Presumptive Eligibility Policies and Procedures Handbook

Transcription

1 Overview Presumptive eligibility is a process that allows qualified hospitals and qualified entities to determine if an individual can get Short-term Medicaid. It provides individuals with Medicaid coverage while HHSC processes their application for regular Medicaid. You can find information here on the: Qualification requirements and process for hospitals and entities Steps for completing presumptive eligibility determinations Eligibility policies and forms Presumptive eligibility for Medicaid for Breast and Cervical Cancer (MBCC) is a separate process with additional requirements and is not included. Definitions Definitions Qualified hospital (QH): A hospital that is a Medicaid provider, notifies HHSC of its election to make presumptive eligibility determinations, and agrees to make determinations for children, pregnant women, parents and caretaker relatives, and former foster care children according to HHSC policies and procedures. Qualified entity (QE): An organization that notifies HHSC of its election to make presumptive eligibility determinations and agrees to make determinations for pregnant women only according to HHSC policies and procedures. Presumptive eligibility: Process that allows qualified hospitals and qualified entities to determine if an individual can get Short-term Medicaid. Presumptive eligibility determination: Qualified hospital or entity decision that an individual meets the criteria for Short-term Medicaid. The QH/QE then enters the individual's demographic information and the type of Medicaid the person is eligible for into the portal. Presumptive Eligibility Portal: HHSC-run portal where QH/QE staff submits determinations, view limited Medicaid history, view determinations submitted by their location, and link those determinations with the application for regular Medicaid. Third-party entity: An organization employed by a qualified hospital or entity to help with business processes. YourTexasBenefits.com: Website where applications for regular Medicaid and Children's Health Insurance Program (CHIP) are submitted to HHSC. Individuals may also view their account status on this website. Presumptive Eligibility website: Website where qualified hospitals and entities: o Submit notices of intent to participate in the program o Access training and policy o Receive ongoing communications from HHSC o Submit an electronic Memorandum of Understanding Page 1

2 Requirements for Qualified Hospitals and Qualified Entities Qualified Hospital To make presumptive eligibility determinations as a qualified hospital, an organization must: Be a hospital Be a Medicaid provider Submit a Notice of Intent (NOI) Agree to make presumptive eligibility determinations in accordance with HHSC policies and procedures Sign a Memorandum of Understanding (MOU) Have staff complete required training Qualified hospitals may designate any clinic owned by the hospital to participate in the presumptive eligibility process. Qualified hospitals may make presumptive eligibility determinations for the following groups: Children Parents and caretaker relatives Former foster care children Pregnant women Qualified Entity Most qualified entities are Medicaid providers. Other types of organizations have the option to become qualified entities without becoming a Medicaid provider. The organizations that may participate as qualified entities are listed at Title 1, Texas Administrative Code (TAC), Part 15, Chapter 366, To be a qualified entity, an organization must fall into one of the categories above and must: Submit a Notice of Intent (NOI). Agree to make presumptive eligibility determinations in accordance with HHSC policies and procedures. Sign a Memorandum of Understanding (MOU). Have staff complete required training. Qualification Process Hospitals and entities must complete the qualification process to make presumptive eligibility determinations. Hospitals and entities interested in becoming qualified can find information on and initiate the qualification process on the Presumptive Eligibility website. In general, the following must occur for a hospital or entity to be considered qualified: Page 2

