1 Hospital Presumptive (Temporary) Medical Process February 14, 2014 Oregon Health Authority Division of Medical Assistance Programs
2 Agenda for today Why does Oregon now have a Hospital Presumptive Medical (HPM) process? What is HPM? Oregon s experience with Presumptive Medical Eligibility Definitions and distinctions The hospitals role in HPM OHA s role in HPM The applicant s role in HPM Accountability and sanctions Feedback and Q & A
3 Why does Oregon now have a Hospital Presumptive Medical (HPM) Process? Section 2202 of the Patient Protection and Affordable Care Act (ACA) allows Hospitals that are participating providers under a state s Medicaid program to determine eligibility for medical assistance. Hospitals are not required to participate as an HPM eligibility determination site. Hospitals have the option to participate or not. The State must allow any qualified and interested hospital to participate.
4 Hospital Presumptive (Temporary) Medical Process WHAT IS HOSPITAL PRESUMPTIVE MEDICAL (HPM)?
5 Why Hospital Presumptive Medical (HPM)? Timely access to necessary health care services Immediate temporary medical coverage while full eligibility is being determined Pathway to longer-term Medicaid coverage Requires minimal eligibility information
6 Why Hospital Presumptive Medical (HPM)? HPM allows hospitals to be reimbursed for services provided during the temporary coverage period even if individual is ultimately determined ineligible for Medicaid/CHIP. NOTE: To be reimbursed, services must be covered under the OHP (i.e., above the finding line on the Prioritized List).
7 Oregon s experience with Presumptive Medical Eligibility Breast and Cervical Cancer Treatment Program (BCCTP) Provides immediate, temporary coverage for individuals who appear to meet basic eligibility criteria Income Must have been screened and found to be in need of treatment for breast and/or cervical cancer or follow-up care for cancer or precancerous conditions A licensed health care provider, qualified to diagnose cancer or precancerous conditions, must determine BCCPT Presumptive Medical. Hospitals may do these determinations per BCCTP or HPM rules.
8 How does HPM differ from Hospital Hold? Hospital Hold Secures a Date of Request (DOR) for an applicant when the individual is unable to apply due to inpatient hospitalization. Only covers hospital services if applicant is determined eligible after full determination. HPM Covers hospital services during the presumptive period, whether or not the individual is ultimately determined eligible for ongoing health care coverage. Hospital Presumptive Medical does not replace Hospital Hold.
9 How long does a period of HPM coverage last? If eligible, the temporary coverage period: Starts at Midnight of the date hospital makes the approval decision. This should match the dat4e of the initial service. Ends based on submission of the completed full Medicaid/CHIP application (7210). If 7210 is submitted timely, the agency determines MAGI Medicaid/CHIP eligibility, and HPM is in effect until the determination is made. If 7210 is not submitted timely, coverage ends on the last day of the month following the month of the hospital s determination date.
10 How often may someone have HPM coverage? Only one period of HPM coverage is allowed in any 12-month period. This is calculated from the last day of the most recent prior period of HPM.
11 What does HPM cover? In general, HPM covers all services covered under OHP, including dental, vision and mental health. This means that HPM will cover only services that are above the funding line on the State s Prioritized List of Health Services.
12 What does HPM cover? Exception: Pregnant Women Pregnant women are covered only for ambulatory prenatal care. Labor and delivery are not covered. For women who were presumptively eligible when they were pregnant and are determined to be Medicaid-eligible, the period including and the labor, delivery and birth will often be covered, even if retroactively. For a pregnant woman applying while in labor, it may be best for the hospital to submit a full 7210 the first date medical benefits were provided, or use the Hospital Hold process.
13 Can newborns be covered? Newborns born to women during the hospital presumptive (temporary) period are not considered Assumed Eligible Newborns (AEN). A separate hospital presumptive (temporary) medical determination is required to cover newborns. If women who were presumptively eligible when pregnant are later determined to be eligible for Medicaid based on the timely submission of a 7210, the newborn s status changes to AEN.
