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Presumptive Eligibility
Web interChange Training
HP Provider Relations/February 2015
Agenda
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Presumptive Eligibility (PE)- Overview
PE Covered Benefits
Qualified Providers
How to Become a QP for PE
Completing the PE Application
2015 IHCP Presumptive Eligibility (PE) Standards
Questions
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Presumptive Eligibility ‒
An Overview
Overview
The presumptive eligibility process includes two
programs: Hospital Presumptive Eligibility (HPE)
and Presumptive Eligibility (PE).
With the expansion of the presumptive eligibility
process to include new provider types and
specialties, the process will be referred to as
Presumptive Eligibility (PE).
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Overview
Presumptive Eligibility (PE) – What is it?
• Hospital Presumptive Eligibility (HPE)
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Effective January 1, 2014, acute care hospitals enrolled as HPE qualified providers
(QPs), may assist qualifying individuals in certain aid categories to receive temporary
coverage until eligibility for the Indiana Health Coverage Programs (IHCP) is officially
determined by the Indiana Family and Social Services Administration (FSSA).
− Effective April 1, 2015, free-standing psychiatric hospitals may also enroll as qualified
providers (QPs).
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Presumptive Eligibility (PE)
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Effective April 1, 2015, federally qualified health centers (FQHCs), rural health centers
(RHCs), community mental health centers (CMHCs), and local county health
departments may also enrolled as qualified providers (QPs).
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Overview
Presumptive Eligibility (PE) – What is it?
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A member's Presumptive Eligibility (PE) status will be identified on the Eligibility
Verification System (EVS) using the benefit category and aid category for which the
member qualifies, for example Package A-PE Infants.
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All services covered by the IHCP within the designated benefit package are covered
during the presumptive eligibility period.
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Overview
PE benefit packages
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Presumptive Eligibility
Package A – PE Infants
Package A – PE Children
Package A – PE Parent/Caretaker
Package A – PE Former Foster Children
Package P – PE Pregnant Women
Family Planning – PE Family Planning
HIP Basic – PE Adult
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Overview
Presumptive Eligibility – Who is eligible?
To qualify for Presumptive Eligibility, applicants must:
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Be a U.S. citizen or a qualified noncitizen
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The applicant must be a citizen of the United States or a qualifying immigrant with one
of the following immigration statuses:
• Lawful permanent resident immigrant living lawfully in the 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
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Overview
Presumptive Eligibility – Who is eligible?
To qualify for Presumptive Eligibility, applicants must:
• Be an Indiana resident
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An Indiana address must be provided on the application.
• Not be currently enrolled in any Indiana Health Coverage Programs (IHCP)
plan, including Healthy Indiana Plan (HIP) or conditional HIP status.
• Not be enrolled in a presumptive eligibility program (PE, HPE, or
Presumptive Eligibility for Pregnant Women)
• Not be currently incarcerated
• Must meet the income level requirements as outlined in Table 1.0.
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Overview
Presumptive Eligibility – Income standards
Table 1.0
Aid Category Description
FPL Limit
PE Infants
213%
PE Children (Ages 1-18)
163%
PE Parents/Caretakers
Converted to AFDC limits
PE Former Foster Care Children
No FPL Requirement
PE Pregnant Women
213%
PE Family Planning
146%
PE Adult
138%
Note: These percentages include a 5 percent income disregard. When
completing a full application, the 5% income disregard will only be
applied if an individual is otherwise eligible for the IHCP.
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Weekly income
should be multiplied
by 4.3 to determine
monthly income
Biweekly income
should be multiplied
by 2.15 to determine
monthly income
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Overview
Presumptive Eligibility (PE) – Why is it important?
• PE allows uninsured or underinsured individuals
and their families to obtain coverage quickly.
They can get care immediately.
• PE allows providers to be reimbursed for
services covered by the PE benefit package
provided immediately after PE approval
• During the presumptive eligibility period, the
individual will be able to receive treatment from
other IHCP providers after he/she leaves the
hospital.
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PE Covered Benefits
PE Benefits and Coverage Limitations
• Package A
− Full coverage benefit package – All IHCP covered services; fee-for-service
delivery system.
 PE Infants
 PE Children
 PE Parent/Caretaker
 PE Former Foster Children
− Fee-for-service delivery system – services can be furnished by any IHCPenrolled provider.
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PE Benefits and Coverage Limitations
• Package P
− Limited coverage for ambulatory pregnancy-related services such as:
 prenatal care including pregnancy-related labs and prescription drugs
 outpatient services
 Immunizations
 transportation for pregnancy or emergency-related care
 mental health
 dental services.
