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Hospital Presumptive
Eligibility Web
interChange Training
HP Provider Relations/March 2014
Agenda
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Overview
Hospital Presumptive Eligibility Qualified Provider
How to become a HPE Qualified Provider
How Hospital Presumptive Eligibility Works
Questions
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Hospital Presumptive
Eligibility- An Overview
HP Provider Relations/March 2014
Overview
Hospital Presumptive Eligibility (HPE) – What is it?
•What is Hospital presumptive eligibility?
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Effective January 1, 2014, qualified acute care hospitals, as qualified providers (QP),
have the ability to enroll 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).
− Hospital PE will be identified on the EVS systems as the AID category that the
member qualifies for.
− All services that are covered by IHCP within the designated HPE aid category are
covered during the presumptive eligibility period.
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Overview
Non-HPE Benefit Packages
HPE Benefit Packages
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Package A – Standard Plan
Package B – Pregnancy Coverage
Package C – Children’s Health Plan
Package E – Emergency Services Only
HIP – Healthy Indiana Plan
Package P – Presumptive Eligibility for
Pregnant Women
• Family Planning
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Package A – HPE Infants
Package A - HPE Children
Package A HPE - Parent /Caretaker
Package A – HPE Former Foster kids
Package P – HPE Pregnant Women
Family Planning – HPE Family Planning
Benefit Package
December 2013
Overview
Hospital Presumptive Eligibility – Who Is eligible?
Hospital Presumptive Eligibility is based on the following criteria:
1. Be a U.S. citizen or a qualified noncitizen
The applicant must be a citizen of the United States or a qualifying
immigrant with one of the following immigration statuses:
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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 discharged
Other qualified alien
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Overview
Hospital Presumptive Eligibility – Who Is eligible?
Hospital Presumptive Eligibility (HPE) is based on the following criteria:
2. Be an Indiana resident
• An Indiana address must be provided on the application.
3. Not be a current Indiana Health Coverage Programs (IHCP) member,
including Healthy Indiana Plan (HIP)
4. Not be enrolled in the presumptive eligibility program (HPE or Presumptive
Eligibility for Pregnant Women [PEPW])
5. Not be currently incarcerated
6. Must meet the income level requirements specific to certain aid categories, as
outlined in table 7.1
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December 2013
Overview
Presumptive Eligibility – Income Standards
Table 7.1 –
Aid Category Description
HPE Infants
HPE Children (Ages 1 to 18)
HPE Parents/Caretakers
HPE Former Foster Care Children
HPE Pregnant Women
HPE Family Planning
Weekly income
FPL Limit
should be multiplied
213%
163%
Converted AFDC limits
No FPL Requirement
213%
146%
by 4.3 to determine
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 ineligible for IHCP.
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monthly income
Biweekly income
should be multiplied
by 2.15 to determine
monthly income
December 2013
Overview
Hospital Presumptive Eligibility (HPE) – Why Is It important?
• HPE allows uninsured or under insured individuals and their families to obtain
healthcare while the Indiana Application for Health Coverage is being
processed.
• Allows providers to be reimbursed for services provided immediately after
HPE approval
• During the presumptive eligibility period, the individual will be able to receive
treatment from other IHCP providers after he or she leaves the hospital.
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December 2013
Hospital Qualified Providers
Who Can Be a Hospital Qualified Provider (QP)?
• Only acute care hospitals will be considered to be a
qualified provider (QP) for Hospital Presumptive Eligibility
(HPE).
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Who Can Be a Hospital Qualified Provider?
Many of the requirements for qualified providers (QP) are mandated by
federal Medicaid regulations:
1.
Hospitals must participate as a provider under the Indiana Health Coverage Programs (IHCP)
State plan or a demonstration under Section 1115 of the Social Security Act;
2. Must Notify the IHCP of its intention to make hospital presumptive eligibility (HPE)
determinations, and
3. Agree to make hospital presumptive eligibility determinations consistent with state policies and
procedures.
The State requires that an HPE QP must:
1. Assist individuals in the process of completing and submitting a full Indiana Application for
Health Coverage;
2. Complete and submit HPE QP eligibility attestations through the HPE QP enrollment process
on Web interChange;
3. Participate in HPE Web interChange training; and
4. Participate in HPE training.
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How to Become a QP for HPE
How to Become a QP
Acute care hospitals must attest to the following:
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Affirm that this organization understands and will abide by any published guidance
regarding the performance of HPE activities.
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Affirm that this organization will not knowingly or intentionally misrepresent client
information in order to inappropriately gain presumptive eligibility.
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Affirm understanding that all HPE QP enrollment activities undertaken in this hospital
must be performed by a hospital employee or hospital designee.
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How to Become a QP
With access to Web interChange, the hospital can complete the HPE QP enrollment application
by following these instructions:
1. Click Provider Profile and then
2. Click View/Edit a Profile
Step #2
3. Choose the appropriate NPI
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 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 complete and
submit the Change of Ownership to HP Provider Enrollment.
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How to Become a QP
5. Answer the following questions on
the Hospital Presumptive Eligibility
Information page:
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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, and then click Submit to complete
the prequalification process.
• The hospital immediately receives an automated email notification with new HPE QP status. The HP Provider
Relations representative will contact the prequalified HPE QP within 10 days to schedule Web interChange
training session.
• The Provider Relations Representative will also provide the acute care hospital with a printed copy and
electronic link of the HPE Process Training. After completing the Web interChange training session, HP
activates the certified QP in IndianaAIM. The HPE QP may then provide services under the HPE program.
