is equal to or under the income limit for their coverage category, the

applicant is considered financially eligible

Note: Income standards for HPE are not the same as the income standards for regular MaineCare eligibility. Please use this table exclusively for Hospital Presumptive Eligibility determinations.

Countable Income Non-Countable Income

Earned Income: wages, salaries, tips, foreign earned

Self-employment income, including income from business or personal services

Interest Alimony received* Unemployment Pension and annuities Social Security benefits (excluding SSI) Military retirement and pensions Other taxable income

Child support Veterans’ benefits Workers’ compensation Supplemental Security Income (SSI) Scholarships, awards, or fellowship

grants used for educational expenses (except room and board)

Native American and Alaska Native Income

* Alimony is only counted if the agreement was executed prior to Jan 1, 2019

Coverage Group Family Size Income Limit

Parent/Caretaker Relative (100% FPL)

Individuals living with and caring for a related child under age 18.

Household Size Includes (if living with): • The individual

o If pregnant, the number of unborn children • The individual’s spouse • The individual’s dependent children or step-children under

age 19

1 $1,074 2 $1,452 3 $1,830 4 $2,209 5 $2,587 6 $2,965 7 $3,344 8 $3,722

Each additional person, add + $379

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Expansion Adults (133% FPL)

Individuals age 19 through 64 (up to 65th birthday) who are not eligible for Medicare or coverage in another category. The individual cannot be eligible for the Pregnant Women or Parent/Caretaker Relative coverage groups.

Household Size Includes (if living with): • The individual • The individual’s spouse • The individual’s dependent children or step-children under

age 19

1 $1,428 2 $1,931 3 $2,434 4 $2,938 5 $3,441 6 $3,944 7 $4,447 8 $4,950

Each additional

person, add

+ $504

Pregnant Women (209% FPL)

Individuals who are pregnant.

Household Size Includes (if living with): • The individual • The individual’s spouse • The number of unborn children • The individual’s dependent children or step-children under

age 19 • If the applicant is a child, also include the child’s parents or

step-parents, and siblings or step-siblings under age 19

1 $2,244 2 $3,034 3 $3,825 4 $4,616 5 $5,407 6 $6,197 7 $6,988 8 $7,779

Each additional

person, add

+ $791

Infants under 1 year of age (191% FPL)

Infants under age 1 who were not born to a mother receiving full MaineCare on the date of birth.

Household Size Includes (if living with): • The individual • The individual’s parents, step-parents or caretaker relative • The individual’s siblings or step-siblings under age 19

1 $2,051 2 $2,773 3 $3,496 4 $4,218 5 $4,941 6 $5,664 7 $6,386 8 $7,109


Children age 1 through 18 (157% FPL)

Children between the ages of 1 and 18 years old (up to 19th birthday).


o If pregnant, the number of unborn children • The individual’s spouse • The individual’s children *continued on next page

1 $1,686 2 $2,280 3 $2,874 4 $3,468 5 $4,062 6 $4,656 7 $5,250 8 $5,844


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• The individual’s parents, step-parents or caretaker relative • The individual’s siblings under age 19

Children age 19 or 20 (156% FPL)

Individuals age 19 or 20 who are not eligible in another coverage category.


o If pregnant, the number of unborn children • The individual’s spouse • The individual’s dependent children or step-children under

age 19

1 $1,675 2 $2,265 3 $2,855 4 $3,445 5 $4,036 6 $4,626 7 $5,216 8 $5,806

Each additional person, add

+ $591

Former Foster Children

Individuals age 19 through 26 (up to 26th birthday) who were in foster care at age 18 and received Medicaid until they aged out of foster care on or after their 18th birthday. Must not be eligible in another coverage category (except Expansion Adults).


1

No income limit

Limited Family Planning Services (209% FPL)

Available to individuals of any age, regardless of gender. Must not be eligible for any other coverage category. Pregnant individuals are not eligible for this benefit. Minors may apply on their own.


1

$2,244

Women in Treatment for Breast or Cervical Cancer (250% FPL)

Women under age 65 and who are in treatment for breast or cervical cancer.


1

$2,684

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MaineCare Health PAS Online Portal

Qualified Providers are responsible for verifying if all potentially eligible applicants have current MaineCare coverage and they have received Hospital Presumptive Eligibility in the last 12 months (or, if the individual is pregnant, she has received HPE during this pregnancy).

