Hospital Presumptive Eligibility (HPE) DPA s Process

Transcription

1 This guide is meant to supplement the processing information in EIS Procedure Do not attempt to authorize Hospital Presumptive Medicaid without following the detailed instructions in the EIS Procedure. I. Receiving an HPE Packet from the hospital: 1) The hospital determines presumptive Medicaid eligibility and submits the HPE Packet to their local DPA office within 5 working days from the date the hospital determined the individual or household eligible for HPE. The hospital will not send over denial paperwork. The HPE packet must contain the following: a. HPE 1 Application for Presumptive Eligibility for Denali Care/Denali KidCare b. HPE 2 Hospital Presumptive Eligibility Worksheet (one for each individual approved for HPE). c. HPE 3 Hospital Presumptive Eligibility Approval Letter Please refer to the approved hospital list posted under ET Resources on the DPAweb prior to authorizing hospital presumptive Medicaid. This document includes: A list of hospitals that are approved to make HPE determinations and their contact information. Assigned EIS caseload id s for each approved hospital and the unit numbers needed to authorize the HPE in EIS. A list of hospital staff members that have successfully completed the HPE training. Only hospital staff members on this list are allowed to make HPE determinations. Remember that the information entered by the applicant on the HPE application (HPE 1) is information reported to the hospital in order for them to make an eligibility determination. The information is not considered to be a report of change to DPA. We should not use the information showing on the HPE application to make case changes to any open program the client may be receiving. Only if the client applies for regular Medicaid using a full Medicaid application should we check for reports of change. 2) If the packet is incomplete, contact the hospital at the number provided on the approved hospital list. A complete packet is needed prior to any HPE authorization. 3) Once DPA receives the HPE packet: 1. Do a client inquiry (in EIS and ARIES) to ensure that there is no open Medicaid case for any of the household members requesting presumptive eligibility. If an individual applying for HPE already has authorized Medicaid coverage, notify the hospital that made the HPE determination of the existing Medicaid case and provide them with a copy of the Medicaid coupon that covers the month of the HPE application. If this occurs, send an to [email protected] that includes the name of the hospital, the name and phone number of the hospital worker that made the HPE determination, and the client name. Please title the HPE determination Medicaid recipient. 5/20/15 Page 1

2 Although the HPE process should not be used to avoid providing information to DPA, if an individual who has been determined eligible for HPE by the hospital has a pending or unworked regular Medicaid application at DPA, no prioritization of the unworked Medicaid application received prior to the HPE start date needs to occur. HPE should be authorized as there is no active Medicaid for the individual. 2. Confirm that the individual(s) have not received HPE within the past 12 months (unless it was a pregnant woman and this is a new pregnancy). If an individual applying for HPE already received a HPE authorization within the past 12 months (at any hospital), notify the hospital that made the HPE determination that the individual is not eligible for HPE. If this occurs, send an to [email protected] that includes the name of the hospital, the name and phone number of the hospital worker that made the HPE determination, and the client name. Please title the HPE determination ineligible. 3. Register the HPE application in EIS. These cases must be stand-alone Medicaid cases. Application received date: Use the date the application was received in the DPA office. Benefit start date: Use the date the hospital determined the client is eligible for presumptive eligibility. Note: register all household members listed on the HPE application. Only code in those household members requesting HPE coverage, all other household members should be coded out. 4. CARC the application/case to 015. Each hospital is assigned a unique caseload number and the unit number will represent the DPA region where the hospital is located. This information is on the Approved Hospital List (HPE) posted on the DPAweb under ET resources. 4) Assign applications to an ET immediately. HPE applications need to be expedited and the Medicaid benefit issued the same day it is received. If the application is received on a holiday or over the weekend, issue the Medicaid benefits by the next business day. 1. The Benefit Start Date entered in EIS for these cases should be the date the hospital determines the individual(s) eligible, not the first of the month. 2. Enter information in EIS provided by the applicant on the HPE application. There is no need to remove additional pre-existing data in EIS if the individual has a public assistance history as long the CSEA screen is coded with EX so a CSED referral does not occur. Exception: Do not enter resources or income information in EIS. If the client does not provide a social security number on the HPE application, enter the application date in the SS5 date field on the SSDO screen. 5/20/15 Page 2

