101.05.06 HOSPITAL PRESUMPTIVE ELIGIBILTY (HPE)

Qualified hospitals are allowed to make presumptive eligibility decisions prior to a formal determination of Medicaid eligibility by the Division of Medicaid. A qualified hospital is one that participates as a Medicaid provider, has executed required HPE formal agreements with DOM and agrees to make HPE decisions according to state policies provided to authorized hospital staff. HPE is time- limited Medicaid eligibility for certain children, pregnant women, parents or caretakers presumed to be eligible for Medicaid. DOM provides qualified hospitals with the HPE application form and model notices to use to establish HPE. The hospital must provide written notice to the HPE applicant regarding their eligibility for HPE and assist the HPE applicant in completing and submitting the full application for Medicaid before the end of the HPE period. The Division of Medicaid provides training and training material to hospital staff assigned to HPE. These individuals are required to pass a knowledge test before becoming certified to authorize HPE decisions. In addition, DOM provides the HPE staff with HPE applications and notices for use in HPE decisions. HPE approvals must be transmitted by the qualified hospital to DOM central office staff assigned to HPE within 5 days after the approval decision. DOM assigns a Medicaid ID and places HPE on file. The begin date of HPE is the day the hospital approves HPE. The end date of HPE is either the last day of the month following the month the HPE period begins, or the day DOM makes the final decision on the full application, which could either lengthen or shorten the HPE period. If a full Medicaid application is submitted to DOM following the HPE decision, the application is auto assigned to the appropriate regional office, but the application is completed by the central office staff member assigned to HPE. If the application is approved, the regional office is responsible for the case after approval, i.e., at the time of the first renewal or reported change. If the full application is denied, identifying information remains on record with the office in the event the individual reapplies.