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How to Locate a QP
• IHCP Web site
–www.indianamedicaid.com
–Select Provider Services > Provider Search
–Click the “Yes” radio button beside “Show only
Presumptive Eligibility Qualified Providers?”
• HP Customer Assistance
–(317) 655-3240 or 1-800-577-1278
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December 2013
Hospital Presumptive Eligibility –
How it Works
How the HPE Process Works
Following is a step-by-step process for the Hospital
Presumptive Eligibility (HPE) applicant enrollment
process is outlined below, as well as in the HPE
Training.
1.
The HPE 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.
2.
As long as the member does not have any coverage, click the HPE
Application button
3.
Eligibility can be verified using the three EVS options – Automated
Voice Response, Omni, and Web interChange however the HPE
application can only be completed using web interChange
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December 2013
How the PE Process Works
May search by Name/DOB, SSN, or Medicare
ID. Users with Web interChange access to
multiple office locations must be sure to select
the actual location that is an enrolled as a QP.
Perform eligibility inquiry to verify the applicant is
not already eligible for Medicaid.
Click here to complete the
HPE Member Application
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Completing the HPE Application
If the individual is not currently presumptively eligible under Presumptive Eligibility for Pregnant Women
(PEPW) or HPE, or enrolled in IHCP, the HPE QP completes the HPE application via Web interChange.
The hospital staff or it’s designee, completes the application with the information provided by the
individuals applying for HPE. The following questions are asked on the application:
• First Name
• Middle Initial
• Last Name
• Suffix
• Social Security Number (SSN)
• Date of Birth (DOB)
• Home Address
• Mailing Address
• Phone number
• Race
• Ethnicity
• Gender
• Marital Status
Hospital Presumptive Eligibility
NOTE: If using a third party vendor to
complete the HPE application, the hospital
as the registered QP, is responsible for
adherence to the guidelines set for the by
the state of Indiana.
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December 2013
Completing the HPE Application
• 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 18th 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 health care must complete his or her own application to
be considered for HPE.
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December 2013
How the PE Process Works
The HPE Application will be opened 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
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December 2013
How the PE Process Works
Move your
pointer over each
field for
convenient HELP
text,
or click on the
question mark
where available
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December 2013
Complete PE Member Application
A disclaimer statement ends the application.
Place a check mark in the Disclaimer check box
and click the Submit Application button.
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Hospital Presumptive Eligibility Approval Determination
Once the application is submitted, you will receive an immediate determination.
600000000000
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Hospital Presumptive Eligibility Approval Letter
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December 2013
Hospital Presumptive Eligibility Denial Determination
Once the application is submitted, you will receive an immediate determination.
600000000000
XXXXX XXXX
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Hospital Presumptive Eligibility Denial Letter
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Completing the HPE Application Process
The HPE QP should inform the member of his or her coverage, including limitations of HPE Family Planning or Pregnant
Women eligibility, the coverage period, and provide guidance on how the hospital will assist the member in completing the
full Indiana Application for Health Coverage.
HPE QPs should inform the individual of the coverage period and conditions. If the individual has filed an Indiana
Application for Health Coverage, his or her presumptive eligibility period lasts until a final eligibility determination from
FSSA has been made. Otherwise coverage ends the last day of the following month that the HPE application is
completed.
During the presumptive eligibility period, the eligible individual will also be able to receive treatment from other IHCP
providers after he or she leaves the hospital. It is imperative that the hospital employee informs the individual that he or
she needs to complete the full application before their temporary eligibility period ends, and provide information on how
he or she can do so. As explained in the acceptance letter, the individual may complete the Indiana Application for Health
Coverage in one of the following ways:
• At the hospital where the individual was determined presumptively eligible.
• Online from the DFR Benefits page at in.gov (link to www.dfrbenefits.in.gov).
• Over the telephone at 1-800-403-0864.
• At an FSSA, Division of Family Resources (DFR) local office.
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December 2013
Completing the HPE Application Process
PE Considerations
– PE coverage begins the same day a QP determines a HPE member to be
presumptively eligible
– PE eligibility is terminated the last day of the following month of eligibility if no
Indiana Application for Health Coverage is pending with the DFR
• Example: HPE member is determined presumptively eligible on July 14 and
does not submit a Indiana Application for Health Coverage - the HPE coverage will
end on August 31
– Failure of the member to cooperate with DFR to complete the enrollment process
will result in termination of HPE eligibility
– PE eligibility is terminated on the day after IHCP benefits are open
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Completing the HPE Application Process
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DFR makes its eligibility determination for Hoosier Healthwise
– Applicants must comply with the IHCP application process (for example,
documentation submission)
– If the Indiana Application for Health Coverage is received by the DFR before the last
day of the month after PE was applied, the individual’s PE will not end until the
IHCP determination is completed
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This ensures there is no gap in coverage
– IndianaAIM receives eligibility determinations from DFR on a daily basis
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Eligibility Verification Systems and HPE
• The eligibility verification systems (EVS) will communicate information
about HPE members the day following the determination by the QP.
– Web interChange
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https://interchange.indianamedicaid.com/
Administrative/logon.aspx
– Omni machine
– Automated Voice Response (AVR)
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(317) 692-0819 or 1-800-738-6770
• Only Web interChange can be used to submit a member application for
HPE.
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December 2013
Questions