Presumptive Eligibility – FAQs
What services are covered under PE?
For pregnant women, only outpatient pregnancy-related services are covered. All other populations will be eligible for all benefits under the group for which they are determined eligible.
Who signs the PE acknowledgment form?
Whoever is designated as the Qualified Entity’s authorized agent should sign and complete the PE acknowledgment form. This individual is usually designated to sign contracts for the hospital. Also, if you have more than one hospital in your health system, ODM would like for you to list those individual locations along with their Medicaid provider ID numbers on the signature page. Only one copy of the acknowledgment form is needed to return to ODM’s PE Questions@Medicaid.Ohio.gov mailbox.
Who completes the PE training?
Any staff person or contractor at your hospital needs to complete the online training at http://Medicaid.Ohio.gov/PROVIDERS/Training/Presumptive eligibility.aspx
However, ODM would like to receive only one acknowledgment form per qualified entity.
What is the hospital’s responsibility after a PE determination is made?
Hospitals are expected to do everything possible to follow through with PE individuals to get them to complete a full Medicaid application through benefits.Ohio.gov. Qualified entities will be held responsible for getting 85% of PE enrollees enrolled into full Medicaid. (See FAQ below.)
What performance metrics do qualified entities need to meet?
The state Department of Medicaid says they expect 85% of PE enrollees to complete a full Medicaid application. In addition, of those completing the full application, the state expects 85% of individuals be eligible for full Medicaid. Hospitals that do not meet these targets could lose their qualified entity status.
Will eligibility vendors and other third party resources used by hospitals to assist patients in getting coverage be able to do PE?
Third party vendors and contractors may assist in the PE process, but are prohibited from making PE determinations and/or submitting a request through the portal.
According to CMS, a qualified entity may implement PE with the support of third party contractors. For example, hospitals can rely on third party contractors to help staff their in-hospital PE operations, by staffing welcome desks, meeting with consumers, and helping them complete PE applications as long as the hospital take responsibility for the PE determinations that result. In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application. Hospitals that conduct off-site, targeted outreach may also employ third party contractors to reach out to individuals who may be Medicaid eligible and assist them with a PE application and the single streamlined application at the individual’s request. Hospitals must oversee such off-site outreach to ensure hospital PE accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. Again, a third-party contract may not complete the actual PE request via the PE portal.
Can physician practices owned by hospitals and health systems perform PE?
Yes. Hospitals have the ability to authorize PE to be performed in physician offices. The hospital or health system’s Medicaid Provider ID# must be used.
If a patient does not complete their follow-up application and is excluded from being deemed PE for 12 months, how will the provider know?
The provider will be denied the PE option when processing the request.
Is the hospital responsible for the cost of the services rendered to PE patients if they are found to be ineligible for Medicaid?
No. There is no recoupment for Medicaid services provided during a PE period resulting from erroneous determination made by qualified entities. Payment for services covered under the state plan (as well as federal financial participation) is guaranteed during a PE period; without such a guarantee, providers could not rely on the PE determination.
Must the hospital complete the PE application and determination process before services can be covered by Medicaid?
Yes. An individual has to be found presumptively eligible (PE application submitted and a determination made) for services to be covered during the hospital PE period.
What is the responsibility of hospitals in getting PE patients to apply for full Medicaid?
Qualified entities will be monitored by the Ohio Department of Medicaid (ODM). ODM expects that 85% of the patients deemed PE in each hospital will complete the full application. Of that 85%, ODM expects 85% of those to be found fully eligible. Hospitals not meeting these success rates could lose their status as a qualified entity. The key is for hospitals to get that full application completed for each PE patients before he/she leaves the facility and/or have a very good mechanism for follow-up with those patients.
Is my facility required to provide the PE patient with medication?
Yes. The agreement states that the qualified entity must provide the patient with 36 hours' worth of medication.
Per the Ohio Department of Medicaid: In order to provide quality care, it is important that a facility provide 36 hours’ worth of medication to a consumer after a Presumptive Eligibility (PE) determination is made. The reason for this is due to timing of the various computer systems.
When a PE determination is approved, the following occurs
Information from the Presumptive Eligibility and Deemed Portal updates the Ohio Medicaid MITS billing system.
The MITS system updates various pharmacy systems throughout the State.
The timing of these updates may take several days and in the interim some pharmacies will not fill a consumer’s prescription(s) even though they receive a MITS billing on their printed PE determination confirmation.
To remedy this situation the following is recommended:
The facility provides a minimum of 36 hours’ worth of medication(s). This is only a minimum, the facility can fill the number of days that they would normally fill for the medications; or
Facilities work with local pharmacies who will accept a consumer’s MITS billing number and fill prescriptions prior to their pharmacy system being updated.
Please note that once all of the system updates have been made, facilities and pharmacies can input prescription information and they can bill Medicaid starting with the date of initial PE Medicaid coverage.
To contact the Ohio Department of Medicaid about PE: pequestions@Medicaid.Ohio.gov.
Provider PE training
Robert Wood Johnson Foundation Health Policy Brief