Presumptive Eligibility Qualified Provider Manual
HP Provider Relations Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Presumptive Eligibility Qualified Provider Manual L P P V I B R A O L I C U B L I E R S I R Y R E F E R E N C E N U M B E R : P R P R 1 0 0 2 0 I E S A N D P R O C E D U R E S A S O F A P R I L 1 , S H E D : J U N E 9 , 2 0 1 5 O N 1 . 0 2 0 1 5 Library Reference Number: PRPR10020 Document Management System Reference: Presumptive Eligibility Qualified Provider Manual Address any comments concerning the contents of this manual to: HP Provider Relations Unit 950 North Meridian Street, Suite 1150 Indianapolis, IN 46204 © 2015 Hewlett-Packard Development Company, LP. Presumptive Eligibility Qualified Provider Manual Revision History Version 1.0 Date Policies and Procedures as of April 1, 2015 Published: June 9, 2015 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Reason for Revisions New Manual Revisions Completed By FSSA and HP Publications iii Presumptive Eligibility Qualified Provider Manual Table of Contents Section 1: Introduction .......................................................................................... 1-1 Overview ............................................................................................................. 1-1 Member Enrollment Process Overview .......................................................... 1-2 Section 2: Presumptive Eligibility Team .............................................................. 2-1 Overview ............................................................................................................. 2-1 HP ................................................................................................................... 2-1 Qualified Providers ......................................................................................... 2-1 FSSA ............................................................................................................... 2-1 Managed Care Entities .................................................................................... 2-2 Indiana Navigators and Application Organizations ........................................ 2-2 Section 3: Presumptive Eligibility Provider Enrollment Requirements ........... 3-1 Eligible Provider Type .................................................................................... 3-1 Qualified Provider Requirements .................................................................... 3-1 Section 4: Presumptive Eligibility Qualified Provider Enrollment Process .................................................................................................................... 4-1 Enrolling as a Presumptive Eligibility Qualified Provider .............................. 4-1 Section 5: Qualified Provider Completing a Member Presumptive Eligibility Application ........................................................................................... 5-1 Completing the Presumptive Eligibility Member Application........................ 5-1 Eligibility Verification System ....................................................................... 5-5 Section 6: IHCP Presumptive Eligibility Programs Overview .......................... 6-1 Comparison of Presumptive Eligibility Programs .......................................... 6-1 Section 7: Presumptive Eligibility Applicant Requirements .............................. 7-1 Specific Requirements for PE Aid Categories ................................................ 7-2 Section 8: Medicaid Coverage per Aid Category ................................................ 8-1 Medicaid Coverage per Aid Category............................................................. 8-1 Section 9: Presumptive Eligibility Claims Submission ....................................... 9-1 Fee for Service ..................................................................................................... 9-1 Managed Care (HPE Adult only) ........................................................................ 9-1 Index ........................................................................................................................... 1 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 v Introduction vi Presumptive Eligibility Qualified Provider Manual Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 1: Introduction Overview Qualified Providers (QPs) can enroll qualifying individuals in certain aid categories to receive temporary coverage at the point of service until eligibility for the Indiana Health Coverage Programs (IHCP) is officially determined by the Indiana Family and Social Services Administration (FSSA). Provider types that can apply to be qualified providers are Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Community Mental Health Centers (CMHCs), and local county health departments. The Presumptive Eligibility (PE) coverage period begins on the date the PE QP determines an individual is presumptively eligible for coverage through the IHCP. Most PE categories are part of the fee-for-service (FFS) delivery system, except for PE Adult, which is managed care. The PE coverage period ends when one of the following circumstances occurs: • The member does not complete and file an Indiana Application for Health Coverage by the end of the month following the month in which PE coverage begins. A completed Indiana Application for Health Coverage must be pending with the FSSA within