CHA News Article

DHCS Announces Policy Changes to Hospital Presumptive Eligibility Program

The California Department of Health Care Services (DHCS) has announced policy changes to the Hospital Presumptive Eligibility (HPE) program, which will be effective June 22, pursuant to Centers for Medicare & Medicaid Services approval of the HPE State Plan Amendment (SPA). According to DHCS, the following new or updated documents will be released in June 2015:

New:

  • Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification Form (DHCS Form 7011)

Updated:

  • Hospital PE enrollment period policy
  • Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS Form 7022)
  • Hospital Presumptive Eligibility (PE) Application Web Portal User Guide
  • Hospital PE Program Provider Election Form and Agreement (DHCS Form 7012)
  • Medi-Cal Learning Portal (MLP) Computer Based Hospital PE Provider Training
  • Manual sections relating to Hospital PE

New: Hospital PE Provider Intake Advisor Verification Form (DHCS Form 7011)
The Hospital Presumptive Eligibility (PE) Provider Intake Advisor Verification will allow hospital PE providers to permit third-party vendors, contractors or subcontractors to assist with HPE applicants by staffing welcome desks and meeting and helping applicants complete the paper version of the Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022).  Hospital PE providers must complete a DHCS form 7011 and keep it on file. However, third-party vendors, contractors and subcontractors are not permitted to make PE determinations or use the Hospital PE application web portal.

Updated: Hospital PE Enrollment Period Policy Updates and Limitations
The HPE enrollment period begins on the date the individual is determined eligible, which is the day DHCS Form 7022 was submitted in the Hospital PE application web portal. HPE can no longer be backdated for any reason (effective December 31, 2014). To obtain coverage prior to the PE start date, individuals must apply for full scope Medi-Cal and mark the box that indicates the individual has medical expenses in the last three months and needs help to pay.

The number of PE enrollment periods an individual may receive will be limited. PE enrollment periods received from any PE program listed below are limited to the past 12 months prior to applying for HPE (except for PE for pregnant women). These PE enrollment periods are as indicated in the table below:

Medi-Cal PE Programs PE Enrollment Period Permitted
HPE – Individuals 18 through 25 years of age who were in foster care at 18 years of age (no income limit) 1 PE enrollment period
HPE – Children 19 years of age or younger 2 PE enrollment periods
HPE – Parents and caretaker relatives 1 PE enrollment period
HPE – Adults 19 through 64 years of age who are not pregnant, not enrolled in Medicare and not eligible for any other group stated above 1 PE enrollment period
HPE – Pregnant Women 1 PE enrollment period per pregnancy
Child Health and Disability Prevention (CHDP) Gateway 2 PE enrollment periods
Breast and Cervical Cancer Treatment Program (BCCTP) 1 PE enrollment period
PE for Pregnant Women 1 PE enrollment period per pregnancy

Updated: Hospital PE Medi-Cal Application (DHCS 7022) and Hospital PE Application Web Portal Updates
The Hospital Presumptive Eligibility (PE) Medi-Cal Application (DHCS 7022) and HPE application web portal will be updated to include new application data fields and functionality to support new HPE policies and processes, as summarized below:

  • DHCS Form 7022 will be available in PDF on the HPE application web portal.
  • The former foster care age category will be changed to 18 through 25 years of age from 18 through 26 years of age.
  • A new question will be created to determine if the applicant currently has Medicare.
  • The Living in California field will be updated to cross-reference the Safe at Home and County Living In fields.
  • References to the Learning Management System will be changed to the Medi-Cal Learning Portal.
  • Changes will be made to the Immediate Need Eligibility Document, which serves as a temporary benefits identification card.
  • All instances of the wording “PE enrollment period lasting 60 days” will be replaced with “PE enrollment periods end on the on the last day of the month following the month PE eligibility was determined, if an insurance affordability application is not filed prior to that date.”

Updated: Hospital PE Program Provider Election Form and Agreement (DHCS Form 7012)
To receive final approval to become a qualified HPE provider and access the HPE application portal, providers and employees must complete the HPE provider training within 60 days of the approved HPE provider contract agreement.

Hospital-Owned Clinics
Approved HPE providers who own clinics listed on their hospital license will be able to expressly indicate whether their hospital-owned clinic(s) may also make HPE determinations. Submission of a completed new DHCS Form 7012 is required with the marked choice to permit the hospital-owned clinic(s) to make HPE determinations. The HPE provider must take full responsibility for permitting their hospital-owned clinic(s) to participate in the HPE program and must adhere to the rules below and in DHCS Form 7012:

  • The applying hospital is responsible for HPE determinations made at the participating clinics.
  • All HPE determinations must be made by HPE-approved hospitals or hospital-owned clinic employees who are HPE-trained and adhere to all HPE rules and guidelines.
  • The applying hospital must maintain a current list of all HPE-trained hospital staff conducting determinations at those locations.
  • If the applying hospital’s clinic has a different National Provider Identifier (NPI) than the applying hospital, the following additional information must be provided of the hospital-owned clinic(s):
    • Clinic(s) business name
    • Clinic(s) NPI
    • Either the federal employer ID number, taxpayer identification number, or Social Security number
    • Clinic(s) business address

In June, DHCS will announce the release of new and updated HPE forms via its ACA Hospital PE Program website. The approved HPE SPA is attached.

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