4.1Overview and Statutory Authority
A.The goal of the federal Affordable Care Act (ACA) of 2010 is to improve access to high quality health insurance coverage for people of all ages and income levels. In keeping with this purpose, the ACA established a presumptive eligibility program for certain individuals and families in the newly reconfigured Medicaid Affordable Care Coverage (MACC) groups. The MACC groups in Rhode Island are described in Part 30-00-1 of this Title.
B.Federal regulations governing the program at 42 C.F.R. § 435.1110 require the states to provide Medicaid for a limited period of time to individuals who are determined by a “qualified hospital”, on the basis of preliminary information, to be presumptively eligible for Medicaid. This initial determination is made by the hospital on the basis of the characteristics for MACC group eligibility. The states have the discretion under these provisions to tailor presumptive eligibility requirements program within certain parameters to meet their own unique needs.
C.Legal Authority
1.This Part is promulgated pursuant to Federal authorities as follows:
a.Federal Law: § 1115 of the Social Security Act, 42 U.S.C. § 1315; Title XIX of the Social Security Act, 42 U.S.C. §§ 1396a-1396w-7; Title XXI of the Social Security Act, 42 U.S.C. §§ 1397aa-1397mm; 42 U.S.C. § 1396k; § 1413(b)(1)(A) of the Patient Protection and Affordable Care Act, Pub. Law No. 111-148.
b.Federal Regulations: 42 C.F.R. Parts 431.1110.
c.The Medicaid State Plan and the Section 1115 Demonstration Waiver granted pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315.
4.2Incorporated Materials
A.These regulations hereby adopt and incorporate 42 C.F.R. § 435.1110 (2023) by reference, not including any further editions or amendments thereof, and only to the extent that the provisions therein are not inconsistent with these regulations.
4.3Scope and Purpose of Hospital Presumptive Eligibility Program for Medicaid
A.For individuals with MACC-like characteristics, presumptive eligibility may be determined by a qualified hospital, licensed in Rhode Island, and is only available in certain circumstances contingent upon preliminary information supplied by the individual. Further, presumptive eligibility is only available on a temporary basis – until the last day of the month following the initial determination of presumptive eligibility or the date full eligibility is determined, whichever comes first.
1.Implementation – Effective January 27, 2014, the State will accept applications from qualified hospitals that wish to make presumptive eligibility determinations pursuant to 42 C.F.R. § 435.1110. If a qualified hospital determines that an individual meets the characteristics of one of the MACC groups identified in Part 30-00-1 of this Title (and as below) they will be granted eligibility
2.Governing Provisions – The purpose of these rules is to set forth the provisions governing hospital presumptive eligibility determinations including, but are not limited to the:
a.Populations for which qualified, participating hospitals may conduct presumptive eligibility assessments and scope of coverage;
b.Requirements for a hospital to participate in the Hospital Presumptive Eligibility Program;
c.Application timelines and procedures for individuals who qualify for Medicaid coverage during the presumptive eligibility period.
4.4Definitions
A.“Children’s Health Insurance Program” or “CHIP” means the program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid.
B.“Executive Office of Health and Human Services” or “EOHHS” means the designated “single state agency”, authorized under Title XIX of the U.S. Social Security Act (42 U.S.C. § 1396a et seq.), to be legally responsible for the programmatic oversight, fiscal management, and administration of the Medicaid program.
C.“Hospital Presumptive Eligibility” or “HPE” means Medicaid eligibility granted on a temporary basis to a person who meets certain criteria during a defined period.
D.“Medicaid Affordable Care Coverage Groups” or “MACC Groups” means a classification of persons eligible to receive Medicaid based on similar characteristics who are subject to the MAGI standard for determining income eligibility beginning January 1, 2014.