that time frame to continue PE coverage. • The member is officially determined eligible for coverage under an IHCP program by the FSSA. Eligibility for PE ends on the day after eligibility information is received from the FSSA. • The member is officially determined ineligible for coverage under an IHCP program by the FSSA. Eligibility for PE ends on the day after the denial of eligibility information is received from the FSSA. NOTE: Members who qualify for PE Adult (HIP) will be able to retain PE eligibility after they have been determined to be conditionally eligible for HIP coverage while they make their POWER Account contribution. This allows these members to avoid a gap in coverage, as long as they meet required application and payment timelines. During the presumptive eligibility period, the individual will be able to receive treatment from any enrolled ICHP provider. If they are in PE Adult category, they should seek care within the managed care network they are enrolled in. The individual must complete an Indiana Application for Health Coverage during the presumptive eligibility period to gain continued coverage through the IHCP. If an individual does not complete this application, he or she will lose coverage once the presumptive eligibility period ends. An individual is allowed only one presumptive eligibility coverage period per rolling 12-month period or per pregnancy. Aid categories eligible for PE include: • Low-income children who qualify for the IHCP • Low-income parents or caretakers • Non-disabled adults 19–64 • Former foster care children • Pregnant women • Individuals eligible for the Family Planning Eligibility Program only Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 1-1 Introduction Presumptive Eligibility Qualified Provider Manual Member Enrollment Process Overview An individual seeking coverage works with an organization or designee to complete an electronic PE application. The individual relays the necessary information to the organization designee, who enters the information online via Web interChange. Enrollment is available during regular business hours. Based on the answers the individual provides during the application process, he or she receives a realtime response as to whether he or she is eligible for PE. Questions include identifying information, family size, and household income. Applicant responses are self-attested; therefore, QPs are not permitted to ask for supporting documentation to verify the applicants’ eligibility. An individual can apply for PE for all members in his or her family, regardless of the person’s need for services at the time of application. Each individual who desires to apply for PE must complete his or her own application for enrollment. After presumptive eligibility is determined, the QP designee informs the individual of PE approval or denial. Approved individuals have coverage for services appropriate to the designated PE aid category for the presumptive eligibility period. 1-2 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 2: Presumptive Eligibility Team Overview Several entities work together to ensure that the Presumptive Eligibility (PE) qualified provider (QP) and member enrollment works properly. The responsibilities of each entity are described in the following sections. HP HP responsibilities include the following: • Maintain and provide training on the Web interChange system. • Enroll new PE QPs and maintain a list of certified PE QPs. • Post enrolled PE QPs in the Provider Search feature at indianamedicaid.com. • Assign the PE member identification number (ID). • Receive and update IndianaAIM with Indiana Health Coverage Programs (IHCP) eligibility information received from the Family and Social Services Administration (FSSA). • Provide PE training materials to PE QPs. • Answer any questions PE QPs may have regarding the PE process. Qualified Providers QP responsibilities include the following: • Verify an individual’s IHCP eligibility via Web interChange, Automated Voice Response, or electronic data interchange. • Enroll presumptively eligible individuals with PE coverage during regular business hours. • Make presumptive eligibility determinations consistent with state policies and procedures. • Guide individuals on the requirements to complete and submit the Indiana Application for Health Coverage within 30 days of a completed PE application. • Enroll PE Adult (HIP, or Healthy Indiana Plan) members with a managed care entity (MCE). QPs also do the following: • Affirm that this organization understands and will abide by any published guidance regarding the performance of PE activities. • Affirm that this organization will not knowingly or intentionally misrepresent client information in order to inappropriately gain presumptive eligibility. • Affirm the understanding that all PE enrollment activities undertaken by this organization must be performed by an employee or organization’s designee. FSSA FSSA responsibilities include the following: Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 2-1 Presumptive Eligibility Team Presumptive Eligibility Qualified Provider Manual • Accept and process Indiana Applications for Health Coverage received from a PE QP or an individual. • Assign the recipient identification number (RID) when eligibility is approved. Managed Care Entities • Request Fast Track payment from PE Adult members. • Pay all claims for PE Adult-covered services. • Provide