3 3. Do not attempt to verify information provided by the applicant. Code verification fields as CS (client statement). Do not check interfaces or request SVES. 4. Enter the appropriate Medicaid subtype for each household member on the MIBW screen and authorize benefits for all household members requesting Medicaid on the HPE application. Use the MAGI MIBW KIDS SUBTYPE Worksheet to determine the correct Medicaid subtype. This resource is posted on the DPAweb under ET Resources in the Manual MAGI Medicaid Toolkit. Remember to use the correct version for the month you are entering into EIS. Make sure that there is no real HIC number or Medicare codes on the MERE or MERI screens for any of the individuals being issued HPE benefits prior to entering your PCN. If there is STOP! Do not delete/remove existing HIC numbers or Medicare codes from the MERE or MERI screens. Contact the EIS Help Desk for assistance. You will need to provide the HPE start and end dates in your so that they can add the K coding to the MERI screen for you. Medicare Premium Assistance is not provided to those individuals receiving only HPE benefits. The individual must apply for regular Medicaid through DPA and provide the required verifications to be potentially eligible for QMB, SLMB, or QDWI. Make sure the correct Medicaid subtype is still showing on the MIAU prior to entering your PCN. 5. Enter HPEXXXXXXX in the HIC NUMBER field on the MERE screen. 6. In the first available MCR line on the MERI screen enter the HPE benefit start date in the START field, the HPE benefit end date in the END field, and K in the CODE field. Make sure that the information is on the correct line. Entering it on a TPR line will cause an error. Authorizing HPE for an individual that has been previously identified as CMP (lock-in) will require special processing and close coordination between DPA workers and Xerox/DHCS staff. HPE approved for CMP clients (that are still under the lock-in period) must have their Medicaid benefits issued via a RESTRICTED field coupon (MIMI) by the Xerox/CMP staff. It is extremely important that the restricted field coupons be issued for the 2 month HPE period the same day that the DPA worker authorized the HPE benefits. If this does not occur, the next Medicaid issuance job will delete the approved HPE benefits from EIS and no longer display or be accessible in the system without being re-authorized. In order for Xerox to complete these timely, there will be a 3:00pm cutoff daily. If HPE is authorized for a CMP client, the primary contact at Xerox and copy the secondary contact and DHCS: 5/20/15 Page 3

4 Primary Xerox CMP Contact Jason Ball Secondary Xerox CMP Contact Wes Amann DHCS CMP Contact Diana McGee Authorize the initial application month and initialize benefits to the month after the application month. Print and sign a field benefit issuance for the initial month using the Medical Insurance Manual Issuance screen (MIMI). Fax this to the hospital at the fax number provided on the Approved Hospital List and mail one to the client. There is no need to attach a cover letter or send it to a specific hospital staff member as each hospital has established an internal communication process. Remember to enter the appropriate wording in the SPECIAL INFORMATION field. If there are multiple MIMI pages (DKC subtypes always create a second page), you must issue a manual issuance for each page and the appropriate wording in the SPECIAL INFORMATION field must be typed again. Include the start and potential end date in the open text section of the field issuance coupon (MIMI). Examples: For all hospital presumptive approvals except the Pregnant Women category: Your temporary Hospital Presumptive Medicaid eligibility begins xx/xx/xx and will end no later than xx/xx/xx. For hospital presumptive approvals for the Pregnant Women category: Your temporary Hospital Presumptive Medicaid eligibility begins xx/xx/xx & will end no later than xx/xx/xx. This coverage is limited & does not cover inpatient hospitalization. For hospital presumptive approvals for households that contain both a pregnant woman and individuals approved for other categories: Your temporary Hospital Presumptive Medicaid eligibility begins xx/xx/xx & will end no later than xx/xx/xx. This coverage is limited for pregnant individuals. To create a MMIS interface record for the month after the application month, issue another field benefit but the special text is not necessary/needed and it does not need to be printed. This is because the field coupon printed for the initial month already displays the special text and date information. 5/20/15 Page 4

