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All You Need to Know About HPE and Coverage Fast-tracked and Extended by HPE Software

If you are a citizen of the United States, you must be familiar with “Medicaid.” But how much do you know about Hospital Presumptive Eligibility (HPE)? The Hospital Presumptive Eligibility (HPE) is a policy that allows timely access to health care services by determining eligibility on-site while allowing participants to move toward longer-term Medicaid coverage.

In the past, presumptive eligibility was only available to children or pregnant women living in states that selected it. However, things changed after January 2014. With the Affordable Care Act, hospitals can now make presumptive eligibility determinations based on a modified adjusted gross income for Medicaid-eligible individuals in every state.

CoverMe’s Hospital Presumptive Eligibility software helps identify patients who qualify for Medicaid in real-time, as per the Affordable Care Act. So, how does this Act modify Presumptive Eligibility? Our article uncovers all the particulars you need to know about HPE. So, read on.

HPE Under Affordable Care Act

Before the Affordable Care Act modified how PE’s function, pregnant women and kids could get temporary Medicaid coverage for years thanks to presumptive eligibility policies. The basic criteria to qualify for Medicaid were based on income and household size information. As a result, these patients are “presumed eligible” and temporarily enrolled in Medicaid.

With the Affordable Care Act, PE now functions like this:

  • Along with pregnant women and children, states can now include caretakers, parents, and other adults covered by the Medicaid program.
  • Former foster children and individuals who need family planning services are also included.
  • All states should implement HPE, thereby allowing hospitals to make PE determinations.

Hospitals can make PE determinations for all groups covered by state Medicaid programs. This list includes:

  • People with income above 133% of the federal poverty level and below 65 years of age.
  • Individuals eligible for family planning services
  • Individuals who need treatment for breast and cervical cancer.
  • Aged, disabled, and blind persons
  • People whose eligibility is established by the section 1115 waivers

Individuals from the wider community can also be considered for hospital PE, in addition to patients and their families.

How HPE Works- Understanding The Details

Let’s take you through a simple process to comprehend how HPE works.

Let’s assume an individual who hasn’t enrolled in Medicaid visits a hospital for the first time. An employee of the hospital trained in conducting hospital PE determinations assists the person with completing a hospital Presumptive Eligibility application. The employee also helps them answer required questions and calculate monthly family income and household size.

If an individual meets the hospital PE criteria, the hospital must provide:

  • A written eligibility notice
  • Information about the beginning and end dates of the hospital PE period
  • Summary of benefits.

The hospital employee also has other responsibilities such as:

  • Encouraging the individual to apply for full Medicaid
  • Helping the person connect with an application counsellor
  • Providing the reason for denial if PE is denied
  • Guiding the individual to submit a full Medicaid application

When the PE period commences, it also includes the day the hospital makes the determination. Here’s what one can expect with PE determinations:

  • When an individual submits a full Medicaid application by the last day of the month following the month PE is determined, the PE period ends the day the state determines whether the individual is eligible for full Medicaid or not.
  • If the individual does not submit the full application, the PE period ends on the last day of the month following the hospital’s decision.
  • Individuals who are presumed eligible for Medicaid receive the same benefits as those under the Medicaid group.
  • There is no coverage for birthing expenses for pregnant women. Only ambulatory prenatal care is available.
    In terms of benefits, family planning services and supplies are limited for individuals seeking family planning care.

Finer Details Of HPE: Important Facts To Note

When it is something as crucial as Hospital Presumptive Eligibility, it is important to get your facts straight. Here’s a detailed list of all the information you need to know about HPE:

1. Who can apply for HPE?

Anyone seeking immediate medical coverage can apply for HPE. An applicant does not have to be a patient at a hospital or seek medical care. However, to qualify for HPE, an applicant must meet a few general requirements.

2. What are the income criteria to qualify for HPE?

HPE eligibility is determined by household income and family size. To calculate the size of your family, add up the number of people on your federal tax return. If you don’t file taxes, count how many of your children and stepchildren are under 19. You should also include the unborn child if you are pregnant.

Household income is the combined income of all members above 15 years in the household. A family’s monthly income is based on all its members’ combined gross income before taxes and deductions. Your eligibility group determines the income limits.

3. How long does HPE coverage last?

The duration of HPE, known as the HPE Period, has a “begin” and an “end” date. It also refers to how often a person can receive HPE.

HPE Begin Date:

The HPE period commences on the date the HPE determination is made and cannot be backdated, regardless of the reason. The individual will be eligible for HPE starting from the date they are determined to be eligible and will receive coverage for the next 60 days.

HPE End Date

HPE coverage will end under any one of the following circumstances:

  • If an individual does not file a full application with OFI, the HPE period ends on the last day of the month following the HPE determination, which is the second month.
  • If an individual files a full application with OFI before the last day of the second month, HPE ends when the eligibility determination is made for regular coverage.

4. What is the frequency of coverage?

How often an individual can apply for HPE depends on the coverage category. For example, a pregnant woman can apply for one HPE during each pregnancy. Other individuals can apply for HPE only once in one year. This one-year period is calculated from the first day of the most recent previous period of HPE.

Also Read: Defining Presumptive Eligibility

5. What are the criteria to become a qualified provider?

TO make HPE determinations, providers must fulfill the following criteria to be qualified:

  • Meet all quality standards
  • Be enrolled
  • Complete the HPE Agreement
  • Agree to comply with OFI policies and procedures

6. How should hospitals enroll to make PE determinations?

Interested hospitals must submit a Memorandum of Understanding (MOU) with the Office for Family Independence (OFI) to qualify for making presumptive eligibility determinations.

7. How to become a qualified representative?

To work as a qualified hospital representative with the ability to determine eligibility on behalf of the provider, you should meet the following criteria:

  • Work in a qualified hospital
  • Complete the OFI training
  • Make PE determinations consistent with OFI policies and procedures

CoverMe: Your Ideal Healthcare Coverage Marketplace

CoverMe’s automated HPE program provides HPE determinations in real-time, thereby allowing individuals to immediate access to coverage. To understand the key aspects of our HPE program and its benefits, CoverMe presents The Healthcare Coverage Marketplace. please visit to learn more.

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