Section 120.68  Hospital Presumptive Eligibility (HPE) under the Affordable Care Act

a)         The purpose of Hospital Presumptive Eligibility (HPE) is to fulfill the mandate of the Affordable Care Act (ACA) that requires states to permit qualified hospitals to make presumptive determinations of eligibility for certain Medicaid eligibility groups pursuant to 42 USC 1396a(a)(47)(B) and 42 CFR 435.1110.

b)         The following classes of persons may be found presumptively eligible by qualified hospitals:

1)         Pregnant women (see Section 5-2(5)(a) and (b) of the Public Aid Code (Code));

2)         Children (see Section 5-2(6)(a) of the Code);

3)         Persons who need treatment for breast or cervical cancer (see Section 5‑2(12)(a) and (b) of the Code);

4)         Parents or other caretaker relatives (see Section 5-2(15) of the Code (FamilyCare));

5)         Persons age 19 or older, but younger than age 65 (see Section 5-2(18) of the Code);

6)         Persons age 19 or older, but younger than age 26, who were formerly in foster care in Illinois (see Section 5-2(19) of the Code).

c)         Criminal Justice Exclusions – Unless the federal Centers for Medicare and Medicaid Services directs the Department otherwise, persons living in jails, prisons, half-way houses, or juvenile detention facilities, including such persons on work release, furlough or admitted for inpatient hospital treatment from such facilities, shall not be found presumptively eligible under this Section.

d)         Presumptive Eligibility Period – The presumptive eligibility period shall be the period that:

1)         begins with the date on which a qualified HPE Provider determines that the individual meets the qualifications for one of the classes listed in subsection (b); and

2)         ends with (and includes) the earlier of:

A)        the date on which a determination is made with respect to the eligibility of the person for medical assistance under the Illinois Medicaid State Plan;

B)        in the case of a person who does not file an application by the last day of the month following the month during which the qualified HPE Provider makes the determination, that last day; or

C)        the day on which a determination is made that the person:

i)          was already actively enrolled under the Illinois Medicaid State Plan when found presumptively eligible by a qualified HPE Provider; or

ii)         did not qualify to be presumptively enrolled in Medicaid under the Illinois Medicaid State Plan because he or she had previously been so enrolled within the past 12 months prior to the start of his or her presumptive eligibility or, if pregnant, during the current pregnancy.

e)         Department responsibilities under this Section shall be:

1)         making training and technical assistance available to the HPE Provider regarding the requirements, policies and procedures of HPE;

2)         assigning a unique HPE number to each individual successfully completing HPE training;

3)         maintaining an online HPE Provider portal through which the HPE Provider shall submit HPE enrollments and associated applications for ongoing health coverage;

4)         registering HPE enrollments for coverage and assigning a Recipient Identification Number (RIN) to each individual;

5)         transmitting a notice to the HPE Provider through the online HPE Provider portal that an HPE enrollment received from the HPE Provider has been registered. The notice shall be in a form suitable for providing to the HPE enrollee and shall include the RIN issued to the enrollee; and

6)         providing reports sufficient for measuring HPE Provider performance as compared to standards established in subsection (k).

f)         An HPE Provider shall provide notice to each HPE enrollee that the individual is registered and presumptively eligible pursuant to the terms and limitations provided under this Section.

g)         Covered Services – Services covered during the presumptive eligibility period under this Section shall be as follows:

1)         For pregnant women eligible under subsection (b)(1), services covered shall be established in Section 120.66(e);

2)         For classes of persons presumptively eligible under subsections (b)(2) through (b)(6), services covered shall include all services covered for the class of eligible persons under which the person was enrolled for HPE.

h)         For purposes of this Section, the term "hospital" means:

1)         Any entity meeting the definition of "hospital" as established in 89 Ill. Adm. Code 148.25(b)(1); or

2)         A State operated mental health facility, as defined in Section 1-114.1 of the Mental Health and Developmental Disabilities Code [405 ILCS 5].