prior authorization (PA) or pre-certification for services as necessary. Indiana Navigators and Application Organizations QPs may apply to be authorized representatives or Application Organizations (AOs), but they are not required to do so. QP staff members helping individuals complete the Indiana Application for Health Coverage also need to be certified as Indiana Navigators or designated as authorized representatives. Only in those roles may the QP staff assist the PE applicant with his or her Indiana Application for Health Coverage. All navigators must receive state training, undergo annual state certification, and meet state-based performance standards monitored by the Indiana Department of Insurance. Some QPs may choose to contract with eligibility assistance companies for completing and submitting the Indiana Application for Health Coverage. If the organization contracts with an eligibility assistance company, that company should have staff that are certified as Indiana Navigators and/or designated as authorized representatives working with PE participants to complete the Indiana Application for Health Coverage. For more information on the Indiana Navigators and AOs, see the Indiana Department of Insurance’s web page at in.gov/idoi. 2-2 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 3: Presumptive Eligibility Provider Enrollment Requirements Eligible Provider Type Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), Community Mental Health Centers (CMHCs), and local county health departments may be considered to be a qualified provider (QP) for Presumptive Eligibility (PE). Qualified Provider Requirements The State requires that a PE QP must meet the following requirements: • Completes and submits PE QP eligibility attestations through the PE QP enrollment process on Web interChange • Participates in PE Web interChange training • Participates in PE training • Helps individuals complete and submit a full Indiana Application for Health Coverage • Meets performance standards determined by the State and documented in Indiana Administrative Code Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 3-1 Presumptive Eligibility Qualified Provider Manual Section 4: Presumptive Eligibility Qualified Provider Enrollment Process Enrolling as a Presumptive Eligibility Qualified Provider Organizations meeting the requirements are encouraged to enroll as a Presumptive Eligibility (PE) qualified provider (QP) through the Provider Maintenance window online via Web interChange. If an organization does not currently use Web interChange, an authorized person from the organization can access the request form on the Web interChange home page. Click How to Obtain an ID, select the link for the interChange Administrator Request Form, and complete the form. With edit access to Web interChange, the hospital can complete the PE QP enrollment application by following these instructions: 1. Click Provider Profile and then click View/Edit a Profile. 2. To select the appropriate National Provider Identifier (NPI) from the list of available NPIs, type the name of the NPI and click Inquire. 3. Identify the appropriate billing provider service location and click Edit for that location. 4. Answer the question, “Does your organization have a change of ownership (CHOW)?” If the answer is “No,” select the correct radio button to answer the question and then click the Presumptive Eligibility tab. If the answer is “Yes,” select the correct radio button to answer the question and then print, complete, and submit the Change of Ownership form from indianamedicaid.com to HP Provider Enrollment. 5. Answer the following questions on the Presumptive Eligibility Information page (Figure 4.1): Affirm that this organization understands and will abide by any published guidance regarding the performance of PE activities. Affirm that this organization will not knowingly or intentionally misrepresent client information in order to inappropriately gain presumptive eligibility. Affirm the understanding that all PE enrollment activities undertaken in this organization must be performed by an organization’s employee or organization’s designee. Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 4-1 Presumptive Eligibility Qualified Provider Enrollment Process Presumptive Eligibility Qualified Provider Manual Figure 4.1 – Provider Maintenance: PE QP Enrollment 6. The individual responding to the questions must provide his or her name and email address in the appropriate fields. 7. Click the Review Summary to Submit tab to verify the responses entered, and then click Submit to complete the prequalification process. The organization immediately receives an automated email notification with new PE QP status. The HP Provider Relations representative contacts the prequalified PE QP within 10 days to schedule a Web interChange training session. The Provider Relations representative also provides the QP with a printed copy and electronic link of the PE Process Training. After completing the Web interChange training session, HP activates the certified QP in IndianaAIM. The PE QP may then provide services under the PE process. 4-2 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 5: Qualified Provider Completing a Member Presumptive Eligibility Application Completing the Presumptive Eligibility Member Application The following is a step-by-step process for the Presumptive Eligibility (PE) applicant enrollment process. 