3 Submit a Qualified Hospital/Qualified Entity Presumptive Eligibility Notice of Intent to HHSC through the Presumptive Eligibility website. HHSC must verify that the hospital/entity is a Medicaid provider. The Memorandum of understanding (MOU) must be signed, first by the hospital/entity and then by HHSC. HHSC provides access to training. Once the hospital/entity has successfully completed training, HHSC provides systems logins and qualified hospital/entity can submit Medicaid presumptive eligibility determinations. Notice of Intent The Notice of Intent is a fillable form available on the Presumptive Eligibility website. The Presumptive Eligibility website also includes the Notice of Intent Instructions which explain the required information that must be submitted with the form. The Notice of Intent must be signed electronically by an individual in a decision making capacity for the hospital/entity, and includes the following information: Hospital/entity name: The name of the hospital/entity with whom the MOU will be signed and will be held responsible for meeting program standards. Texas Provider Identifier (TPI) number: This number is mandatory for all Medicaid providers and will be used to verify status as a Medicaid provider through Texas Medicaid and Healthcare Partnership (TMHP). Contact person (System Administrator) and the person s telephone number, address, and mailing address. Hospital/Clinic name: Any clinic owned by a hospital that will be participating in the presumptive eligibility process must be provided. Clinic TPI number. Contact person (Site Administrator) and the person s telephone number, address, and mailing address. Hospital/entity staff may participate at multiple locations within the same QH/QE system, but must identify all of the locations where they are participating. If an individual participates at multiple locations, that person will receive login information for each location so presumptive eligibility determinations can be accurately tracked to the locations. Each staff person s role must be designated. The roles include: System Administrator: Individual who oversees the presumptive eligibility process for the hospital/entity system. This may be the same person as the Site Administrator. Site Administrator: Individual who oversees the presumptive eligibility process at the hospital/entity location. Staff: Individuals employed directly by the hospital/entity who will be making presumptive eligibility determinations. Page 3

4 Contractor: Individuals employed by a third party that contracts with the hospital/entity. These individuals can help make presumptive eligibility determinations but may not make final determinations. Medicaid Provider Verifying Medicaid Provider Status All hospitals, and clinics must be Medicaid providers. Qualified entities that are not hospitals or clinics are not required to be Medicaid providers. The status of a Medicaid provider is verified through the TPI number. The TPI numbers for the hospital, entity, and any associated clinics must be provided in the Notice of Intent. Memorandum of Understanding (MOU) The MOU must be signed by the qualified hospital/entity and HHSC representatives. The MOU is a static document that may be signed electronically through the Presumptive Eligibility website. The MOU must be signed by an individual who is in a decision making capacity for the hospital/entity, such as the CEO or CFO. Once the hospital/entity has signed the MOU, the HHSC representative will sign the MOU. The hospital/entity will receive a pdf version of the MOU. Training Hospital/entity staff must complete required training to make presumptive eligibility determinations. Trainings must be completed with a passing score of 80 percent or higher. Trainings may be accessed through the Presumptive Eligibility website. The trainings that must be completed include: 1. Policy Course o Program Overview o Eligibility Criteria o Household Income/Expenses/Standard Disregards o Coverage Periods and Forms o Presumptive Eligibility Portal o Determination Steps/Putting it All together 2. QH/QE Login and Client Account Set up 3. Completing the Online Application 4. Client Account Overview Once staff has successfully completed the training, HHSC will provide login information for the Presumptive Eligibility Portal to the staff and they may begin submitting determinations. Page 4

5 Conflicts of Interest Avoiding Conflicts of Interest and the Appearance of Impropriety All hospital/entity staff must avoid conflict of interests or the appearance of impropriety. Staff is not allowed to make presumptive eligibility determinations if the individual is a relative (by blood or marriage), roommate, dating companion, co-worker, supervisor, friend, acquaintance, or volunteer or staff at the hospital/entity. In cases with a potential conflict of interest, staff may provide the patient with a paper application and information about other options on how and where to apply for benefits. If staff is unsure if a potential conflict of interest exists, they should consult with their site administrator before making a PE presumptive eligibility determination Steps to Complete Presumptive Eligibility Determinations Step 1 The qualified hospital/entity staff member logs in to the Presumptive Eligibility Portal with the staff person's unique login. Look up the following eligibility requirements: Does the individual currently receive Medicaid or CHIP? Has the individual received presumptive eligibility within any of the past two calendar years of this application or within the same period of pregnancy if applying for a pregnant woman? If the individual is currently receiving Medicaid or CHIP or has received presumptive eligibility within the time periods listed above, the individual is ineligible. If the individual is not ineligible, proceed to the next step. Step 2 Collect information related to an individual s citizenship/immigration status, residency, household composition, and income using Form H1265, Presumptive Eligibility Worksheet. Ask applicants to attest to their citizenship/immigration status and residency. Verification is not required for any eligibility criteria when making a presumptive eligibility determination. Step 3 If eligible, issue the form H1266, Short-term Medicaid Notice - Approval to the individual. Enter into the Presumptive Eligibility Portal the individual s demographic information and the program for which the individual qualifies. There are presumptive eligibility programs for pregnant women, children, parents and caretaker relatives, and former foster care children. When a presumptive eligibility determination is submitted, the confirmation page displays a PE submission ID. Save this number because it will be needed later. If ineligible based on non-financial or financial eligibility criteria, follow the process under Denials. Page 5

