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.

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.

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.

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.

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.

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.

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.

The purpose of section 1202 of the Affordable Care Act and the final rule is to ensure access to and utilization of beneficial primary care services. Towards that goal, eligible primary care physicians must receive the full benefit of the enhanced payment at the Medicare rate for eligible services rendered. If a Medicaid managed care health plan retains sub-capitation arrangements, the health plan would be obligated to provide additional payments to providers to ensure that every unit of primary care services provided is reimbursed at the Medicare rate.

Yes. A state may elect to delegate the self-attestation process to its contracting health plans under the following circumstances:

CMS acknowledges the customary practice of reimbursing out-of-state or out-of-network providers at a base rate minus a defined percentage. The applicable Medicare rate effectively becomes the'floor' for payments to eligible providers for eligible services rendered in CYs 2013 and 2014. Health plans may pay above that rate but not below.

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