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HPE Medicaid

Get comprehensive information about HPE Medicaid participation and compliance. Know what performance standards apply to your state.

How Can Your Hospital Participate in Hospital Presumptive Eligibility?

HPE is available in most states, and participation is optional. However, the benefits of HPE enable hospitals to deliver a Continuum of Coverage envisioned by the law, thereby benefiting the hospitals and patients. In order to participate in this beneficial program, hospitals must submit the appropriate paperwork to their state Medicaid office. They are also required to meet a series of qualifications, standards, and training to enroll and stay in compliance with the program. Find out what the eligibility rules and standards are for your state.

HPE FAQs

HPE Performance Standards

As per the federal regulations at 42 CFR § 435.1110(d) for PE determinations, every participating hospital is required to adhere to the performance standards as mandated by the state. If standards are not met and maintained, this can result in corrective action or termination from the HPE program.
Alabama HPE Performance
  • Medicaid enrollment must be made by 50% of HPE enrollees on an ongoing basis.
  • 70% of enrollees must submit the Medicaid application before the end of the presumptive eligibility period
  • 90% presumptive eligibility determinations must be conducted in accordance with the Alabama Medicaid eligibility rules
  • The hospital should maintain complete records on all PE clients. These records will be subject to a detailed review by the state and/or federal departments.
  • The hospital staff should sign and adhere to the Determiner Code of Conduct.
  • Not signing the code of Conduct or failing to comply with the stipulated guidelines for establishing the PE status may lead to the denial of the application for the determiner or even immediate termination of the determiner status
Download Alabama HPE application
Georgia HPE Performance
  • 90% of enrollees must submit their Medicaid application before the end of the presumptive eligibility period
Download Georgia HPE application
Mississippi HPE Performance
  • No performance standard for the first 6 months
  • During the next 6 months, 90% of enrollees must submit their Medicaid application before the end of the presumptive eligibility period. After this, the accuracy percentage is 95%.
Download Mississippi HPE application
Oklahoma HPE Performance
  • 95% of people with Hospital Presumptive Eligibility should submit the application within 15 days of completing the HPE application.
  • 95% of those determined eligible for HPE who present a full Soonercare application are deemed eligible for Medicaid by the OHCA.
  • 99% of HPE applications use the OHCA's Secure Provider Portal to conduct an eligibility verification check with the HPE application.
Download Oklahoma HPE application
Texas HPE Performance
  • 95% of individuals determined presumptively eligible submit a regular application.
  • 95% of presumptive eligibility determinations and corresponding regular Medicaid applications are electronically submitted within one working day.
  • 100% of presumptive eligibility determinations and corresponding regular Medicaid applications are electronically submitted within five working days.
  • 97% of individuals determined presumptively eligible are determined eligible for Medicaid based on submitting a regular application for Medicaid.
Download Texas HPE application
Texas
Alabama
Georgia
Mississippi
Oklahoma
  • 95% of individuals determined presumptively eligible submit a regular application.
  • 95% of presumptive eligibility determinations and corresponding regular Medicaid applications are electronically submitted within one working day.
  • 100% of presumptive eligibility determinations and corresponding regular Medicaid applications are electronically submitted within five working days.
  • 97% of individuals determined presumptively eligible are determined eligible for Medicaid based on submitting a regular application for Medicaid.
Download Texas HPE application
  • Medicaid enrollment must be made by 50% of HPE enrollees on an ongoing basis.
  • 70% of enrollees must submit the Medicaid application before the end of the presumptive eligibility period
  • 90% presumptive eligibility determinations must be conducted in accordance with the Alabama Medicaid eligibility rules
  • The hospital should maintain complete records on all PE clients. These records will be subject to a detailed review by the state and/or federal departments.
  • The hospital staff should sign and adhere to the Determiner Code of Conduct.
  • Not signing the code of Conduct or failing to comply with the stipulated guidelines for establishing the PE status may lead to the denial of the application for the determiner or even immediate termination of the determiner status
Download Alabama HPE application
  • 90% of enrollees must submit their Medicaid application before the end of the presumptive eligibility period
Download Georgia HPE application
  • No performance standard for the first 6 months
  • During the next 6 months, 90% of enrollees must submit their Medicaid application before the end of the presumptive eligibility period. After this, the accuracy percentage is 95%.
Download Mississippi HPE application
  • 95% of people with Hospital Presumptive Eligibility should submit the application within 15 days of completing the HPE application.
  • 95% of those determined eligible for HPE who present a full Soonercare application are deemed eligible for Medicaid by the OHCA.
  • 99% of HPE applications use the OHCA's Secure Provider Portal to conduct an eligibility verification check with the HPE application.
Download Oklahoma HPE application