1. The PE qualified provider (QP) uses the Eligibility Inquiry feature in Web interChange to verify that the individual is not already an Indiana Health Coverage Programs (IHCP) member. The Eligibility Inquiry window appears (Figure 5.1). Figure 5.1 – Presumptive Eligibility Inquiry for an Individual 2. If the individual is not currently presumptively eligible under Presumptive Eligibility for Pregnant Women (PEPW), PE, or Hospital Presumptive Eligibility (HPE), or enrolled in the IHCP, the PE QP completes the PE application (Figure 5.2) via Web interChange. The QP staff completes the application with the information provided by the individuals applying for PE. The following questions are asked on the application: • First name • Middle initial • Last name • Suffix • Social Security number (SSN) • Date of birth (DOB) Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 5-1 Qualified Provider Completing a Member Presumptive Eligibility Application Presumptive Eligibility Qualified Provider Manual • Home address • Mailing address • Phone number • Race • Ethnicity • Gender • Marital status • Is the applicant an Indiana Resident? • Is the applicant incarcerated? • Is the applicant pregnant? • Number of people in applicant’s family • Is the applicant a U.S. citizen? • Family income amount • Does the applicant have health insurance coverage? • Does the applicant have Medicare coverage? • Does the applicant have a pending Indiana Application for Health Coverage on file? • Was the applicant in foster care in Indiana on his or her 18 th birthday, under the responsibility of the State of Indiana, and was the applicant enrolled in an IHCP program on his or her 18 th birthday? • Is the applicant the parent or legal guardian living in the same household of at least one child under 18 years of age and is the primary caretaker? NOTE – Each individual who is seeking healthcare must complete his or her own application to be considered for PE. Information on the PE application is self-attested by the individual. QPs may not ask for verification documents when completing a PE application. Proof of income, residency, citizenship, and any other documents are not required. 5-2 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Qualified Provider Completing a Member Presumptive Eligibility Application Presumptive Eligibility Qualified Provider Manual Figure 5.2 – PE Member Application 3. After completing a PE application, the QP needs to attest that he or she has been trained to process applications for PE and submit the application. A determination notice is immediately generated onscreen. 4. If the individual is found eligible for PE Adult, they will be asked to select a managed care entity (MCE). If the individual does not select an MCE, he or she will be auto-assigned. The MCE assignment appears on the approval letter. 5. The PE QP clicks Print Acceptance/Denial Letter (to print the PE Determination Notice). The PE QP must provide a copy of the Acceptance/Denial Letter to each applicant. The PE QP directs the member to keep this information and use the ID number as his or her reference for the Indiana Application for Health Coverage and to seek services. The PE member does not receive a Hoosier Health Card. 6. The PE QP should verbally inform the member of his or her coverage, including limitations of PE Adult, Family Planning, or Pregnant Women eligibility. They should also discuss the coverage 5-3 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Qualified Provider Completing a Member Presumptive Eligibility Application Presumptive Eligibility Qualified Provider Manual period and provide guidance on how the QP will help the member complete the full Indiana Application for Health Coverage. 7. If the member is on PE Adult on HIP Basic, the QP should alert the member to the Fast Track option and let the member know that his or her MCE will contact the individual to make a $10 Fast Track payment. The payment is optional, but there are benefits to making that payment. Individuals who are enrolled as presumptively eligible will not have a gap in coverage between PE coverage and their HIP coverage if they are found eligible. An individual’s $10 Fast Track payment counts towards his or her first POWER Account contribution. 8. The provider should alert the member that after making the payment, the individual may not change his or her health plan. If the person wishes to change his or her health plan before paying the Fast Track invoice, the individual should call 1-877-GET-HIP-9. Figure 5.3 – Printing the Determination Letter PE QPs should inform the individual of the coverage period and conditions. Specific information for fee-for-service PE If the individual files an Indiana Application for Health Coverage, his or her presumptive eligibility period lasts until a final eligibility determination from FSSA has been made. Without a completed application, the PE period lasts until the end of the month following the month in which the PE determination was made. For example, if the PE determination was made on March 10, the individual would remain eligible as though he or she were fully enrolled in the IHCP, until April 30. All services that are covered by the IHCP within the designated PE aid category are covered during the presumptive eligibility period. During the presumptive eligibility period, the eligible individual is also able to receive treatment from other IHCP