6 Step 4 Help the individual complete the application for regular Medicaid. To do this, go to YourTexasBenefits.com with the individual and log in at the QH/QE login. If the individual does not already have an account with YourTexasBenefits.com, help them create one. Once the individual has an account and is logged in, help them complete the application for regular Medicaid, Form H1205, Texas Streamlined Application through YourTexasBenefits.com. Before submitting the application, a question will appear requesting the PE submission ID. Enter the PE submission ID that was provided when the presumptive eligibility determination was submitted. This number links the presumptive eligibility determination to the individual s application for regular Medicaid. Once the application has been submitted, explain to the individual what documents may be required to be sent to the state to verify eligibility for a regular Medicaid determination. Note: If an individual chooses not to submit a regular Medicaid application, do not delay in entering the individual s presumptive eligibility determination into the portal. Denials If the individual is ineligible for Short-term Medicaid based on either financial or nonfinancial eligibility requirements, indicate the reason for ineligibility in the Form H1265. Give the individual the Form H1267, Short-term Medicaid Notice: Not Approved and information about how to apply for regular Medicaid or CHIP. Linking Determinations and Medicaid Applications Presumptive eligibility determinations must be linked to the application for regular Medicaid. This is accomplished with the PE submission ID. When a presumptive eligibility determination is submitted through the portal, a PE submission ID is generated. There are two ways the PE submission ID can be used to link the determination with the application for regular Medicaid: 1. When helping the individual complete an application for regular Medicaid, sign into YourTexasBenefits.com before the individual gets to the end of the application and gets a prompt to enter the PE submission ID. This prompt appears directly above the individual's signature. 2. You may also use the Presumptive Eligibility Portal to search for determinations submitted by your qualified hospital/entity and link the determination and application through the search functionality. Due Dates Page 6

7 Due Dates and Processing Timeframes Within one business day of making a presumptive eligibility determination, the qualified hospital / qualified entity must submit the determination to HHSC through the Presumptive Eligibility Portal. The application for regular Medicaid must also be submitted within one business day of making the presumptive eligibility determination. The presumptive eligibility information should be viewable in the portal hours after submission. Note: The determination must be submitted through the Presumptive Eligibility Portal for the individual to be able to print a Medicaid ID card through YourTexasBenefits.com. Any delay in submission of the determination will delay the availability of the Medicaid ID card. Eligibility Policy Groups Eligible for Presumptive Eligibility Determined by Hospitals The eligibility requirements for Short-term Medicaid are consistent with the eligibility requirements for regular Medicaid coverage for the same group. Children To qualify for children s Medicaid, an applicant must: Be age 18 or under Meet citizenship or immigration status requirements Meet income standards Be a resident of Texas and intend to remain in Texas Former Foster Care Children (FFCC) To qualify for FFCC, an applicant must: Be age 18 up to 26 Meet citizenship or immigration status (CHIPRA Qualified Aliens eligible to age 21) requirements Have aged out of foster care or voluntary agency (VolAg) conservatorship at the age of 18 or older in Texas Have received Medicaid at the time of aging out of foster care Be a resident of Texas and intend to remain in Texas Pregnant Women To qualify for Medicaid as a pregnant woman, an applicant must: Be pregnant Meet citizenship or immigration status requirements Page 7