14 What eligibility groups are included? Refer to OHA s Quick Guide to Income Eligibility at: Hospital Presumptive Medical uses the following income guidelines. Parents and Caretaker Relatives (specific $ limits) Pregnant Woman ( through185% FPL) Medicaid Children Under age 1: (through 185% FPL) Age 1 18: (through 133% FPL)
15 What eligibility groups are included (cont )? CHIP Children Under age 1: (above 185% through 300% FPL) Age 1-18: (above 133% through 300% FPL) Newly Eligible Adults (through 133% FPL) Individuals (to age 26) formerly in Foster Care in Oregon (no FPL limit) Individuals in the Breast and Cervical Cancer Treatment Program (BCCTP) (through 250% FPL)
16 Does the applicant have to be admitted to the hospital? No, there is no requirement that the applicant be admitted or be seeking Hospital services at the time of an HPM determination. HPM is a path to ongoing eligibility for any eligible individual.
17 Hospital Presumptive (Temporary) Medical Process THE HOSPITAL S ROLE IN HPM
18 The Hospital s Role in HPM Identify individuals who may be eligible for Medicaid/ CHIP health coverage; Make immediate temporary eligibility determinations for these individuals; Educate individuals about their responsibility to complete the full Cover Oregon/OHA application (7210) for health coverage with timeframes required by the Hospital Presumptive Medical process; Provide the 7210; and Assist the individual with completing the 7210, or Provide information on specific resources to help individuals complete the 7210 within required timeframes.
19 Qualified Hospitals: Agreement/Certification To become an approved eligibility determination site, hospitals must: Be enrolled with Oregon Medicaid as a participating provider; Notify OHA of their decision to become a Hospital Presumptive Medical eligibility determination site; Agree to make determinations consistent with OHA policies and procedures; and Meet established quality standards.
20 Qualified Hospitals: Agreement/Certification Hospitals may not contract HPM site functions to other entities or use contracted hospital personnel to make HPM determinations. Exception - Certified Application Assisters who specifically work with a Qualified Hospital may make HPM determinations for the hospital.
21 What do the hospitals do? I. Check MMIS for current OHP eligibility and recent HPM eligibility II. Complete Part 1 of the OHP 7260 (Application for HPM Eligibility). III. Make eligibility determination based on required information in Part 1 of the OHP 7260 IV. Notify the applicant V. Notify OHP Customer Service (Branch 5503)
22 I. Check eligibility using MMIS Before making HPM determinations, check MMIS to see if the applicant is currently receiving Medicaid/CHIP Individuals in MMIS with ADMIN exam coverage should not be treated as already having medical coverage) If an applicant has Medicaid or CHIP coverage, the individual will not be eligible for HPM.
23 II. Complete Part 1 of the OHP 7260 Use the OHA Hospital Presumptive Medical application (OHP 7260). The most current application will be available at: Use only information provided by the applicant or his/her representative in Part 1 of the OHP No additional documentation or verification may be required at the time of the HPM determination. Document the decision and the date of the decision on the application form (7260). The decision should be made the first day the patient received services.
24 II. Complete Part 1 of the OHP 7260, continued Information Required for Determination Applicant s full legal name Family size Household s gross monthly income Oregon resident? (Yes/No) U.S. citizen, U.S. national or qualified non-citizen? (Yes/No) Previous period of Hospital Presumptive Medical Assistance? (Yes/No) If Yes, when?
25 II. Complete Part 1 of the OHP 7260, continued If information is readily available, also complete the following: Other medical coverage? (precludes HPM for CHIP and BCCTP applicants) Pregnant? (Yes/No) If yes, pregnancy due date In Foster Care at age 18? Eligible for or receiving SSI benefits? Receiving Medicare benefits? (precludes HPM coverage for new adult applicants)
26 III. Make eligibility determination Refer to the Quick Guide to Income Eligibility to help make the determination. Income guidelines may change yearly. Please be sure you are using the most recent version. These may also be found at: The Quick Guide includes the following guidance for each eligibility group: What income to count in the applicant s family Who to include in applicant s family size
27 III. Make eligibility determination, continued When is the HPM eligibility determination made? At the time of the presumptive determination. The hospital gives the individual immediate written notice of whether s/he is eligible, or ineligible, for Hospital Presumptive Medical coverage. To the greatest extent possible, the determination date should match the first day the patient received services as this is the date used to start medical in the system.