− Inpatient care, labor and delivery, postpartum care, abortion services, sterilizations,
hospice, long-term care, and services unrelated to pregnancy or birth outcome are
NOT covered.
− Fee-for-service delivery system – services can be furnished by any IHCP-enrolled
provider.
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PE Benefits and Coverage Limitations
• PE Adult
− HIP Basic – limited benefit package that includes:
 Ambulatory services such as physician services, outpatient surgery, dialysis,
emergency services, hospitalization, mental health and substance abuse,
prescription drugs, rehabilitative services, lab and x-rays, preventive care, and
hearing aids.
 Dental and vision services, bariatric surgery, treatment for temporomandibular joint
(TMJ) disorder are NOT covered.
 Copayments apply to office and other outpatient services, inpatient services,
prescription drugs, and non-emergency emergency department services
 PE Adult members will be served under the managed care delivery system and will
need to select a managed care entity (MCE) during the presumptive eligibility
application process. Individuals who do not select an MCE will be automatically
assigned to an MCE.
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PE Benefits and Coverage Limitations
• Family Planning
− Limited coverage for services and supplies intended to prevent or delay
pregnancy including:
 sterilization services
 annual family planning visit
 oral contraceptives including necessary related lab services
 initial diagnosis of sexually transmitted diseases (STDs) or sexually
transmitted infections (STIs)
 HIV screening
 pap smear
 limited history and physical exams
− Fee-for-service delivery system – services can be furnished by any IHCP-enrolled
provider.
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Qualified Providers
Which provider types can be Qualified Providers (QPs) for PE?
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Effective January 1, 2014, acute care hospitals were eligible to
become qualified providers (QPs) for Presumptive Eligibility (PE).
 Provider Type: 01
 Provider Specialty: 010
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Effective April 1, 2015, the free-standing psychiatric hospitals are
eligible to become QPs for Presumptive Eligibility (PE):
 Provider Type: 01
 Provider Specialty: 011
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Which provider types can be Qualified Providers (QPs) for PE?
• Effective April 1, 2015, the following provider types/specialties are also eligible to
become QPs for Presumptive Eligibility (PE):
federally qualified health centers (FQHCs) - provider type 08, specialty 080
rural health clinics (RHCs) - provider type 08, specialty 081
community mental health centers (CMHCs) - provider type 11, specialty 111
county health departments – provider type 13, specialty 130
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Requirements for Qualified Providers (QPs) for PE?
Many of the requirements for Qualified Providers (QP) are mandated by
federal Medicaid regulations:
• Hospitals and other QPs must participate as providers under the Indiana Health Coverage
Programs (IHCP) State Plan or a demonstration under Section 1115 of the Social Security Act.
• The provider must notify the IHCP of its intention to make presumptive eligibility (PE)
determinations, and
• The provider must agree to make presumptive eligibility determinations consistent with state
policies and procedures.
The State requires that a PE QP must:
• Participate in PE Web interChange training
• Participate in PE training
• Complete and submit PE QP eligibility attestations using the PE QP enrollment process on Web
interChange
• Encourage individuals to complete and submit a full Indiana Application for Health Coverage.
Only Navigators may assist with plan and provider selections, completing, and submitting the
application.
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Requirements for Qualified Providers (QPs) for PE?
Performance Measures
•Specific performance measures for QPs are forthcoming. The following are examples of
possible measures:
Percent of PE eligible members who complete the Indiana Application for Health
Coverage
Percentage of PE eligible members who’s Indiana Application for Health Coverage
is completed correctly
Percent of PE eligible members who are subsequently determined eligible for an
IHCP plan such as Traditional Medicaid or HIP
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How to Become a QP for PE
How to Become a QP
Eligible providers must affirm the following:
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That the organization understands and will abide by any published guidance regarding
the performance of PE activities.
That the organization will not knowingly or intentionally misrepresent client information
in order to inappropriately gain presumptive eligibility.
That the organization understands that all PE QP enrollment activities undertaken this
organization must be performed by an organization’s employee or designee.
Note: Enrolled QPs and their staff may not perform presumptive eligibility determinations
for other non-QP providers, such as physician groups or dentists.
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How to Become a QP
Using Web interChange only, an eligible PE provider type and specialty can complete the PE QP
enrollment application by following these instructions:
1. Click Provider Profile.
2. Click View/Edit a Profile.
3. Choose the appropriate NPI.
Step #2
Step #1
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How to Become a QP
4. Answer the question, “Does your organization have a change
of ownership (CHOW)?”
