Frequently Asked Questions

Per our regulations at 42 CFR 435.1103(a), pregnant women may have one PE period per pregnancy. If a woman is pregnant more than once in a calendar year, they may have more than one PE period in a calendar year due to the multiple pregnancies.

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FAQ ID:91631

In general, for individuals determined eligible under hospital PE, the benefits provided are the same as those provided under the eligibility group for which PE is determined. See 42 CFR 435.1103(a) and (c)(1)(ii), which specifies that covered benefits for pregnant women during a PE period are limited to ambulatory prenatal care, and benefits covered under family planning PE are limited to family planning services.

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FAQ ID:91641

If a state has elected to provide PE for individuals with breast or cervical cancer under section 435.1103(c)(2), it can limit qualified entities under that section to providers who conduct screenings for breast and cervical cancer under the state's CDC BCCEDP, and if it has done so, the state may limit hospitals that may determine PE for individuals with breast or cervical cancer on that basis to hospitals that conduct screenings under the state's BCCEDP. In states that do not opt to provide PE for individuals with breast or cervical cancer under section 435.1103(c), states similarly may limit hospitals' ability to determine PE for individuals with breast or cervical cancer under section 435.1110 to those that conduct screenings under the state' BCCEDP.

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FAQ ID:91651

When hospitals determine PE, they are subject to the same general rules set out for other qualified entities that may determine PE, including that they cannot "delegate the authority to determine presumptive eligibility to another entity." (See 42 CFR 435.1102(b)(2)(vi). However, they may implement PE with the support of third party contractors. For example, hospitals can rely on third party contractors to help staff their in-hospital PE operations, by staffing welcome desks, meeting with consumers, and helping them fill out PE applications as long as the hospital takes responsibility for the PE determinations that result. In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application.

Hospitals that conduct off-site, targeted outreach may also employ third party contractors to reach out to individuals who may be Medicaid eligible and assist them with a presumptive application and the single streamlined application at the individual's request. Hospitals must oversee such off-site outreach to ensure hospital accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. States should not unduly limit a hospital's ability to rely on third-party contractors as long as the hospital is not delegating its authority to determine presumptive eligibility to a third party and is meeting appropriate state-established performance standards.

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FAQ ID:91656

Keeping track of all eligible providers is important to ensure ongoing training and that the providers have regular updates in policy as well as to review performance, implement performance standards and develop quality assurance measures. Some states maintain a centralized list of all providers who have completed the process for learning the state's policies and procedures; the state may wish, for example, to periodically review the list by calling all identified providers or settings and asking whether or not listed individuals are currently conducting PE determinations. It is important for states to ensure, over time, that hospital PE is functioning throughout the state.

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FAQ ID:91671

States have used a number of strategies to engage hospitals, such as reaching out to the state hospital association or local hospital groups, sending hospitals a letter of interest to get feedback on their plans to participate in the program, and inviting hospital representatives to teleconferences and webinars about the policy. CMS has also reached out to various hospital associations to advise them of this new provision and the federal guidance supporting it.

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FAQ ID:91681

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.

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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.

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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.

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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.

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FAQ ID:91706