Frequently Asked Questions

Yes, services covered under the state plan rendered during the PE period will qualify for federal match regardless of the ultimate Medicaid eligibility decision. The standards that states can set for hospitals and the findings from reviews of hospital performance relative to those standards are intended to ensure that hospitals are making appropriate PE determinations and following state hospital PE procedures. When problems are identified, states should take corrective action to ensure future compliance with state policies and procedures.

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

FAQ ID:92111

No, the information must be submitted by the State Medicaid Director (or designated state official).

FAQ ID:92246

The state should complete one template each for the DRG and per diem UPL calculations and these should be placed in one file. The state should also include a summary worksheet in the same file that shows the UPL gap for each ownership category (state government owned, non-state government owned, and private). States should include all necessary supporting documentation.

FAQ ID:92276

Unlike the UPLs for other Medicaid institutional payments, which rely on an aggregate approach by ownership category (private, state owned, non state government owned) to ensure Medicaid payments are consistent with efficiency and economy, the PRTF UPL is calculated for each facility. Specifically, the UPL relies on 42 CFR 447.325 which states that Medicaid agencies “may pay the customary charges of the provider but must not pay more than the prevailing charges in the locality for comparable services under comparable circumstances." The plain language meaning of this requirement is that a state may pay a PRTF no more than it charges for covered Medicaid services provided to Medicaid recipients.

FAQ ID:92416

Yes, the state is required to report the number of Medicaid days. This information is recorded at variable 310 – Medicaid days.

FAQ ID:92421

States have the option to require hospitals to assist individuals in submitting the full application, which can help connect more people to longer-term coverage. While we encourage states to do so, to promote ongoing coverage, as noted above, a full application cannot be required as a condition of receiving a hospital PE determination, as the purpose of PE is to promote quick access to care on an interim basis while the full application process is underway. States can strike a reasonable balance by using the full application for hospital PE determinations, but clearly delineating which questions are necessary for PE purposes. States and hospitals can also use inserts or additional language to differentiate between the hospital PE application and the full application.

Supplemental Links:

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

FAQ ID:91581

Real-time eligibility determinations make the role of PE different than it has been in the past. In situations in which the individual files a full application right away, the PE period would likely be considerably shorter-and eliminated altogether, as a practical matter, if a real-time determination is made. However, even with the most modernized systems, there invariably will be individuals for whom a real-time eligibility determination will not be possible. There also will be individuals who will not be comfortable with the online application, or ready with the information needed to complete a full online application and will instead opt to apply later or use a paper application. In such situations and for such individuals, PE remains a useful tool to facilitate prompt coverage and enrollment in the program. States have flexibility to in effect minimize the length of the PE periods by requiring that hospitals and other qualified entities assist individuals in submitting the single streamlined application online, as long as the individual is not required to submit the full application online as a condition of qualifying for PE.

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

FAQ ID:91586

Yes. A simplified method of determining income (e.g., using use of gross income rather than or other simplified approximation of MAGI) per 42 CFR 435.1102(a) is permitted for all types of PE. Our regulations at 42 CFR 435.1102(a) discuss the use of simplified income methods and clearly state that full MAGI-based eligibility determinations cannot be used to determine PE. This requirement applies to all forms of PE, including hospital PE, per 42 CFR 435.1103(a) and 435.1110(a).

Supplemental Links:

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

FAQ ID:91591

Yes. A reasonable and simplified way of determining household composition for purposes of determining presumptive eligibility, including under hospital PE, would be to apply the rules for individuals who do not file taxes (i.e. the non-filer rules) as described at 42 CFR 435.603(f).

Supplemental Links:

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

FAQ ID:91596

At a minimum, states must implement hospital PE to ensure that hospitals are able to make PE determinations for all of the populations included in section 435.1102 and section 435.1103 (that is, all MAGI-eligible groups: pregnant women, infants, and children, parents and caretaker relatives, the adult group, if covered by the state, individuals above 133 percent of the Federal Poverty Level under age 65, if covered by the state, individuals eligible for family planning services, if covered by the state, former foster care children, and certain individuals needing treatment for breast or cervical cancer, if covered by the state). States may allow hospitals to determine PE for other groups, such as the aged, blind, and disabled, and those whose eligibility is established by section 1115 waiver authority. States permitting hospital PE for other groups are responsible for providing information on relevant state policies and procedures and information on how hospitals should fulfill their responsibilities in making presumptive eligibility determinations for such individuals.

Supplemental Links:

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

FAQ ID:91606