5 For example, if the HPE application was approved on 10/21/14, the household is eligible for HPE Medicaid until 11/30/ Close the HPE Medicaid case at the end of the approved HPE period via REVERT PROGRAM TO CLOSE (REPC) function. As described in the example above, this case should be closed 11/30/14. Unless the client submits a full Medicaid application (GEN 50C, SSP, or FFM) prior to the end of the approved HPE period, the 11/30/14 closure will remain in effect. If the client submits a full Medicaid application after the HPE period has ended (12/1/14 or later in this example), the application is treated as a normal Medicaid application for services. 9. Delete the pending EIS notice that is auto-generated because of the Medicaid application registration. DPA does not send any notices when the HPE is authorized. The hospital must provide individuals with a written notice after the HPE determination is made (HPE 3). When HPE ends, individuals do not receive a notice of their coverage ending. The approval notice they received from the hospital serves as their notice that this benefit is temporary and will end. DPA staff will not send any notices for HPE cases but must send all normal notices when a full Medicaid application is received and an eligibility determination is made. II. Receiving a full Medicaid application after HPE was authorized: ALL MEDICAID APPLICATIONS RECEVIED BY A DPA OFFICE (GEN 50C, SSP, or FFM) MUST BE SCREENED IMMEDIATELY TO SEE IF ANY HOUSEHOLD MEMBER LISTED ON THE APPLICATION RECEIVED A HPE AUTHORIZATION AND IF THE CURRENT MEDICAID APPLICATION HAS BEEN RECEIVED DURING THE HPE AUTHORIZED PERIOD. a) DPA offices will need to ensure that each household member listed on a full Medicaid application did not receive coverage recently through HPE by checking CLPM and looking for ME cases assigned to FSO 015 caseload. b) If any of the household members received Medicaid through HPE and the Medicaid application is received within the HPE coverage period, the application must be prioritized and processed immediately. For example, if a GEN 50C application is received on 10/21 for regular Medicaid and HPE Medicaid was issued from 9/15 through 10/31, the Medicaid application needs to be prioritized and processed immediately. This is to ensure that a Medicaid determination (approval or denial) on the regular Medicaid application is made before HPE Medicaid ends. If a Medicaid eligibility determination is not made by 10/31, the HPE Medicaid case must be processed and authorized for another month (this will also require reopening the HPE Medicaid case). c) HPE extensions staff must print a field issuance for the additional month of benefits. This must be faxed to the hospital at the fax number listed on the Approved Hospital List (HPE) document and a copy mailed to the client. Include the start and end dates in the free form section of the field issuance. 5/20/15 Page 5

6 Examples: For all hospital presumptive extensions except the Pregnant Women category: Your Hospital Presumptive Medicaid extension starts on xx/xx/xx and ends no later than xx/xx/xx. For hospital presumptive extensions for the Pregnant Women category: Your Hospital Presumptive Medicaid extension starts on xx/xx/xx and ends no later than xx/xx/xx. Coverage is limited and does not cover inpatient hospitalization. d) When an application is received for regular Medicaid, it is processed in ARIES. A full Medicaid eligibility determination must occur. The only exception to this is for Breast and Cervical Cancer Medicaid (BCCM) which must be processed in EIS. Please contact policy at [email protected] if you need to work a BCCM application for an individual who received HPE benefits and we will provide you special processing instructions. If the individual is found to be eligible for regular Medicaid, there is no need to make any changes to the HPE case in EIS as this should already be closed. When making the Medicaid eligibility determination in ARIES, make sure that you are not duplicating Medicaid coverage months already approved in EIS. The only exceptions are: If you must authorize a full month of regular Medicaid in ARIES for a pregnant woman who gave birth in a month that HPE was received. See e) below. If you must authorize a full month of regular Medicaid in ARIES for an individual that has medical bills during the period outside of their authorized HPE period. This may be because of a retroactive Medicaid request. See f) below. If the individual is found to be ineligible for regular Medicaid, the HPE case in EIS should be ended on the date DPA determines the individual to be ineligible for Medicaid. This includes if you must deny the regular Medicaid application because the household did not provide the verification necessary to make an eligibility determination. Example: Jon was approved for HPE benefits from 3/13/15 4/30/15. He submitted a GEN 50C to his local office on 4/27/15. Since the application was submitted within the approved HPE period, it was processed immediately. The application was pended for verification needed to make an eligibility determination that was not due until 5/8/15. HPE benefits for Jon must be issued for 5/15 since we are unable to make eligibility determination by 4/30/15. Jon fails to provide the verification and his Medicaid application is denied on 5/11/15. The HPE benefits must be ended on 5/11/15 the date the Medicaid application is denied. For example, the hospital found an individual eligible for HPE on 10/21/14. DPA authorizes HPE from 10/21/14 11/30/14. The individual submits a full Medicaid application on 11/14/14 and is found ineligible for Medicaid on that date. The Eligibility Technician must go back into the first available MCR line on the MERI screen and change the HPE end date to 11/14/14 in the END field. To pass this changed HPE end date to MMIS, issue another field benefit but the special text is not needed and it does not need to be printed. A CANO must be created indicating that the HPE end date was 5/20/15 Page 6

