1. Implications of Community Engagement on Presumptive Eligibility and Presumptive Eligibility Determined by Hospitals

Sections 1920, 1920A, 1920B, and 1920C of the Act provide States with the option to designate “qualified entities” who are able to make presumptive eligibility (PE) determinations for pregnant women, children, certain breast and cervical cancer patients, and family planning services. States that have adopted this policy for children or pregnant women have the option to extend it to certain other groups covered under the State plan, including the adult group, under section 1920(e) of the Act (implemented at § 435.1103(b)).

Section 1902(a)(47)(B) of the Act provides that all hospitals enrolled as a Medicaid provider may elect to be a qualified entity able to determine PE for Medicaid, subject to the same procedures and requirements as are applied to determinations by qualified entities of PE for pregnant women, children, or certain breast and cervical cancer patients, whether or not the State has elected to designate qualified entities to make PE determinations for any such individuals. We refer to the option provided to hospitals as “hospital presumptive eligibility” (HPE). States that cover the adult group in the State plan must allow HPE for this group (§ 435.1110(c)(1)). [ 119 ] States may allow hospitals to determine PE for other groups approved under the State plan, or those whose eligibility is established by section 1115 demonstration authority (§ 435.1110(c)(2)).

Section 1902(xx)(1) of the Act establishes a new condition of eligibility for applicable individuals in the State plan adult group or those eligible for or enrolled under a waiver of such plan. Specifically, a State shall provide, as a condition of eligibility for medical assistance for an applicable individual, that such individual is required to demonstrate or be deemed as demonstrating community engagement. Section 1902(xx)(2) of the Act, implemented at § 435.552, sets out the qualifying activities that an applicable individual can use to meet the community engagement requirement. Section 1902(xx)(3)(A) of the Act establishes mandatory exceptions for certain applicable individuals implemented at § 435.553. Section 1902(xx)(3)(B) of the Act provides States the option to offer short-term hardship exceptions, implemented at § 435.555. Both mandatory and optional short-term hardship exceptions would deem an applicable individual as demonstrating community engagement. Section 1902(xx)(9) of the Act defines specified excluded individuals, who are not applicable individuals and are not subject to the community engagement requirement, implemented at § 435.554.

The community engagement requirement applies when an individual completes a full Medicaid application and when an individual applies for PE and HPE and appears to be eligible in the adult group. If a State has elected to cover a section 1115 demonstration population in HPE, and that population includes applicable individuals, the community engagement requirement applies to those HPE determinations as well. Therefore, all HPE programs in States that have adopted the adult group, that have elected the option to cover a section 1115 demonstration population that includes applicable individuals, and that have elected optional PE programs for the adult group will need to include the community engagement requirement as a factor of eligibility in the PE determination. For those individuals who appear to be eligible in the adult group or in an applicable section 1115 demonstration population, qualified entities must assess and obtain an attestation as to whether the individual appears to be a specified excluded individual (at § 435.554), an applicable individual, or meets a mandatory or optional exception (at §§ 435.553 or 435.555, respectively). The State determines if someone is a specified excluded individual or an applicable individual based on the month of application, as a State does when evaluating other factors of eligibility (§ 435.554). If the applicant is an ( printed page 33424) applicable individual (thus does not meet any specified excluded individual criteria) and does not qualify for a mandatory or, if applicable, optional exception, the qualified entity must assess whether the applicant demonstrated community engagement prior to the month of application for the number of months elected by the State, as specified in the State plan and defined at § 435.556.

The new requirement to condition Medicaid eligibility on demonstrating community engagement or being deemed as demonstrating community engagement because of an exception only applies to applicable individuals, and not to those who are specified excluded individuals. As described in detail at § 435.556, applicable individuals must demonstrate or be deemed as demonstrating community engagement at least 1 but not more than 3 consecutive months, as specified by the State, immediately preceding the month of application. Therefore, an applicable individual who applies for PE or HPE must attest they demonstrate community engagement, at a minimum for the month prior to the PE or HPE application, and up to 3 consecutive months prior at State option or qualify for an exception for those month(s) which deems them as demonstrating community engagement. Those that meet the criteria to be a specified excluded individual are demonstrated in the month of application.

Due to the new requirement, States will need to update PE and HPE training materials, train qualified entities on the requirement, and update PE and HPE application materials, including eligibility determination notices, to capture this information. These updates should include information on how providers can assess who is an applicable individual and who is a specified excluded individual. Once that is determined, providers will need to determine if an applicable individual meets exception criteria. In addition, applicable individuals who do not qualify for an exception must then be screened to identify the ways in which they may have demonstrated community engagement. The new questions should only be requested of those who appear eligible in the adult group or, if applicable, a section 1115 demonstration population that includes applicable individuals in a State that has elected to cover that group in HPE, and who could be considered an applicable individual. Determinations of PE and HPE, including whether an individual is a specified excluded individual or demonstrates or is deemed to have demonstrated the community engagement requirement, must continue to be based on attested information from the applicant per sections 1920, 1920A, 1920B, 1920C, and 1902(a)(47)(B) of the Act.