providers. It is imperative that the QP informs the individual that he or she needs to complete the Indiana Application for Health Coverage before the temporary eligibility period ends and facilitates a process for the individual to do so. As explained on the acceptance letter, the individual may complete the Indiana Application for Health Coverage in one of the following ways: • At the provider where the individual was determined presumptively eligible • Online from the DFR Benefits page at in.gov • Over the telephone at 1-800-403-0864 • At an FSSA, Division of Family Resources (DFR) local office Specific information for Managed Care PE (Adult): 5-4 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Qualified Provider Completing a Member Presumptive Eligibility Application Presumptive Eligibility Qualified Provider Manual • PE coverage for PE Adult members who do not complete an Indiana Application for Health Coverage by the end of the month will end on the last day of the second month following the month PE was established. • A PE Adult member who completes an Indiana Application for Health Coverage by the end of the month following the month PE was established will have coverage for up to 60 days provided application and payment timelines are met. This time frame allows members to make a Fast Track payment or regular POWER Account contribution and gain full HIP coverage without a gap in coverage. If the member is approved for HIP and his or her income is less than 100% of the federal poverty level (FPL) and he or she fails to make a payment (Fast Track or regular POWER Account), he or she will be enrolled in HIP Basic coverage. A member with an income greater than 100% of the FPL who fails to make a payment will lose coverage. • PE Adult members will be enrolled with an MCE. If the member is determined PE eligible and receives emergency services in a hospital that is not with the MCE network, the MCE is obligated to make arrangements to pay for services rendered. PE Adult members who seek further care during their PE period should seek care within the MCE network. They can call their MCE for assistance in finding a provider. • PE Adult members may notice a lag between their PE eligibility and the time when their information is visible in all MCE vendor systems. Please advise the member that it will take at least 24 hours before they are visible to pharmacy systems. If the member is in need of a prescription fill immediately, he or she must contact their MCE. As explained on the acceptance letter, the individual may complete the Indiana Application for Health Coverage in one of the following ways: • At the provider where the individual was determined presumptively eligible • Online from the DFR Benefits page at in.gov • Over the telephone at 1-800-403-0864 • At an FSSA, DFR local office Eligibility Verification System As part of the PE process, PE QPs use the Eligibility Verification System (EVS) to determine if the applicant is already covered through the IHCP. Individuals are allowed only one presumptive eligibility coverage period per rolling 12 months or pregnancy, whichever is applicable. As with all IHCP members, providers serving individuals who have previously been determined presumptively eligible must verify the individual’s eligibility on each date of service. The EVS options – Automated Voice Response and Web interChange – accept the PE identification number. PE is identified by the following aid categories: • HI – PE Infants • HK – PE Children • HA – PE Adult • HP – PE Parent/Caretaker • HW – PE Pregnant Women • H1 – PE Former Foster Care Children • HF – PE Family Planning If the FSSA approves an individual for IHCP eligibility, his or her benefit package changes from the PE package assigned during the PE process to the appropriate IHCP benefit package. He or she also 5-5 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Qualified Provider Completing a Member Presumptive Eligibility Application Presumptive Eligibility Qualified Provider Manual receives a member card with his or her recipient identification number (RID). PE coverage ends on the day after HP receives notification of IHCP eligibility from the FSSA, whether approved or denied, except for PE Adult, as explained previously. 5-6 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 6: IHCP Presumptive Eligibility Programs Overview The Indiana Health Coverage Programs (IHCP) operates three presumptive eligibility programs: • Presumptive Eligibility for Pregnant Women (PEPW): PEPW is a process by which pregnant women can be presumptively eligible for temporary IHCP coverage for ambulatory prenatal services through a simplified application while their Indiana Application for Health Coverage is processed. The PEPW process was introduced in July 2009. • Hospital Presumptive Eligibility (HPE): HPE is a process where acute care hospitals and psychiatric hospitals can complete a simplified application to find an individual presumptively eligible for Medicaid. The coverage is temporary, and a member must complete a full Indiana Application for Health Coverage to retain coverage. • Presumptive Eligibility (PE): PE allows a broader range of provider types to perform presumptive eligibility for individuals. The PE process is similar to the HPE process and uses the same simplified application and web-based tool to determine eligibility. The coverage is temporary and a member must complete a full