Hospital Presumptive

Hospital presumptive eligibility

Laurie c., alma r., karen e., & liz q.

What is HPE

The Hospital Presumptive Eligibility Program (HPE) was implemented on January 1, 2014 by the Department of Healthcare Services to allow authorized qualified hospitals and qualified providers the ability to grant individuals with immediate, temporary Medi-Cal coverage to low-income, uninsured patients who require immediate medical care pending a formal Medi-Cal application.

What is hpe (cont.)

For a hospital or provider to be considered qualified they must complete the Hospital Presumptive Eligibility (PE) Program Provider Election Form and Agreement. Within 60 days. HPE providers are responsible for ensuring that all their hospital personnel participating in the HPE program take an online training course.

Who is eligible

Must be a CA resident

Income must be below monthy limit for Household. (MAGI FPL)

Cannot have other health insurance

Have not recieved PE within the last 12 months

CHART

pe periods

PE establishes different coverage groups and enrollment period limits for each group

PE: PREGNANCY

"The exception to this rule is pregnant woman. Pregnant women are permitted one HPE period per pregnancy for ambulatory prenatal services. Therefore, a pregnant woman could potentially receive more than one PE period in a 12-month period with a new pregnancy."

• Income below 231% FPL (higher FPL, than for non pregnant individuals)
• Confirmed pregnancy
• Get 2 months of PE

Enrollment process

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1. You visit a qualified HPE Hospital

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2. Application gets submitted

3. MEDS

4. Eligibility Ddetermination

5. HPE Aid Codes

5. Duration of Eligibility

CONTINUATION OFBENEFITS

• HPE providers are required to provide applicants an insurance affordanbility application prior to leaving hospital
• Clients must submit a completed MC application before their PE period end date to be eligible for continued coverage beyond their PE enrollment end date/ and or to request retroactive benefits.
• MEDS is programmed to automatically terminate all HPE benefits for individuals who reach the 60-day limit unless MEDS has a record of a pending insurance affordability program application

• They can complete an application online, via paper, over the phone, or in person

the end!

GAME TIMEEE

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dhcs 7022

Can be completed via HPE Medi-Cal Application portal or sent to the California Welfare Department

Eligibility response

• The response message will be printed twice, one for the patient one for the provider
• When the response message includes a signature line, the printout is used as an "Immediate Need Eligibility Document." Client will sign and used as a temporary BIC
• Clients do not sign if they are denied service through the HPE program or if they already have a BIC

enrollment period

• Beginning date of eligibility for HPE is established on the date the application is submitted, not the day the patient arrived to the hospital
• Will not include bills acquired prior to the application being submitted
• HPE ends with the day that Client receives eligibility determination for full Medi-Cal or the last day of the month following the HPE determination

meds responsemessage:

• Temporary Medi-Cal eligibility is approved or denied.
• Eligibility for full-scope or limited-scope, no cost Medi-Cal eligibility.
• The program for which the individual is currently eligible (Medi-Cal).
• If denied, the denial reason