Frequently Asked Questions

The difference between a prospective and retrospective UPL is in the relationship between the UPL demonstration period and the date when the UPL is submitted. For a UPL demonstration period of 7/1/2018 to 6/30/2019, a UPL is considered retrospective when it is submitted on or after the start of the demonstration period (on or after 7/1/2018). Using the same UPL demonstration period (7/1/2018 to 6/30/2019), a UPL is considered prospective if it is submitted prior to 7/1/2018.

FAQ ID:92431

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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FAQ ID:92111

States have flexibility in establishing agreements with hospitals, structuring training programs and conducting oversight consistent with overall federal guidance and the goal of ensuring that hospital PE is available as a way for individuals to access coverage. Under the regulations, states must explain their PE policies and procedures to their qualified entities. To provide transparency into the states' approach to ensuring that qualified entities have information on state eligibility policies and procedures, states must describe their process as part of their state plan amendment (SPA) submission and include with their SPA copies of training materials, documents or other materials provided to qualified entities demonstrating that the state is fulfilling its responsibilities. To assist states, CMS has provided a model structure for training materials and examples from other states where hospital PE has been approved. CMS will review materials in draft form in order to facilitate the SPA review and approval process. Materials relating to hospital PE are available on Medicaid.gov at www.medicaid.gov/resources-for-states/medicaid-and-chip-mac-learning-collaboratives/index.html.

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FAQ ID:91466

The timeline is the same for all types of PE, including hospital PE. The hospital PE period begins on the day that the qualified hospital approves PE. The end date, if a Medicaid application is filed by the last day of the month after the month that PE is determined, is the date full Medicaid eligibility is approved or denied. If a Medicaid application is not filed by the last day of the month after the month that hospital PE is determined, the PE period ends on that day. The statute (section 1920(b)(1), 1920A(b)(2), and section 1920B(b)(1)), codified at section 435.1101 (definitions), discusses the beginning and end dates for coverage based on presumptive eligibility.

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FAQ ID:91471

The purpose of hospital PE and PE more broadly is to provide a streamlined option for people who appear to be eligible to get access to immediate coverage. The statute makes it clear that a full eligibility determination is not immediately needed and cannot be required in order for hospital PE to be approved.

While states may not require an individual to fill out a full Medicaid application in order to receive a hospital PE determination or before a PE period begins, individuals should be informed that filing a full Medicaid application is necessary for coverage to continue, and states may require that qualified entities assist individuals determined presumptively eligible in completing a full Medicaid application during the PE period.

A state may use the full application for enrollment into hospital PE as long as the application clearly notes which questions need not be answered for PE purposes. An applicant can decide whether to answer those questions at the same time they are enrolling in PE, or to finish the application at a later time. Alternatively, a state could use a separate, short-form hospital PE application and then direct the qualified entity to help the applicant complete the full application by the end of the hospital PE period.

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FAQ ID:91476

Yes, this is a state option. Consistent with 42 CFR section 435.1102(d)(i), the individual or another person completing the application on the individual's behalf (who has reasonable knowledge of the individual's status) may be asked to attest that the individual is a citizen or in satisfactory immigration status, and is a resident of the state. It is important to note that while questions regarding attestation for citizenship, immigration status, and state residency are allowed, hospital PE determinations cannot be held up pending verification of such status. Verification of citizenship and immigration status is, however, required before a final eligibility determination can be made.

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FAQ ID:91481

As noted above, states have many different options for developing and administering the presumptive eligibility application. States are not required to use a written application for hospital PE; they can permit qualified entities to ask the applicant for the information needed to make a PE determination and be accountable for accurately recording the information provided. States can also choose to use a written application for hospital PE. If a state requires the use of the single, streamlined application for hospital PE, it must denote which fields must be filled out in order for PE to be determined, meaning that the PE determination will be denied or delayed if this information is not provided by the applicant. The state cannot require the full Medicaid application be filled out in order to receive a PE determination. Questions that are not related to making a PE determination cannot be required (e.g. race and ethnicity).

If the state intends to use a separate application designed specifically for hospital PE, the questions must be limited to those needed by the qualified hospital to make a PE determination. CMS is available to provide technical assistance on the application questions that are necessary and that cannot be required for hospital PE purposes.

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FAQ ID:91496

No, policies and procedures may differ between each type of PE, or the state can choose to align its policies. All policies must be consistent with applicable federal law.

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FAQ ID:91506

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.

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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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FAQ ID:91586