28 IV. Notify the applicant Hospital provides the eligible individual: Approval Notice (OHP 3263A); A copy of the completed OHP 7260; The full 7210 packet, marked with Hospital Presumptive at the top of the front page of the 7210; Explanation that the individual must complete and submit the 7210 no later than their temporary coverage end date; and Assistance with completing the 7210, or information on resources to help the individual complete and submit the 7210 by the coverage end date listed on the Approval Notice.
29 IV. Notify the applicant, continued Hospital provides the ineligible individual: Denial Notice (OHP 3263B); A copy of the completed OHP 7260; The full 7210 packet; do NOT mark these applications Hospital Presumptive ; and Assistance with completing the 7210, or information on resources to help the individual complete and submit the 7210 by the coverage end date listed on the Approval Notice.
30 OHP 7260 For all applicants, make sure all parts of the form are completed.
31 IV. Notify the applicant, continued What is in a Notice of Approval (OHP 3263A)? Client name, SSN, date of birth Hospital name, provider number, date of notice Eligibility approval date This should be the date of initial service to the greatest extent possible. Next steps: OHA 7210 and assistance, or information on getting assistance, with completing the 7210 Ensure individual knows the date the 7210 must be submitted in order to be determined for coverage No appeal rights - PE determinations are final. Hospital representative signature, title and contact information
32 IV. Notify the applicant, continued The Approval Notice (OHP 3263A) is proof of coverage. If the applicant is eligible, the Notice of Approval will be the individual s proof of coverage until they receive their Oregon Health ID and Coverage Letter.
33 OHP 3263A Hospital gives an Approval Notice to all eligible applicants.
34 IV. Notify the applicant, continued What is in a Notice of Denial (OHP 3263B)? Applicant name, SSN, date of birth Hospital name, provider number and date of notice Denial of eligibility for Hospital Presumptive Medical Next steps: Application (not marked Hospital Presumptive ), information on completing full application and why they may want to do so No appeal rights - Presumptive Medical determinations are final. Hospital representative signature, title and contact information
35 OHP 3263B Hospital gives a Denial Notice to all ineligible applicants.
36 IV. Notify the applicant, continued Hospitals are responsible to: Provide the eligible individual with the full Cover Oregon/OHA application (OHA 7210) Provide individual assistance in completing the 7210, or Inform the individual that the 7210 must be completed by the last day of the second month following the Presumptive Medical determination in order to determine ongoing Medicaid eligibility. Inform the individual of resources for assistance with the Hospitals may also want to follow up with each individual with Presumptive Medical to check on their progress with submission.
37 V. Notify OHP Customer Service (Branch 5503) What to fax to OHP Customer Service: A copy of the completed Approval or Denial Notice (the 3263A or 3263B) issued to the individual, and A copy of the individual s completed Hospital Presumptive Medical application (the 7260). All presumptive determination forms for each individual applicant must be faxed together. Do not include completed 7210s for these individuals must be faxed SEPARATELY to
38 V. Notify OHP Customer Service (Branch 5503) Within 5 working days of each HPM determination (approval or denial), the Hospital must FAX the required documents to OHP Customer Service at (Salem). Mark the fax cover sheet Attention Hospital Presumptive Team
39 V. Notify OHP Customer Service (Branch 5503) Hospitals should check MMIS within a week of submitting the required forms to OHA to confirm if approved individuals are in the system. If the MMIS enrollment is not complete, contact the OHP Customer Service HPM Team. If an individual has already submitted a 7210 medical application but has not received an update on the status of the application: Contact the OHP Customer Service HPM Team to identify the application and ensure its processing is expedited.
40 Hospital Presumptive (Temporary) Medical Program OHA S ROLE IN HPM
41 What are OHA s responsibilities? Confirm initial screening criteria: Hospital is a qualified hospital. Individual reflects no OHP eligibility on MMIS. Individual does not currently receive Hospital Presumptive Medical coverage. Individual has not received Hospital Presumptive Medical coverage within the past 12 months.
42 What are OHA s responsibilities? Accept the hospital s determination and not question the decision unless: The determination comes in from a non-qualified hospital; The individual is found to have current OHP coverage; or The individual has HPM benefits or has had HPM benefits in the prior 12 months. Under no circumstances, will an HPM decision be reversed, or HPM eligibility terminated retroactively, even though someone determined eligible through HPM could potentially be found ineligible based on the 7210 full determination.