 If the answer is “No,” select the “No” radio button then click
the Presumptive Eligibility tab.
 If the answer is “Yes,” select the “Yes” radio button and
complete and submit the IHCP Provider Change of
Ownership Addendum form to HP Provider Enrollment.
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How to Become
a QP
5. Answer the questions
on the Presumptive
Eligibility page:
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How to Become
a QP – Go to
Review &
Submit
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How to Become a QP
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, then click Submit to
complete the prequalification process.
The provider immediately receives an automated email notification with their PE QP status. An
HP Provider Relations Field Consultant will contact the prequalified PE QP within 10 business
days to schedule Web interChange training.
The Provider Relations Field Consultant will also provide the PE QP with a printed copy of and
electronic link to the Presumptive Eligibility Process Training. After the Web interChange training
is complete, HP activates the provider’s “certified QP” status in IndianaAIM. The PE QP may then
provide presumptive eligibility determinations to qualified individuals.
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How to Locate a QP
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IHCP website
– www.indianamedicaid.com
– In the Quick Links menu on the right side of the screen select Provider Search
(non-OPR)
– To search for a hospital that provides PE determinations, click the “Hospital” radio
button under Provider, then click the “Acute Care” or “Psychiatric” radio button
under Specialty, then click the “Yes” radio button beside “Show only Presumptive
Eligibility Qualified Providers?” and click “Search” at the bottom of the screen to
return the list of PE QPs.
– To search for an FQHC or RHC that provide PE determinations, click the “Other”
radio button under Provider, then click the “Federally Qualified Health Clinic
(FQHC)” or “Rural Health Clinic (RHC)” radio button under Specialty, then click
the “Yes” radio button beside “Show only Presumptive Eligibility Qualified
Providers?” and click “Search” at the bottom of the screen to return the list of PE
QPs.
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HP Customer Assistance
– 1-800-577-1278
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Completing the Presumptive
Eligibility Application
How the PE Process Works
Caution: The PE member application system is a live production environment.
Providers should not create test cases and use the live application for training
purposes. Per the provider’s attestation during QP enrollment:
• the organization will not knowingly or intentionally misrepresent client
information in order to inappropriately gain presumptive eligibility.
• Providers must not hit submit multiple times on one application
Note: The screen prints on the following pages represent the current state,
this presentation will be updated with new screen prints when all system
updates have been completed.
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How the PE Process Works
Step-by-step procedures for enrolling applicants in the
Presumptive Eligibility (PE) process follows.
1.
2.
3.
The PE QP uses the Eligibility Inquiry feature in Web interChange to
verify that the individual is not already an IHCP member.
If no active coverage is found for the individuals, click PE Application.
Eligibility can be verified using EVS – Automated Voice Response or
Web interChange. However, the HPE application may only be
completed using Web interChange.
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How the PE Process Works
Users with Web
interChange access to
multiple office locations
must be sure to select the
actual location enrolled as
a QP.
Perform eligibility inquiry
to verify that the applicant
is not already eligible for
Medicaid.
Search by name/DOB,
SSN, or Medicare ID.
Click here to complete the
PE Member Application.
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Completing the PE Application
If the individual is not currently presumptively eligible under Presumptive Eligibility for Pregnant
Women (PEPW) or PE, or otherwise enrolled in the IHCP, the PE QP may complete the PE
application via Web interChange. The QP provider staff or its designee completes the
application with the information provided by the individual applying for PE. The following
questions appear on the application:
*Required field
• Mailing address
• First name*
• Phone number
• Middle initial
• Race
• Last name*
• Ethnicity
• Suffix
• Gender*
• Social Security number (SSN)
• Marital status
• Date of birth (DOB)*
• Home address*
Note: If the QP uses a third-party vendor to complete the PE application, the registered QP is
responsible for adherence to the guidelines set by the state of Indiana.
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Completing the PE Application
*Required field
Note: Each individual who is
seeking health care must
complete his or her own
application to be considered
for PE.
•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 *‒
–Multiply weekly income by 4.3 to determine the monthly income
–Multiply biweekly income by 2.15 to determine the monthly income (biweekly is every two weeks)
•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 18th 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?*
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How the PE Process Works
The PE application will open in a new window.
Enter responses on the
PE Member application.
Move your pointer over
each field for convenient
HELP text, or click on
the question mark where
available.
An asterisk (*) identifies
required fields.
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How the PE Process Works
Note: If the individual
qualifies for PE Adult HIP Basic, a question
will appear asking for
MCE selection. If
applicant does not
make a selection, one
will be auto-assigned.