8 Meet income standards Be a resident of Texas and intend to remain in Texas Parents and Caretaker Relatives To qualify for Medicaid as a parent and caretaker relative, an applicant must: Meet citizenship or immigration status requirements Meet income standards Be a resident of Texas and intend to remain in Texas Be a parent or caretaker relative caring for a dependent child who receives Medicaid Note: Qualified Entities may only make presumptive eligibility determinations for pregnant women. Citizenship or Immigration Status U.S. citizens and certain non-citizen residents are eligible for presumptive eligibility. A person born in the 50 states, District of Columbia, Puerto Rico, Guam, the Virgin Islands, America Samoa, Swain's Island, and Northern Mariana Islands, is considered a U.S. citizen. If not a citizen, an individual must have eligible immigration status. Use the Immigration Status Job Aid to assist an individual in determining if they have a satisfactory immigration status. Applicants must attest to being a US citizen or to having eligible immigration status. Note: Applicants who do not meet the immigration status requirement may be eligible for Emergency Medicaid if they meet all other eligibility criteria. Refer them to or the local HHSC eligibility office if they wish to apply for Emergency Medicaid. Residence Applicants must live in Texas and intend to remain in Texas to be eligible for benefits. The household is not required to have a permanent dwelling or fixed residence. Household Composition The following individuals are included in the Household Composition if living together: The individual The individual s spouse The individual s children who are ages 18 and under If the individual is age 18 or under, count the individual s parents and siblings ages 18 and under who are living with the individual. Page 8

9 When determining household composition for a pregnant woman or the child of a pregnant woman who receives Medicaid, include the needs of the unborn child/ren. Consider the countable income of any individual included in the household composition. Income Income To determine a household s income, include any non-exempt income received by members of the household and deduct any acceptable expenses. See chart below for listing of the non-exempt types of income. Earned Income Income an individual receives for a certain degree of activity or work. Earned income entitles the individual to work-related deductions. Unearned Income Payments received without performing work-related activities, including benefits from other programs. Income = earned income + unearned income + self-employment income expenses income disregard Types of Income Earned Income Wages and Tips On-the-job training income Welfare-to-work income Military allotment Vacation pay Capital gains Interest Unearned Income Note Interest Dividends Royalties Award prizes Alimony received Page 9

10 RSDI Unemployment compensation Pension/retirement Railroad retirement Annuity Canceled Debts Court Awards Jury duty pay Life estate Trust payments Gifts or contributions Rental Farming/fishing Sales Self-employment Income Construction/repair work Commission Odd jobs Contract/seasonal work Other income Income Conversions All income must be converted to a monthly amount. Use the following conversion factors to convert incomes to a monthly amount. If Paid Then Multiply weekly gross pay x 4.33 every other week gross pay x 2.17 Page 10

11 semi-monthly gross pay x 2 Note: Divide yearly income by 12 for monthly income. Clients may not have the weekly/biweekly gross pay. To calculate the gross pay, multiply the hourly amount by the number of hours worked per week. Examples Mrs. Callahan works 30 hours per week at $7.24 per hour; she is paid weekly. 30 x $7.24 = $ weekly gross earnings The converted monthly income is $ x 4.33 = $ Mr. Burns works 40 hours per week at $7.15 per hour; he is paid bi-weekly. 40 x $7.15 x 2 = $ bi-weekly gross earnings The converted monthly income is Expenses $ x 2.17 = $ Allowable expenses include: alimony paid; educational expenses/student loan interest; moving expenses; tuition or GI Bill (military); educator expenses; expenses of reservists, performing artists, or fee-basis government officials; health savings account; deductible part of self-employment tax; self-employed IRA, simple IRA, and qualified plan deductions; self-employed health insurance; penalty on early withdrawal of savings deduction; IRA deduction; domestic production activities deduction; and costs related to self-employment income such as labor, sales tax, stock, raw materials, rent, insurance. Disregards Page 11

12 Once the income has been calculated, subtract the standard income disregard, which provides the total net income. The income disregard is equal to five percentage points of the Federal Poverty Level (FPL) for the applicable household size. The table below illustrates the disregard amounts by household size: Standard Disregard Five Percentage Points of FPIL (for 2014) Household Size Monthly Disregard Amount 1 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Per each additional member $16.95 Once the income has been determined, establish the maximum household income for the relevant household size and applicable Medicaid program. If the income is equal to or less than the maximum household income, the individual is eligible for presumptive eligibility, if all other eligibility criteria are met. Income Limits Use the charts found here to determine whether an applicant is within the relevant income limit. Periods of PE Periods of Presumptive Eligibility For children, parents and caretaker relatives, and former foster care children, an individual is allowed no more than one period of presumptive eligibility per two calendar years, 24 months (January - December). For example, if an individual received Short-term Medicaid anytime in 2015, they are ineligible for a presumptive eligibility determination until the year Pregnant Page 12