E.“Qualified Hospital” means any licensed Rhode Island hospital participating in the Medicaid program that elects to participate in the HPE Program by executing a Notice of Intent to Participate in the HPE Program and a Memorandum of Understanding with EOHHS to conduct presumptive eligibility determinations, participates in training and certification sponsored by EOHHS, and remains in good standing with EOHHS protocols.
F.“Self-Attestation” means the act of a person affirming through an electronic or written signature that the statements the person made when applying for Medicaid eligibility are truthful and correct.
4.5Populations for Which Qualified Participating Hospitals May Conduct Presumptive Eligibility Assessments
A.Qualified hospitals that elect to participate in the HPE Program may complete presumptive eligibility assessments for individuals who have the characteristics of members of the MACC groups funded through Title XIX. HPE excludes individuals eligible for coverage funded through CHIP and any individuals eligible for Medicaid on the basis of age, blindness or disability and/or in need of Medicaid-funded long-term services and supports.
4.6Scope of Coverage
A.Eligibility Period. The hospital presumptive eligibility period will begin on, and include, the date the hospital makes the HPE determination. The hospital presumptive eligibility period ends on the date that the Medicaid agency renders a determination for full Medicaid eligibility; or the last day of the month following the month in which the hospital made the HPE determination, whichever comes first.
B.Covered Services. Individuals determined eligible for HPE, will receive the same scope of State Plan and Section 1115 waiver services as members of a MACC group, except as follows:
1.All HPE beneficiaries -- No transportation services.
2.Pregnant individuals -- Maternity services are limited to prenatal ambulatory care only. (Birthing expenses are not covered.)
C.Service Delivery. Individuals determined to be presumptively eligible for Medicaid will be enrolled in a fee-for-service plan. When full Medicaid eligibility is determined, participants will be enrolled at EOHHS’ discretion in a managed care organization (MCO), as indicated in Subchapter 05 Part 2 of this Chapter.
4.7Requirements for Hospitals to Participate in the HPE Program
A.A hospital must meet certain requirements to be deemed qualified to participate in the HPE.
1.Participation. A qualified hospital must be licensed in RI and a participating Medicaid provider under the Rhode Island Medicaid State Plan or Section 1115 waiver. The hospital must notify EOHHS of its election to make presumptive eligibility determinations, and agree to HPE determinations in compliance with State policies/procedures and these rules.
2.Application Process: The qualified hospital must:
a.Assist individuals in completing and submitting the full application for health insurance affordability programs in Rhode Island. This assistance includes assuring that the individual understands any documentation requirements.
b.NOT require individuals assessed for HPE to verify information related to any HPE eligibility criteria/characteristic, including pregnancy.
c.Accept self-attestation of income, citizenship, and residency, as applicable, when determining eligibility.
d.Provide individuals with written notice after the HPE determination is made that includes, but is not limited to:
(1)HPE determination (i.e., approved or denied);
(2)If approved, the beginning and ending dates;
(3)If denied, the reason(s) for the denial, options for submitting a regular Medicaid application and information on how to make application.
e.The qualified hospital must utilize EOHHS-approved materials and methods in determining HPE and completing full Medicaid applications, including the EOHHS and HSRI websites and the State’s single streamlined application.
3.Confidentiality. The qualified hospital must comply with all applicable State and federal laws and regulations regarding patient privacy and the confidentiality of health care communications and information.
4.Records Retention. In accordance with the provisions of the state agency’s record retention policy, the qualified hospital shall maintain organized records of all HPE applications for ten (10) years from the date the last Medicaid billing was submitted to EOHHS.
5.Medicaid Agency Notification. The qualified hospital shall notify the state agency of HPE approvals, and the applicable date ranges, within five (5) business days.
