Frequently Asked Questions

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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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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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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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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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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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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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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We are working with states to help them complete all of the steps needed to implement the new adult group on January 1, 2014. States need to make changes and updates to their Medicaid state plan (and sometimes waiver programs) as expeditiously as possible, so they can accurately determine who is eligible, assist individuals with enrollment, contract with health care plans, provide access to quality care health care for their beneficiaries, and receive federal financial assistance for these costs. They will also need to submit state plan amendments (SPAs) describing how they will claim the appropriate federal medical assistance percentage (FMAP) for expenditures for the new adult group. In addition, states will need to submit their budget estimates related to the new adult group, so CMS can provide funding at the appropriate levels.

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As states compile their budget estimates for the first calendar quarter of 2014, or for future quarters, states that will adopt the new adult group should include in those estimates the impact of the increased newly eligible FMAP rates available for the new adult group. CMS typically issues quarterly grant awards prior to the beginning of the quarter, so that states can make payments to Medicaid providers during the quarter. We will issue grant awards associated with expenditures related to the new adult group once eligibility SPAs reflecting the new adult group have been approved and the associated FMAP SPAs have been submitted.

For states that have not yet reached these milestones, CMS can quickly issue supplemental grant awards once the new adult group SPA is approved and the FMAP SPA is submitted. States expanding coverage are likely to achieve these milestones early in the quarter but, as always, SPAs do not need to be submitted until the end of the quarter to be made effective retroactively to the beginning of the quarter. CMS is working with states to secure approval of new adult group eligibility SPAs on an expedited basis, and will provide technical assistance as needed so that states can submit their FMAP SPAs in a timely manner.

After the grant award reflecting estimated new adult expenditures is issued, states will be able to draw down federal funds during the quarter, in advance of submitting claims for such expenditures. Finally, as is our regular process, states can begin claiming for expenditures made during the quarter following the close of the quarter, subject to approval of all required eligibility, benefit, and FMAP SPAs. States that do not have approved SPAs can claim retroactively after approval is granted, as long as timely filing requirements are met.

States with waivers should note that, as always, waivers are prospective only - so any waiver changes need to be submitted and approved by January 1, 2014 if a state if trying to make coverage effective on that date.

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Typically, grant awards exclude any amounts associated with unapproved SPAs. If the eligibility SPA for a state is approved after the initial grant award to the state was issued (and which, therefore, would not have included amounts for the new adult group), the state could subsequently submit a request for additional funds at any time during the quarter once the eligibility SPA was approved. We consider the approval of the eligibility SPA for the new adult group to provide the necessary basis and authority for this grant action. However, to ensure that states demonstrate they will be able to claim federal funds properly, grant awards will also be contingent upon the submission (but not approval) of an FMAP claiming SPA. These steps will enable states to draw down federal funds during the quarter. However, states must still have all applicable SPAs (eligibility, benefits, and FMAP) approved before they claim expenditures on the CMS-64 after the quarter has closed. If they don't, they can claim retrospectively once approval is granted, as long as timely filing requirements are met. It is important to note that retroactive claiming is not possible when eligibility is triggered by a section 1115 waiver.

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