13 women are allowed one presumptive eligibility period per pregnancy. This means a woman applying for Pregnant Women Presumptive could potentially receive presumptive eligibility more frequently than once per two calendar years. If a woman is now applying for Presumptive Eligibility as a child, parent or caretaker relative, or a former foster care child, and received Presumptive Eligibility as a pregnant woman, do not count her receipt of Presumptive Eligibility as a pregnant woman as a period of Presumptive Eligibility. Note: Check the Presumptive Eligibility Portal to determine if individuals received a presumptive eligibility determination within two calendar years or within the same pregnancy for pregnant women. Three Months Prior Coverage Eligibility for three months prior Medicaid will be determined when HHSC eligibility staff makes the determination for regular Medicaid. Current Medicaid Recipients An individual is not eligible for Short-term Medicaid if they are currently certified for regular Medicaid or CHIP. Note: Check the Presumptive Eligibility portal to determine if the individual is receiving Medicaid or CHIP Verification Verification is not required when making a presumptive eligibility determination. Eligibility Dates Short-term Medicaid coverage begins the date the presumptive eligibility determination is made. The length of coverage depends on several factors: If the individual submits an application for regular Medicaid, the short-term Medicaid coverage ends the date the state makes a determination for regular Medicaid. If the individual does not submit an application for regular Medicaid, the short-term coverage ends the last day of the month following the presumptive eligibility determination. Short-term Medicaid services are provided as fee-for-service coverage. For applications for regular Medicaid that HHSC receives outside of business hours or when HHSC is closed, including weekends and holidays, the file date is the next business day. Page 13

14 The file date for the regular Medicaid application is the day HHSC receives the application. The Medicaid coverage is effective the first day of the month of the application month if all eligibility requirements are met. Systems Support Login details for the Presumptive Eligibility Portal and YourTexasBenefits.com will be ed to staff who have successfully completed training. Submitting determinations through the portal requires the following system capabilities: Internet Explorer v8 32-bit Virus protection with up-to-date virus definitions Applications submitted through YourTexasBenefits.com require Adobe Flash Player 11.1 or higher. If you have any IT support questions regarding the Presumptive Eligibility Portal, call , option 1 and explain that you have a Presumptive Eligibility Portal question. If you have a question about the Presumptive Eligibility website, please contact OSS_QHQE_PE@hhsc.state.tx.us. On weekends that system maintenance is performed, the Presumptive Eligibility Portal is unavailable beginning 8 p.m. Friday until 7 a.m. the next business day. If a qualified hospital/entity attempts to submit a presumptive eligibility determination when the system is down, the following message will appear "Error connecting to web services. Please try again after 7 a.m." Resubmit the determination once the portal is available. For all other issues, contact the Technical Help Desk at , option 1 between 7 a.m. and 7 p.m. central time and indicate that this is a presumptive eligibility issue. Case Example On June 17, Rebecca Fowler brings her 3-year-old daughter Chloe to the hospital. Chloe has a broken arm. Rebecca reports she is four months pregnant. Rebecca indicates that she is not able to pay the bill for Chloe and that she would like to have coverage for her pregnancy. Rebecca says that neither she nor Chloe has Medicaid and have not received Short-term Medicaid. Rebecca says both she and Chloe are U.S. citizens, Texas residents and intend to remain in Texas. Rebecca works at Home Care Inc. and earns $300 per week. Her husband, Page 14