7 changed because the individual submitted a full Medicaid application and was found to be ineligible for Medicaid, even though a system generated CANO will be created when the MERI screen is updated and the END DATE(S) are pulled-back/changed. The Medicaid denial must still be input into ARIES to complete the FFM referral and a denial notice sent to the applicant. e) Since HPE covered services are limited for pregnant women and do not cover the birth expenses, authorizing full Medicaid benefits in a month the client already received HPE will be needed if she is requesting Medicaid for the birth month. Example: Providence Hospital determined Sue Johnson presumptively eligible for Medicaid on 9/8/14 in the pregnant woman category and provides Sue with an approval letter. The hospital worker submits the HPE 1, HPE 2, and HPE 3 to their local DPA office. These materials are provided to an ET and treated as an urgent application. The ET enters the information from the application into EIS and authorizes HPE through October 31, The case is closed 10/31/14. The Medicaid is authorized based on the hospital s determination so DPA does not need to verify any of the information. Sue gives birth on 10/20/14 and submits a regular Medicaid application on 10/28/14. The Medicaid application is screened and because the Medicaid application was received within the authorized HPE period, the application is given to an ET to expedite the eligibility determination. The ET finds Sue eligible for Medicaid. Because Sue received HPE in 10/14, we would normally start full Medicaid 11/1/14 but since Sue applied for full Medicaid in the month she gave birth, we must issue Medicaid in ARIES starting 10/1/14 to cover the birth expenses. f) Since HPE starts the date the hospital approves the individual(s), most HPE cases will start mid-month. If an individual is eligible for Medicaid and did not receive a full month s coverage with HPE, we will need to authorize a duplicate month of benefits in ARIES to cover the individual for a full month. Example: Providence Hospital determined David Smith presumptively eligible for Medicaid on 9/8/14 in the former foster care category and provides David with an approval letter. The hospital worker submits the HPE 1, HPE 2, and HPE 3 to their local DPA office. These materials are provided to an ET and treated as an urgent application. The ET enters the information from the application into EIS and authorizes HPE through October 31, The case is closed 10/31/14. The Medicaid is authorized based on the hospital s determination so DPA does not need to verify any of the information. David submits a regular Medicaid application on 10/28/14. The Medicaid application is screened and because this individual received HPE and the Medicaid application is received within the authorized HPE period, the application is given to an ET to expedite the eligibility determination. The ET finds David eligible for Medicaid. Because David received HPE in 10/14, we would normally start full Medicaid 11/1/14 but since David has medical expenses for the period that was not covered in the HPE authorization (9/1/14 9/7/14), we must issue Medicaid in ARIES starting 9/1/14 to cover the entire month. g) Newborns born to women during the HPE period are not eligible for newborn BA Medicaid as they were not born to women eligible for and receiving Medicaid in the month of delivery. 5/20/15 Page 7

8 Exception: If regular retroactive Medicaid was approved for the mother in the birth month, the newborn would then be eligible for newborn BA Medicaid. For example: The same PI used in the example e) above Providence Hospital determines Sue Johnson presumptively eligible for Medicaid on 9/8/14 in the pregnant woman category and provides Sue with an approval letter. Her eligibility for HPE ends on 10/31/14. However, since Sue applied for full Medicaid in the month she gave birth and we issued Medicaid starting 10/1/14 to cover the birth expenses, the baby is also eligible for BA Medicaid. III. Request for retroactive Medicaid coverage: a) If the applicant submits a regular application and requests retroactive Medicaid coverage, the same rules for retroactive coverage apply. Refer to Family Medicaid Eligibility Manual section 5008 for information about retroactive Medicaid eligibility. b) If the applicant is requesting retroactive Medicaid coverage for a month that HPE Medicaid was already authorized, ET will skip this month and document that applicant (or if there are other household members) already received coverage. Send the applicant(s) the equivalent of an M221 notice, adding text in the notice explaining that they are not eligible for retroactive Medicaid in the requested month(s) because they had already received Medicaid coverage in that month. Example: if the GEN 50C application is received on 7/21, the retro months are 6/14, 5/14 and 4/14. If HPE was issued on 6/14, the ET will not determine retroactive coverage for this month (unless the retro month was requested for the month a pregnant woman gave birth or the individual has medical expenses for the period that was not covered in the HPE authorization. See examples e) and f) above). IV. Filing the HPE Packet Follow the procedure in Administrative Procedures Manual section103 for filing the HPE packet and other documents in the case file. V. Contact person in DPA field offices: Each field office will have a designated contact person for the hospitals to call should they have any questions about a HPE application packet they submitted. If a hospital or local DPA office has questions about HPE, they should [email protected]. 5/20/15 Page 8