Frequently Asked Questions

Where inflation is not applied to property costs, please separate out this cost from the Medicare UPL by reporting these amounts in variable 402 - Adjustment to the Medicare UPL.

FAQ ID:92361

Yes, in order to ensure that hospitals comply with the agreement to make presumptive eligibility determinations consistent with state policies and procedures, states have the flexibility to require hospitals to have the staff that will do PE determinations take and pass knowledge tests in order to make PE determinations. Since the PE enrollment process does not require detailed knowledge of Medicaid eligibility policy, the test should be appropriately geared to the information needed to make an appropriate decision and comply with state procedures.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91691

The use of the two performance metrics CMS described in the final rule at section 435.1110 (the proportion of individuals determined PE who submit a full application and the proportion of those who submit an application who are deemed to be Medicaid eligible) is optional for states. States may choose to use other or additional metrics in their hospital PE programs. All states should collect data on hospital performance to fulfill their oversight responsibilities.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91696

States are considering a number of different types of performance standards, including the proportion of hospital PE determinations made in an outpatient setting (given that a strong incentive exists for determinations in inpatient settings but it is desirable to also implement PE for outpatients to ensure reaching as broad a population as possible) and the number of hospital PE applications completed in one month. Other states are collecting baseline data in order to measure hospital performance and plan to establish specific standards at a later point.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91701

While individuals may be determined "presumptively eligible" for coverage under the new adult group by a qualified hospital or qualified entity, the newly eligible FMAP is only available once the full eligibility determination has been completed. In these circumstances, the newly eligible FMAP is only authorized with respect to individuals determined eligible for the new adult group by the state agency or other public entity authorized to make final Medicaid eligibility determinations. The regular FMAP applies until such time as the state (or other authorized entity) determines an individual to be eligible for the new adult group and the state confirms that they also meet the definition of a "newly eligible individual."

As noted in our August 2013 FAQs, in appropriate circumstances, a state may retroactively adjust claiming for services provided during a presumptive eligibility period. Specifically, newly eligible status is available based on the effective date of eligibility for the new adult group, which may be as early as the third month prior to the month that the individual applied for Medicaid in accordance with 42 CFR section 435.914 (re-designated at section 435.915 under the March 2012 final eligibility rule), provided that the individual would have been eligible for Medicaid had he or she applied as of the earlier date. To the extent to which the presumptive eligibility period is encompassed within such retroactive eligibility period and the state determines that the individual meets the criteria for newly eligible status, the state may retroactively adjust claiming for services provided during a presumptive eligibility period. The state is not required to make such a retroactive adjustment if the state determines that an adjustment would be administratively burdensome.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91706

There is no recoupment for Medicaid services provided during a PE period resulting from erroneous determinations made by qualified entities. Payment for services covered under the state plan (as well as federal financial participation) is guaranteed during a PE period; without such a guarantee, providers could not rely on the PE determination. As noted, states have various ways to ensure that hospitals are making appropriate PE determinations and must fulfill their oversight responsibilities.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91711

Yes, an individual has to be found presumptively eligible (the PE application is submitted and a determination made) for services to be covered during the hospital PE period.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91716

For years, states have had the option to use presumptive eligibility (PE) to connect pregnant women and children to Medicaid. Hospitals were often key to implementing PE for those populations. Starting in January 2014, the Affordable Care Act gives qualified hospitals a unique new opportunity to connect other populations to Medicaid coverage. Under this new PE authority, hospitals will be able to immediately enroll patients who are likely eligible under a state's Medicaid eligibility guidelines for a temporary period of time. An individual provides information about his or her income and household size, and (at state option) information regarding citizenship, immigration status, and residency, and if they appear to be eligible for Medicaid based on this information, a hospital shall determine that individual to be "presumptively eligible" for Medicaid. The individual is temporarily enrolled, and health care providers (not just hospitals) will receive payment for services provided during this interim period pending a final adjudication of Medicaid eligibility by the state Medicaid agency. Like other forms of PE, hospital PE aims to:

• Assure timely access to care while a final eligibility determination is made; and
• Promote enrollment (beyond the interim PE period) in ongoing Medicaid coverage by offering additional channels through which individuals can apply.

The choice to make PE determinations rests with each individual hospital (not with the state) and is not dependent on whether the hospital (or the state) operates PE for other populations.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91721

Yes, under the law, all states must implement hospital PE to include all qualifying hospitals willing to abide by state policies and procedures. States have discretion in how they operate hospital PE to ensure that appropriate PE determinations are being made. In order to be considered a qualified entity, under the regulation at 42 CFR 435.1110(b)(1), the hospital must agree to make presumptive eligibility determinations consistent with state policies and procedures, and the state can and should exercise oversight to ensure proper administration of hospital PE. To fulfill this responsibility, states must provide qualified entities with information on relevant state policies and procedures and information on how to fulfill their responsibilities in making presumptive eligibility determinations.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91726

The latest date by which the SPA must be filed in order to meet the required effective date of January 1, 2014 is March 31, 2014 (the end of the quarter in which the policy will take effect). However, the hospital PE provision took effect on January 1 and every state is expected to implement this provision in compliance with the law.

CMS has provided a series of guidance and tools designed to assist states in implementing hospital presumptive eligibility, including proposed and final regulations, several all-state SOTA calls and webinars, and a model set of training materials for states to use in educating hospitals about PE. In addition, CMS convened an "affinity group" of a dozen states designed to share questions and best practices in detail as states were designing their hospital PE policies. These discussions were informed by several internal and external subject matter experts in the field of PE who offered suggestions about developing training materials, simplifying applications, and considering standards for states to use in measuring hospital performance and ensuring accountability. CMS is available to provide ongoing technical assistance and to review preliminary SPA proposals to help ensure that states are implementing hospital PE properly. States that wish to discuss mitigation approaches for implementing hospital PE should reach out through the SOTA process.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91731