43 What are OHA s responsibilities? Systems entry and documentation Enter Hospital Presumptive Medical applicants in the system. For approved individuals, start the eligibility effective at Midnight of the date the hospital makes the approval decision (this should match the date of initial service). Ensure eligible individual is not auto-enrolled in a Coordinated Care Organization (CCO), other physical health managed care organization (MCO or FCHP) or dental plan for the presumptive period. This means the individual will receive all health care services (physical, dental, mental health) on a fee-for-service (open card) basis. Send individual an ID card and coverage letter.
44 What are OHA s responsibilities? Prior to end of HPM period, check to confirm receipt of an application. Upon receipt of a 7210 from a HPM beneficiary, staff at OHP Customer Service will: Complete the determination of ongoing eligibility under the appropriate program, and If found eligible for Medicaid/CHIP, ensure that the individual is enrolled in a Coordinated Care Organization (CCO) or other physical health managed care entity (MCO or FCHP), as appropriate.
45 What are OHA s responsibilities? Ensure that the presumptive coverage ends: If 7210 submitted timely, the date the formal determination of Medicaid/CHIP eligibility (or ineligibility) is made. If 7210 not submitted or late, at the end of the month following the month of the HPM determination. When HPM ends, individuals do not receive a notice of their coverage ending. The approval notice they receive in the hospital serves as their notice that this benefit is temporary and will end within two months of the approval date.
46 Hospital Presumptive (Temporary) Medical Process THE APPLICANT S RESPONSIBILITIES
47 What are the applicant s responsibilities? Provide true and accurate information for OHP If approved: If interested in pursuing ongoing eligibility, submit completed 7210 prior to the end of the month following the month of Hospital s determination If no application is received, coverage closes effective the end of the month following the month of Hospital s determination. If denied: No obligation, but may complete 7210 for full eligibility determination
48 Hospital Presumptive (Temporary) Medical Program ACCOUNTABILITY
49 Partners in accountability Hospital Recordkeeping Requirements (maintain records for three years): Presumptive Medical Eligibility determinations completed (retain 7260s) Approval Notices issued (retain 3260As) Denial Notices issued (retain 3260Bs) Record of applicants given, prior to leaving the Hospital, 7210s, with information on the requirement to complete the 7210 and instructions on how to get help completing the application Record of applicants given, prior to leaving the Hospital, 7210s, and also given help completing the 7210
50 Partners in accountability OHA Recordkeeping Requirements: Number of applicants, statewide and by Hospital, who: Submitted a full Cover Oregon/OHA application within the required timeframes. Were ultimately determined eligible for Medicaid/CHIP. Were ultimately determined ineligible for Medicaid/CHIP. All claims and payments related to Hospital Presumptive approvals for: Individuals ultimately eligible for Medicaid/CHIP, and Individuals ultimately ineligible for Medicaid/CHIP
51 Standards for accountability The HPM program is launching with the following test standards which will be refined over time.
52 Standards and criteria
53 Sanctions and disqualification As the program progresses and Standards and Criteria are refined, OHA proposes to enforce the Standards as follows:
54 Sanctions and disqualification Plan of Correction If the prescribed standards are not met for a period of one calendar quarter, OHA will establish with the Hospital a written Plan of Correction (POC) that describes: Targets and timelines for improvement; Steps to be taken in order to comply with the performance standards; How additional staff training would be conducted, if needed; The estimated time it would take to achieve the expected performance standards, which would be no greater than three months; and How outcomes would be measured.
55 Sanctions and disqualification OHA may impose additional correction periods, as appropriate. If targets are not met after a sufficient period for improvement, as determined in discussions between OHA and the hospital, OHA may disqualify a hospital from making eligibility determinations under the HPM program.
56 Hospital Presumptive (Temporary) Medical Program CONTACTS AND INFORMATION
57 Contacts and information OHA Customer Service HPM Team: Anselma Ulluoa-Avalos: ext or or Ellen Rust: ext or OHA Policy Analyst for HPM: Angel Wynia: or OHA eligibility analyst for HPM: Yer Vue-Xiong: or OHP implementation manager for HPM: Janna Starr: or HPM Web page:
58 Hospital Presumptive (Temporary) Medical Program FEEDBACK AND Q & A
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