15 Joe, is unemployed and receives $250 unemployment bi-weekly. They have no allowable expenses. Step 1 Complete a Form 1265, Presumptive Eligibility Worksheet for the household. Complete Section 1 to determine the household composition and if Chloe and Rebecca meet the non-financial eligibility for Short-term Medicaid. Both Rebecca and Chloe meet non-financial eligibility criteria. Continue to Section 2 to determine their financial eligibility. Determine the household size for Chloe and Rebecca using Rebecca s statement. Rebecca s household consists of Rebecca, Joe, Chloe, and the unborn child, totaling four. Chloe s household consists of Chloe, Rebecca, Joe, and the unborn child also totaling four people. Convert the household s income to a monthly amount. Rebecca is paid weekly. Convert her income to a monthly amount by multiplying the $300 by 4.33 (conversion factor). $300 x 4.33 = $1299 Joe is paid bi-weekly. Convert his income to a monthly amount by multiplying the $250 x 2.17 (conversion factor). $250 x 2.17 = $ To determine the net household income, add Rebecca and Joe s income and subtract the 5 percent income disregard. For a household size of four in 2014, the standard disregard is $ $ $ $99.40 = $1, The total net income for both Rebecca and Chloe is $1, The 2014 Income limit for pregnant women with a household size of four is $3,936. The income limit for children ages 1-5 is $2,862. As the household income for both Chloe and Rebecca is $ , they both fall below the income limits for Medicaid. Step 2 Log in to the Presumptive Eligibility Portal and perform inquiry for both Rebecca and Chloe. Inquiry confirms that Rebecca and Chloe do not receive Medicaid and have not had a period of presumptive eligibility within the past two calendar years for Chloe or current pregnancy for Rebecca. Based on inquiry, income and information provided, both Rebecca and Chloe are eligible for Short-term Medicaid effective June 17, the same day the presumptive eligibility determination is made. Enter the determination of eligibility into the Presumptive Eligibility Portal. Provide Rebecca with Forms H1266, Short-term Medicaid Notice: Approved for both Rebecca and Chloe. Step 3 Rebecca chooses to apply for regular Medicaid for herself and Chloe. Go to the Presumptive Page 15

16 Eligibility state page on YourTexasBenefits.com and login using your unique staff login. Help Rebecca create an account at Once an account is created, help Rebecca complete and submit an application for regular Medicaid. Rebecca has a copy of a check stub and her driver s license with her. Scan these documents and upload them to Rebecca s account. Explain to Rebecca that electronic verifications will be explored first for any required verification. If electronic verification is not available, HHSC will request paper verification. Also explain any additional documents the state may need from her using form H1858, Items we might need from anyone on your case. Rebecca and Chloe will have Short-term Medicaid beginning June 17 through the last day of the month HHSC makes the regular Medicaid determination, if HHSC finds both individuals eligible for regular Medicaid. If HHSC finds either ineligible for regular Medicaid, Short-term Medicaid ends the date that HHSC made the eligibility determination. Forms Form H1265, Presumptive Eligibility Worksheet: Use this form as a tool for determining eligibility for: Children Under 1 Children 1-5 Children 6-18 Pregnant Women Parents and Caretaker Relatives Former Foster Care Children Form H1266, Notice of Presumptive Eligibility: Use form to notify an individual that they are eligible for Short-term Medicaid, explain the type of Medicaid coverage they will receive, and provide the individual with information about the full Medicaid application process. Form H1267, Presumptive Eligibility: Notice of Ineligibility: Use this form to inform an individual who is not eligible for Short-term Medicaid, of their denial and to tell the individual of their right to file a regular Medicaid application. Form H1205, Texas Streamlined Application: Individuals use this application to apply for health care coverage and help paying for health care costs only. Individuals can apply online at YourTexasBenefits.com or can apply using the paper version of the form. Help individuals in applying online for the benefits or provide a paper version of the form to individuals who do not want to apply online. Form H Items We Need When You Apply for Benefits: This form provides applicants with a list of the information they may need to send to the state to get regular Medicaid. Give this form to individuals applying for regular Medicaid. Page 16

17 Form H0401, HIPAA - Privacy Notice - The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. Give the notice to individuals determined eligible for Short-term Medicaid to inform them of their privacy rights, along with the Form H0403, HIPAA - Explanation of Health Information Privacy Rights. Form H HIPAA - Explanation of Health Information Privacy Rights - The form is a cover letter to Form H0401, HIPAA - Privacy Notice. Give the form along with Form H0401 to all individuals determined eligible for Short-term Medicaid. Medicaid ID - This document provides proof of receipt of Medicaid coverage and may be presented to medical providers. There are several ways an individual with Short-term Medicaid can get a Medicaid ID card: A Medicaid ID card will be mailed to the person. Individuals can login into their YourTexasBenefits.com account and print a Medicaid ID after the presumptive eligibility determination has been submitted through the Presumptive Eligibility Portal. Form H1266, Short-term Medicaid Notice: Approved, may be presented at the local eligibility office where a temporary Medicaid ID card can be printed. Page 17