i)          Qualified HPE Providers are those hospitals that:

1)         participate as a provider under the Illinois State Medicaid plan;

2)         notify the Department of their election to make presumptive eligibility determinations under 42 CFR. 435.1110;

3)         enter into and abide by the terms of the Illinois Hospital Presumptive Eligibility Provider Agreement established by the Department;

4)         assist individuals in completing and submitting an application for medical benefits as defined in 89 Ill. Adm. Code 110.10;

5)         agree to make presumptive eligibility determinations consistent with the Department's rules, policies and procedures;

6)         achieve the performance standards established in subsection (k); and

7)         have not been disqualified from HPE participation pursuant to subsection (l).

j)          HPE Provider Limitation.  Only HPE Providers that participate in the provision of services under the Illinois Breast and Cervical Cancer Program administered by the Illinois Department of Public Health may make HPE determinations for persons under subsection (b)(3).

k)         HPE Performance Standards – To remain in good standing as a Qualified HPE Provider, a hospital must meet all of the following performance standards in each calendar quarter:

1)         Achieve a percentage of HPE enrollments associated with an application for ongoing benefits during the presumptive eligibility period of at least 65 percent for calendar quarters in calendar year 2015, at least 80 percent for calendar quarters in calendar year 2016, and at least 90 percent for calendar quarters in calendar year 2017 and thereafter.

2)         Achieve a percentage of HPE enrollments for patients who the provider should have known were not HPE eligible of less than 5 percent for calendar quarters in calendar year 2015, less than 4 percent for calendar quarters in calendar year 2016, and less than 3 percent for calendar quarters in calendar year 2017 and thereafter.

3)         Achieve the established percentage for at least one of the following standards with regard to HPE enrolled persons found eligible for ongoing health benefits under the Illinois State Medicaid Plan in one of the classes of eligible persons listed in subsection (b) when review of an application for ongoing eligibility is completed by the State.

A)        No more than 1 standard deviation below the mean approval rate for applications associated with HPE enrollments calculated for all HPE Providers as a group for the calendar quarter; or

B)        At least 50 percent of the HPE Provider's own HPE enrollments for calendar quarters in calendar year 2015, at least 70 percent for calendar quarters in calendar year 2016, and at least 90 percent for calendar quarters in calendar year 2017 and thereafter.

l)          Disqualification for Failure to Meet Performance Standards – The Department shall disqualify hospitals from participation as HPE Providers as described in this subsection (l).

1)         HPE Providers will be provided with reports on performance on at least a quarterly basis.

2)         An HPE Provider whose performance fails to meet an applicable performance standard will be notified in writing by the Department.

3)         Beginning January 1, 2016, to remain in good standing, the HPE Provider must meet all performance standards in each of the two consecutive quarters following the quarter in which the Department provides notice of failure to achieve a required performance standard.  The Department shall terminate the HPE Provider Agreement and issue a notice of disqualification if the HPE Provider fails to achieve all performance standards in either of those quarters.

4)         Any hospital disqualified as an HPE Provider may not reapply to participate as an HPE Provider for six months following the date of notice of disqualification.  Any such hospital must submit a detailed plan of how it will assure full compliance with the performance standards and HPE Provider Agreement with a written request to rejoin HPE.  The Department shall have sole discretion to determine whether a disqualified hospital may enter into a new HPE Provider Agreement.

5)         Nothing in this subsection (l) shall preclude the Department from terminating an HPE Provider Agreement under the terms of that agreement should an HPE Provider otherwise fail to comply with the HPE agreement or the enrollment agreement to participate as a provider under the Illinois State Medicaid Plan.

m)        This Section will apply upon receipt of federal approval of the amendment to the Illinois State Medicaid Plan to authorize Hospital Presumptive Eligibility and upon successful deployment of the data system required to support the HPE process outlined in this Section (Phase 2 of the Integrated Eligibility System).

(Source:  Added at 40 Ill. Reg. 2784, effective January 20, 2016)