Indiana Application for Health Coverage to retain coverage. Comparison of Presumptive Eligibility Programs The following table describes the most significant differences between the PEPW, HPE, and PE programs. Table 6.1 – PEPW, HPE, and PE comparison Aid categories PEPW Pregnant Women only HPE Infants Infants Children Children Pregnant women Pregnant women Adults 19–64 Adults 19–64 Parents/caretakers Parents/caretakers Former foster care children Former foster care children Individuals seeking family planning services Qualified providers (QP) Advanced practice nurse practitioners Family/general practitioners Certified nurse midwives PE Individuals seeking family planning services Acute care hospitals FQHCs Psychiatric hospitals RHCs Community mental health centers (CMHCs) Local county health Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 6-1 IHCP Presumptive Eligibility Programs Overview General internists Obstetricians or gynecologists General pediatricians Federally Qualified Health Clinics (FQHCs) Rural Health Clinics (RHCs) Medical clinics Family planning clinics Local health departments Presumptive Eligibility Qualified Provider Manual departments Enrollment broker requirement Delivery system 6-2 Hospitals Pregnant women found presumptively eligible must contact the enrollment broker, MAXIMUS, to select a primary medical provider (PMP) and managed care entity (MCE) on the same day that a woman is found presumptively eligible. Managed care No requirement No requirement Fee-for-service Fee-for-service Except PE Adult, which is managed care Except PE Adult, which is managed care Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 7: Presumptive Eligibility Applicant Requirements NOTE: Qualified providers (QPs) may not ask for verification documents when performing Presumptive Eligibility (PE) tasks. Proof of income, residency, citizenship, and any other documents for eligibility verification are not required at the time of application for PE. NOTE: Although verification is not allowed, providers must not enter information they know to be false into Web interChange. Presumptive Eligibility (PE) is based on the following criteria. The applicant: * Must be a U.S. citizen, qualified noncitizen, or a qualifying immigrant with one of the following immigration statuses: Lawful permanent resident immigrant living lawfully in U.S. for five years or longer Refugee Individual granted asylum by immigration office Deportation withheld by order from an immigration judge Amerasian from Vietnam Veteran of U.S. Armed Forces with honorable discharge Other qualified alien * Must be an Indiana resident An Indiana address must be provided on the application. * Must not be a current Indiana Health Coverage Programs (IHCP) member, including a member of the Healthy Indiana Plan (HIP) * Must not be enrolled in the presumptive eligibility process ‒ HPE (Hospital Presumptive Eligibility), PE, or Presumptive Eligibility for Pregnant Women (PEPW) * Must not be currently incarcerated * Must not be an adult (21-64) admitted or a resident of an Institute for Mental Disease (IMD) * Must meet the income level requirements specific to certain aid categories, as outlined in Table 7.1 * Must meet any additional requirements specific to certain aid categories, as described in Table 7.1 Table 7.1 – Aid Category and Federal Poverty Level Limit (FPL) Aid Category Description PE Infants PE Children (Ages 1 to 18) PE Adults (Ages 19–64) PE Parents/Caretakers PE Former Foster Care Children PE Pregnant Women PE Family Planning FPL Limit 213% 163% 138% Converted Modified Adjusted Gross Income (MAGI) equivalent limit No FPL Requirement 213% 146% NOTE: These percentages include a 5% income disregard. When completing a full application, the 5% income disregard is applied only if an individual is otherwise ineligible for IHCP. Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 7-1 Presumptive Eligibility Applicant Requirements Presumptive Eligibility Qualified Provider Manual These percentages include an addition of 5% points to roughly estimate the 5% income disregard that will be disregarded from the individual’s income based on the applicable income standard if the individual would have otherwise been ineligible when a full application is submitted to DFR. Specific Requirements for PE Aid Categories Infants Individual must be under the age of one (1); and The individual’s family income must be less than 213% of the federal poverty level (FPL). Children Individual must be under the age of 19; and The individual’s family income must be less than 163% of the FPL. Adults Individual must be 19–64 Individual cannot have Medicare Individual cannot have a HIP conditional status The individual’s family income must be less than 138% of the FPL Parents/Caretakers Individual must live with a person under the age of 18 and must be the individual taking care of the minor person. Individual must have income less than converted MAGI equivalent limits. Former Foster Care Individual must be between the ages of 18 through 25 years old (up to 26th birthday); Individual must have been in foster care at age 18; and Individual must have been enrolled in the IHCP at age 18. Pregnant Women Individual must be pregnant, but the pregnancy does not need to be medically verified; Individual must have income less than 213% of the FPL; and Individual’s family size must be at least two members ‒ the individual and her unborn child or children. Family Planning 7-2 Individual must not be eligible for any other HPE category; and Individual must have income less than 146% the FPL. Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Applicant Requirements Presumptive Eligibility Qualified Provider Manual The PE QP enters the applicant’s monthly income and family size into the PE application. The application systematically determines whether the PE applicant meets the income criteria for each PE aid category. Although PE is systematically determined, the following examples are used to illustrate how a determination is made and which individuals are likely to be PE candidates. QPs can refer to the Eligibility Guide on the IHCP member website at indianamedicaid.com to find actual income guidelines for the eligibility groups: 1. Infant – 23-year-old single mother who makes $1,100 per month ($900 in wages, $200 in other interest payments), 8-month-old male baby; no other household members or tax dependents Because the child is less than one year old, the family size is two (woman and baby), and the woman makes less than $2,828 per month (213% FPL for family size of two), the child is eligible for PE Infant. A PE application for the infant must be completed. The mother does not meet the requirements for the infant, children, parents/caretakers, former foster care, and pregnant women categories. However, because she makes less than $1,939 a month (146% FPL for family size of two), the mother is eligible for PE Family Planning. The mother must complete a separate PE application. 2. Children (1 to 18) – 30-year-old mother who makes $700 a month in wages; 33-year-old father who makes $900 a month in wages; 13-year-old son born to both the mother and father who makes $200 per month; total counted income = $1,600 per month; no other household members or tax dependents On each individual’s PE application, the family size is three Son = Because his family unit’s total income of $1,600 per month is less than $2,729 (163% FPL for family size of three), the son is eligible for PE Children. A PE application for the son must be completed. Parents = Because of their income, age, and family size, the parents do not meet the requirements for the infant, children, parents/caretakers, former foster children, and pregnant women categories. However, because the parents make less than $2,445 a month (146% FPL for family size of three), the parents are eligible for PE Family Planning. Each parent must complete a separate PE application. 3. Pregnant women – 22-year-old pregnant woman who earns $800 per month in wages; 69-year-old grandmother who claims the 22-year-old, earns $700 per month in Supplementary Security Income (SSI) payments; total counted income = $800 (family size of three because the unborn child is counted) Pregnant woman = Because her family’s income is less than $3,566 per month (213% FPL for family size of three), she would qualify for PE Pregnant Women. A PE application for the woman must be completed. 4. Adult – 23 year old male who earns $1,285 per month in wages. He is single and has no children. Because his income is below 138% FPL for a family of one, a PE application should be completed. However, his income is above 100% FPL, therefore, after completing the full Indiana Application for Health Coverage, he must make a POWER Account Contribution in order to gain full HIP Coverage. If he fails to make a contribution, he will lose coverage. 5. Parents/caretakers = 30-year-old single mother who earns $300 in wages each month; four children (ages 2, 3, 5, and 6); total counted income = $300 (family size of five) Mother = The woman earns less than $457 per month (converted AFDC rate for family size of five with a 5% disregard), so she is eligible for PE Parents/Caretakers. The mother would need to complete a PE application. All four of the children would be eligible for PE Children. A separate HPE application is needed for each child. 7-3 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Applicant Requirements Presumptive Eligibility Qualified Provider Manual 6. Former foster children = 23-year-old male, lived in foster care at age 18 and was enrolled in the IHCP on his 18th birthday; earns $1,600 per month (family size of one) Because the individual was in foster care at age 18 and was enrolled in the IHCP, he is automatically eligible for PE Former Foster Care without regard to his income; he is not categorically eligible under any other PE group. The individual would need to complete a PE application. 7. Family planning = 27-year-old woman with no children earns $1,400 per month (family size of one) Because her income is more than $1,354 (138 % FPL for family of one), she does not qualify for PE Adult. Her income is less than $1,433 per month (146% FPL for family size of one), so the woman qualifies for PE Family Planning. The woman would need to complete a PE application. 