Quick Facts About HPE Medicaid

Hospital Presumptive Eligibility (HPE) is a healthcare policy under the Affordable Care Act (ACA) that lets hospitals provide temporary Medicaid coverage to uninsured individuals who may likely be eligible for Medicaid under specific categories. The temporary eligibility ensures that qualified individuals get improved access to Medicaid and other critical services. Further, it encourages and assists the individual in submitting a full Medicaid application.

HPE allows qualified hospitals to get reimbursed for the care they provide for eligible individuals as if they enrolled in Medicaid.

What defines a qualified hospital?

A hospital is qualified to make PE determinations if

  • The hospital is participating in the Medicaid program
  • They have notified the state affirming its election to determine PE.
  • They agree to adhere to state policies and procedures for making HPE determinations.
What is the hospital’s responsibility in PE determinations?

Once qualified to make PE determinations, the hospital must ensure that:

  • Only hospital staff who are adequately trained and certified are making the PE determinations
  • The responsibility of making HPE determinations are not delegated to non-hospital staff
Who is eligible to enroll in Medicaid through the HPE program?

HPE determinations are based on 3 core eligibility criterias that are based on whether or not the individual:

  • Is a US national, or a US citizen
  • Is a resident of the state where they are seeking eligibility
  • Belongs to a group of Medicaid-eligible populations (shown below )
  • Has income and assets within the eligibility limits set forth by the state
  • Is not already enrolled in Medicaid
  • Has not already received HPE during the current calendar year
  • Has not already received HPE for the current pregnancy, if pregnant
Who are the Medicaid-eligible population?
General
  • Pregnant Women
  • Infants and children (0-5 years)
  • Children less than 19 years of age (6 - 18 years)
  • Children formerly under foster care
  • Adults without children
  • Parents/caretaker relatives
State-Specific (if covered by the state)
  • Specific adult groups
  • People over 133% FPL and under age 65
  • Those eligible for family planning services
  • Eligible groups over 65 years of age
  • Eligible groups with disabilities
  • Eligible groups who are blind
  • Those who require treatment for conditions such as cervical or breast cancer
What is the Duration of Eligibility
  • The HPE program begins on the day the hospital starts the PE determinations.
  • It ends on:
    • The day the state determines the eligibility for full Medicaid or,
    • The last day of the month after the month when the hospital makes the HPE determination if the individual had not applied for full Medicaid by then.
  • The HPE period is limited to once per calendar year, or if it was for pregnancy, once during the current pregnancy.
How do the PE Determinations Work?

When an individual visits a healthcare facility, the PE worker in the facility will take the following steps:

  • Explain the HPE policy option under the Affordable Care Act
  • Help the individual complete the HPE application by
    • capturing the necessary information
    • answering the required questions
    • offering help to calculate the monthly family income
  • Determine eligibility for HPE
  • Enter the individual’s information
  • Provide the HPE eligibility notice to the individual
  • Explain the eligible benefits under HPE and clarify any questions
  • Encourage the individual to go for complete Medicaid

Get the HPE Advantage for Your Facility

Besides helping you register for HPE, CoverMe will ensure that you remain 100% compliant with your state standards. Talk to us to see how it works!
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