6.Hospital Staff. The qualified hospital must only use employees of the hospital to assist with HPE applications. The hospital is prohibited from subcontracting HPE work to a non-hospital based company or independent contractor. In addition:
a.Each qualified hospital shall have a minimum of one (1) staff member trained and certified to perform HPE duties on each shift.
b.The hospital must affirm that all HPE personnel meet the minimum qualifications specified herein and comply with EOHHS policies and procedures for participation in the Medicaid hospital presumptive eligibility program and participate in all trainings, knowledge-based tests, and keep up-to-date on notifications with regard to HPE. The hospital must assign one accountable individual to be the liaison with the State Medicaid Agency and its designees.
c.The qualified hospital HPE staff must assist Medicaid applicants with the completion and submission of a Medicaid application. Additionally, qualified hospital staff must provide the information specified in this subsection pertaining to the HPE decision, eligibility period, and requirement to complete a full application.
d.HPE staff must complete the requisite EOHHS training and maintain knowledge of any program changes. HPE staff training must include: in-person training; computer-based training; and proficiency testing and certification. Training and testing shall be completed at specific intervals as directed by EOHHS, but no less than annually.
(1)Assignment of Qualified Hospital Staff Online Application Credentials. Prior to assignment of online HPE administrator credentials, qualified hospital staff must complete EOHHS-approved training and provide documentation of completion of training in the format required. Proof of training also must be made available upon request by applicants.
(2)Proficiency standards. Hospital HPE staff must achieve the minimum certification testing score set forth in contractual standards established with EOHHS.
4.8Reporting
A.All qualified hospitals must submit monthly reports in a standardized format as defined by EOHHS. These reports must be submitted electronically by the fifth business day of the month following HPE determinations. The reports must reflect accurate measurement of the performance requirements described in § 4.9 of this Part below. In addition, the qualified hospital must prepare and submit any ad-hoc reports to EOHHS upon request.
4.9Performance Requirements
A.The EOHHS requires that a qualified hospital meet certain performance standard to continue participation in the HPE. First, the qualified hospital must submit full Medicaid applications for ninety-five percent (95%) of the individuals granted HPE within five (5) calendar days from the date of the initial determination of presumptive eligibility. Second the percentage of these Medicaid applications that must be deemed fully complete by the EOHHS -- that is, contain no errors or otherwise require the State’s intervention in processing -- is set forth in contractual standards between the hospital and the EOHHS. Last, the number of individuals qualifying for HPE who must be determined to be eligible for full Medicaid, as determined by the EOHHS, is also set forth in the Notice of Intent to Participate in the HPE Program and a Memorandum of Understanding with EOHHS for the qualified hospital established by EOHHS. In the event a qualified hospital does not meet acceptable performance standards, participation in the HPE may be suspended or terminated at the discretion of the EOHHS.
4.10Office of Program Integrity Agency Authority
A.The EOHHS may undertake an array of actions to assess whether qualified hospitals are meeting the performance standards for the program. The EOHHS Office of Program Integrity (OPI) has been assigned responsibility for performing routine audits and intensive reviews of the HPE program, as appropriate. The OPI is also responsible for overseeing the development and submission of any hospital Corrective Action Plans deemed warranted.
4.11Corrective Action
A.In the event a qualified hospital does not achieve proficiency on the performance requirements outlined in § 4.9 of this Part, the EOHHS may require the development of Corrective Action Plan (CAP) indicating interventions the hospital proposed to take to achieve compliance with these and/or other contractual standards. The OPI is responsible for reviewing and monitoring compliance with the CAP. HPE determinations may be suspended while the CAP is being prepared or implemented, as appropriate.
B.EOHHS reserves the right to request modifications to the CAP if the CAP is deemed ineffective to achieve compliance;
C.The qualified hospital must submit weekly CAP reports to EOHHS measuring the outcome of the corrective actions the hospital has instituted;
D.HPE suspensions remain in full force and effect until such time as the hospital demonstrates to EOHHS that it has instituted corrective measures to bring the hospital into full compliance with State and federal requirements.
4.12For Further Information or to Obtain Assistance
A.For further information or to obtain assistance, please contact: 1-855-697-4347.
4.13Severability
A.If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable.