7-4 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Applicant Requirements 7-5 Presumptive Eligibility Qualified Provider Manual Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Section 8: Medicaid Coverage per Aid Category Medicaid Coverage per Aid Category Presumptive Eligibility (PE) benefit packages vary based on the category for which the member is eligible. The following explains each PE benefit package: PE Infants and Children includes all covered services available under Hoosier Healthwise Package A. PE Adults includes all covered services available under Health Indiana Plan (HIP) Basic, including copayments for covered services. Copayments are: Outpatient services: $4 Inpatient services: $75 Preferred drugs: $4 Non preferred drugs: $8 Nonemergency ER visit: $8/$25 PE Parents/Caretakers includes all covered services available under Hoosier Healthwise Package A. PE Former Foster Care Children includes all services available under Hoosier Healthwise Package A. PE Pregnant Women is limited to ambulatory prenatal care services only, defined under Package P. The following items and services are covered under PE Pregnant Women (for codes, see Chapter 8 of the IHCP Provider Manual): Doctor visits for prenatal care Prescription drugs related to pregnancy Prenatal lab work Transportation to prenatal visits PE Family Planning is limited to family planning services only, defined under the Family Planning Eligibility Program benefit package. The following items and services are covered under PE Family Planning (for codes, see Chapter 8 of the IHCP Provider Manual): Family planning visits Laboratory tests (if medically indicated as part of the decision-making process regarding contraceptive methods) Limited health history and physical exams Pap smears Initial diagnosis of sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) Follow-up care for complications associated with contraceptive methods FDA-approved oral contraceptives, devices, and supplies Screening, testing, counseling, and referral of members at risk for human immunodeficiency virus (HIV) Tubal ligations Hysteroscopy sterilization Vasectomies All PE categories are reimbursed through the fee-for-service delivery system, with the exception of PE Adult. The Adult group is reimbursed through the risk-based managed care delivery system. Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 8-1 Presumptive Eligibility Qualified Provider Manual Section 9: Presumptive Eligibility Claims Submission As noted previously in Section 5, Presumptive Eligibility (PE) qualified providers (QPs) should use the Eligibility Verification System (EVS) to determine if the individual is already covered by the IHCP. Additionally, PE QPs should verify whether the individual has other health insurance before submitting claims for PE services because Medicaid is always the payer of last resort. Fee for Service Claims for PE services are submitted with the PE ID number starting with a “6.” QPs should submit claims compliant with applicable program standards. If a PE member is officially determined eligible for coverage under the Indiana Health Coverage Programs (IHCP), QPs should use the RID (recipient identification number). QPs are reimbursed at regular IHCP rates for services rendered during the presumptive eligibility period. Reimbursement for covered services rendered during the presumptive eligibility period is allowable, even if the person ultimately fails to complete the Indiana Application for Health Coverage application, or if the Family and Social Services Administration (FSSA) determines the individual to be ineligible for the IHCP. Members in the fee-for-service PE categories will have at least a 24-hour delay before they are visible in the eligibility system. Therefore, they may have difficulty getting prescriptions filled in the first 24 hours of coverage. Managed Care (HPE Adult only) Claims for services for members found eligible for PE Adult should be submitted to the appropriate MCE (managed care entity). Claims should be submitted using the PE ID number starting with a 6. QPs should submit claims compliant with applicable program standards. A member in the PE Adult category is eligible for a service package that mirrors the HIP Basic program and is subject to copays. Copay amounts will be applied. Providers will be reimbursed HIP program rates for members in the PE Adult category. Members of Managed Care PE may have up to a three-day delay before they are visible in the MCE and Pharmacy systems. If a member requires prior authorization (PA) or urgent medications before the three days are up, providers should call the MCE. Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 9-1 Medicaid Coverage per Aid Category 9-2 Presumptive Eligibility Qualified Provider Manual Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 Presumptive Eligibility Qualified Provider Manual Index C M Children ....................................................... 7-2 Medicaid Coverage per Aid Category ......... 8-1 Member Enrollment Process Overview ...... 1-2 E Eligibility Verification System .................... 5-5 Eligible Provider Type ................................ 3-1 N Navigators and Application Organizations . 2-2 F P Family Planning .......................................... 7-2 Former Foster Care ...................................... 7-2 Parents/Caretakers ....................................... 7-2 Pregnant Women ......................................... 7-2 Presumptive Eligibility Team ..................... 2-1 H HP................................................................ 2-1 I Infants .......................................................... 7-2 Library Reference Number: PRPR10020 Published: June 9, 2015 Policies and Procedures as of April 1, 2015 Version: 1.0 S Specific Requirements for HPE Aid Categories ................................................... 7-2 State-Specific Requirements ....................... 3-1 1
© Copyright 2024