PE coverage can be verified through the Provider Portal:

1. Log in to the Provider Portal, accessible at: https://mainecare.maine.gov/Default.aspx 2. Check the Portal for coverage

a. If the applicant has MaineCare for the application month and ongoing, PE coverage is not needed.

b. If the applicant does not have MaineCare, search for prior PE coverage under the Eligibility Inquiry.

i. Enter Dates of Service from a year prior to the application date. ii. Presumptive Eligibility will generally be displayed as coverage with effective and

termination dates that indicate a period of less than two months. The type of PE coverage will display as one of the following:

1. Hospital Presumptive 2. Pregnancy Presumptive 3. Limited Family Planning Benefits

Plan Coverage Status Coverage Level Plan Type Effective Date Termination Date MaineCare Coverage Code Description: Hospital Presumptive

Partial Primary MEDICAL 6/24/2020 7/31/2020

Unlike other MaineCare coverage PE may have effective or termination dates that are in the middle of the month. The effective date can, but often will not be the 1st day of the month. The termination date may be the last day of the month following the effective month or a day in the middle of the month.

Note: Some PE coverage code descriptions may not be available in early 2021. Descriptions may display as follows:

• Hospital Presumptive – Adults and Children • Pregnancy Presumptive – Special Populations with Limited Benefits

PE coverage can also be verified by contacting Provider Services at 1-866-690-5585.

https://mainecare.maine.gov/Default.aspx

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Citizenship and Immigration Status for HPE Determinations

Applicants must meet citizenship requirements to be eligible for Presumptive Eligibility. If the applicant is not a U.S. Citizen (or naturalized citizen), you must determine whether the applicant has a qualifying immigration status.

The following are qualifying immigration statuses. The individual must have held their qualifying status for at least 5 years (unless exempt).

Exempt from 5-year waiting period: Status must be held for at least 5 years:

• Afghan or Iraqi special immigrant visa holder • Battered Individuals or Specified Relatives • Amerasian Immigrants • Conditional Entrants prior to April 1, 1980 • Asylees • Paroled into the U.S. for at least one year • Cuban/Haitian Entrant • Lawful Permanent Resident (unless they

previously held a status that was exempt from the 5-year waiting period)

• Deportees whose deportation is withheld • Refugees • Victims of sever form of trafficking

The following qualifying individuals are also exempt from the 5-year waiting period:

• Lawful Permanent Residents who previously held a status that was exempt from the 5-year waiting period

• Members of a federally recognized Indian tribe • American Indians born in Canada • Non-citizens receiving SSI • Individuals with an immigration status that would be subject to the 5-years waiting period

except they are: - Veterans who received an honorable discharge - A military service member on active duty in the armed forces of the United States - A spouse or unmarried dependent child of a veteran or active duty services member

Individuals under the age of 21 and pregnant women, who are lawfully present do not have a 5-year waiting period. The following individual are considered lawfully present:

• All qualified non-citizen even if within the 5-year waiting period (see above); • Non-citizen in a valid non-immigrant status (e.g. student visas, worker visas, etc.);

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• Non-citizen who has been paroled into the United State for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

• A non-citizen who belongs to one of the following classes: o Currently in temporary resident status o Currently under Temporary Protected Status (TPS) (including individuals with pending

applications for TPS who have been granted employment authorizations) o Granted employment authorizations o Family Unity beneficiaries o Currently under Deferred Enforced Departure (DED) in accordance with a decision made

by the President o Currently in deferred action status (note that this does not include individuals with

DACA granted under June 2012 DHS Policy [Deferred Action for Childhood Arrivals] status)

o Granted an administrative stay of removal o Beneficiary of approved visa petition who has a pending application for adjustment of

status • A pending application for asylum or for withholding of removal under the Convention Against

Torture who has been granted employment authorizations or is under the age of 14 and has had an application pending for at least 180 days;

• A non-citizen who has been granted withholding of removal under the Convention Against Torture;

• A child who has a pending application for Special Immigrant Juvenile status; • Is lawfully present in American Samoa under the immigration laws of American Samoa

Self-attestation must be accepted for PE determinations. Verification cannot be requested.

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Terms and Definitions Ambulatory Prenatal Care: Services related to the pregnancy excluding labor and delivery

Applicant: An individual who is seeking eligibility determination for him/herself through an application submission

Child Support: Money that is ordered by a court on behalf of a minor child, or paid by the non- custodial parent without a court order

Client: An individual who has been determined eligible for and is receiving MaineCare

Department: The Maine Department of Health and Human Services

Dependent Child: A child who is under the age of 18 or is age 18 and a full-time student in secondary school (or equivalent vocational or technical training), if before attaining age 19 the child may reasonably be expected to complete such school or training

Eligibility Determination: An approval or denial of coverage, as well as a renewal or termination of coverage

Federal Poverty Level (FPL): The FPL is the minimum amount of income a person or family needs for necessities. These limits may change every year

Office for Family Independence (OFI): OFI is responsible for determining individuals’ eligibility for MaineCare, and other programs that are designed to give temporary support to Mainers in financial need.

MaineCare: MaineCare is Maine’s Medicaid program. MaineCare is both state and federally funded and provides healthcare coverage for eligible individuals and families.

Modified Adjusted Gross Income (MAGI): The methodology used to determine financial eligibility

Hospital Presumptive Eligibility

Documents