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Complete PE Member Application
• Click the attestation statement box at the end
of the application and then click Submit
Application.
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Presumptive Eligibility Approval Determination
Once the application is submitted, you will receive an immediate determination.
600000000000
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Presumptive Eligibility Approval Letter
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Presumptive Eligibility Denial Determination
Once the application is submitted, you will receive an immediate determination.
600000000000
XXXXX XXXX
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Presumptive Eligibility Denial Letter
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Completing the PE Application Process
• The PE QP should inform the member of his or her coverage, including limitations of the PE benefit package, especially
family planning or pregnant women eligibility, the coverage period, and guidance for how the hospital will help the
member complete the full Indiana Application for Health Coverage.
• The PE QP should inform the PE Adult members of his or her coverage, the limitations of HIP Basic benefits,
covered/non-covered services, and copayments. (See BT201505)
• The PE QP should inform the member of the coverage period and conditions. If the individual does file an Indiana
Application for Health Coverage, his or her presumptive eligibility period lasts until a final eligibility determination from the
Indiana Family and Social Services Administration (FSSA) has been made. Otherwise, coverage ends the last day of the
month following the month that the PE application was completed.
• Exception: PE Adult - This group will retain PE coverage until they make the required contributions or a fast track
payment. If they meet application and payment timelines, there will be no gap in coverage.
• During the presumptive eligibility period, the eligible individual will also be able to receive treatment from other IHCP
providers. It is imperative that the hospital employee inform the individual that he or she needs to complete the full
application before the temporary eligibility period ends, and provide information about how the applicant can do so. As
explained in the acceptance letter, the individual may complete the Indiana Application for Health Coverage:
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At the location where the individual was determined presumptively eligible
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Online from the DFR Benefits page at in.gov
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Over the telephone at 1-800-403-0864
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At an FSSA/Division of Family Resources (DFR)
local office.
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Completing the PE Application Process
Presumptive Eligibility (PE) considerations
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PE coverage begins the same day a QP determines an PE member to be presumptively eligible.
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PE eligibility is terminated the last day of the month following the month in which their PE status was
granted if no Indiana Application for Health Coverage is pending with the DFR.
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Example: If an PE member is determined presumptively eligible on July 14 and does not submit an
Indiana Application for Health Coverage, the PE coverage will end August 31.
•
Applicants must comply with the IHCP application process (for example, documentation
submission). Failure of the member to cooperate with the DFR to complete the enrollment process
will result in termination of their PE status.
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Prior to clicking “Submit Application”, providers should carefully review all information with the
patient to ensure it has been entered correctly i.e., check the spelling of the patient’s name, correct
date of birth, etc. Once the application is submitted there is no mechanism to allow the provider to
make corrections.
 If information is accidentally and inadvertently entered incorrectly during the member
enrollment process, the provider must contact their Provider Relations Field Representative
to have the information corrected.
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Completing the Indiana Application for Health Coverage
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Qualified PE organization may apply to be authorized representatives
or Application Organizations (AOs)
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QP staff members or it’s designee helping consumers complete the
Indiana Application for Health Coverage also need to be certified as
Indiana Navigators or designated as authorized representatives.
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Only in those roles, may the organization staff assist the PE
participant with his or her Indiana Application for Health Coverage.
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Completing the Indiana Application for Health Coverage
The DFR makes all eligibility determinations.
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If the Indiana Application for Health Coverage is received by the DFR before the last day of
the month following the month in which PE was approved, the individual’s PE will not end
until the DFR’s determination is completed.
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This ensures there is no gap in coverage.
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If the Indiana Application for Health Coverage is approved, PE is terminated on the day after
IHCP benefits begin.
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IndianaAIM receives eligibility determinations and updates from the DFR on a daily basis.
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Eligibility Verification Systems and HPE
• The eligibility verification systems (EVS) communicate information about PE
members the day following the determination by the QP.
– Web interChange
•
https://interchange.indianamedicaid.com/
Administrative/logon.aspx
– Automated Voice Response (AVR)
•
1-800-738-6770
• Only Web interChange can be used to submit a member application for PE.
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Other Resources
Other Resources
• This training course provides an overview of the Presumptive Eligibility programs and
the functionality of Web interChange related to enrolling as a QP and enrolling eligible
applicants.
• QPs are also encouraged to review the Hospital Presumptive Eligibility Qualified
Provider Manual for additional details about the program include information about
navigators, determining family income, family size, eligibility examples, and more.
 A Presumptive Eligibility for Qualified Provider Manual is in development and will
be posted in the near future.
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2015 IHCP Presumptive
Eligibility Standards
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Questions