TO: All Providers Participating in MassHealth
FROM: Daniel Tsai, Assistant Secretary for MassHealth [Signature of Daniel Tsai]
RE: Coverage Provided via Hospital-Determined Presumptive Eligibility
Introduction
This bulletin, which supersedes All Provider Bulletin 244 published in May 2014, summarizes MassHealth's Hospital-Determined Presumptive Eligibility (HPE) process. This publication largely restates the requirements laid out in All Provider Bulletin 244, but also (a) clarifies how MassHealth will treat the submissions of both an HPE application and the Massachusetts Application for Health and Dental Coverage and Help Paying Costs (ACA-3) application for the same person on the same day; and (b) clarifies that an individual may apply for HPE even if they have received HPE benefits or MassHealth Standard, MassHealth CommonHealth, MassHealth CarePlus, or MassHealth Family Assistance within the previous 12 months; provided that the hospital determines that such individual either meets MassHealth's clinical eligibility criteria for inpatient or 24-hour mental health or substance use disorder treatment services or the individual has a diagnosis or a presumptive diagnosis of COVID-19.
Overview
The Affordable Care Act (ACA) allows qualified hospitals to make presumptive eligibility determinations for immediate, time-limited Medicaid coverage using self-attested information from certain individuals who appear to be eligible for Medicaid coverage, but are unable to complete a full Medicaid application at that time. (See 42 CFR 435.1110; 130 CMR 502.003(H): Hospital-Determined Presumptive Eligibility.) Qualified hospitals may include both acute hospitals and psychiatric hospitals. In addition to meeting other requirements, qualified hospitals may make hospital-determined presumptive eligibility (HPE) determinations for certain individuals if they have notified EOHHS of their election to make HPE determinations; agreed to make HPE determinations in accordance with federal and state statutes, regulations, policies, and procedures, including training requirements; and signed a contract with EOHHS allowing the qualified hospital to make HPE determinations. (See 130 CMR 450.110: Hospital-Determined Presumptive Eligibility.)
Once a qualified hospital has contracted with MassHealth to make HPE determinations, its HPE-trained Certified Application Counselors (CACs) may determine whether an individual is eligible for HPE by completing the MassHealth Application for Hospital-Determined Presumptive Eligibility (HPE application) using self-attested information provided by the applicant. The HPE-trained CAC must complete a separate HPE application for each individual seeking HPE coverage.
The MassHealth HPE team will process each CAC-approved HPE application to enter into MassHealth's systems. Once the information is entered, providers may view member information on the MassHealth Eligibility Verification System (EVS) the next business day.
Prior to completing and submitting an HPE application, the CAC must
• ensure that the applicant is unable to complete a full Massachusetts Application for Health and Dental Coverage and Help Paying Costs (ACA-3) at that time;
• determine the applicant's eligibility for HPE;
• explain the HPE application process to the applicant and describe the applicant's rights and responsibilities; and
• assign the applicant the appropriate MassHealth coverage type.
Once the HPE-trained CAC approves the application, the applicant receives immediate, time-limited MassHealth coverage corresponding to the coverage type assigned by the CAC. The expiration date of the applicant's HPE coverage is described in greater detail later in this bulletin. Qualified hospitals must also offer to assist applicants in completing a full ACA-3 application, to ensure that the applicant will be considered for continued MassHealth coverage beyond the HPE coverage period.
Eligibility
Eligibility for HPE is based on the applicant's self-attested responses to a limited set of questions in the HPE application. These include questions about household income (as opposed to modified adjusted gross income (MAGI)), household size, pregnancy status, parent or caretaker relative status, immigration status, and Massachusetts residency status. When assessing whether an applicant qualifies for HPE, neither the qualified hospital nor MassHealth will perform any matching or verifications. To retain coverage after the expiration of the HPE period, applicants must submit a full application before the HPE coverage end-date. The full ACA-3 application is subject to customary matching, verification, and MAGI requirements.
Only individuals who are unable to complete a full ACA-3 application at the time that they seek MassHealth coverage may apply for HPE. Consequently, if MassHealth receives a full ACA-3 application and an HPE application for the same individual on the same day, MassHealth will process only the full ACA-3 application.
An individual may not apply for HPE if the individual has been approved for MassHealth benefits through HPE within the previous 12 months or if the individual has been enrolled in MassHealth Standard, MassHealth CommonHealth, MassHealth CarePlus, or MassHealth Family Assistance within the previous 12 months. However, these limitations do not apply if the qualified hospital determines that the individual has a diagnosis or a presumptive diagnosis of COVID-19 or meets
MassHealth's clinical eligibility for inpatient or 24-hour mental health or substance use disorder treatment services. These services include, but are not limited to,
• inpatient psychiatric treatment;
• Level 4 withdrawal management;
• community crisis stabilization (CCS); and
• acute treatment services (ATS), enhanced acute treatment services (E-ATS), clinical support services (CSS), transitional support services (TSS), or residential rehabilitation services (RRS).
When invoking one of these exceptions, the HPE-trained CAC should note that the applicant requires such level of care on the HPE Cover Sheet.
If a qualified hospital erroneously approves HPE eligibility for an individual who is ineligible to apply for HPE, MassHealth's HPE team will notify the hospital. The hospital will be instructed to correct its mistake by contacting the member and explaining to the individual that they already have, or had, comprehensive MassHealth benefits or HPE. Such a member will remain in the existing MassHealth benefit, if applicable. No new coverage under HPE will be entered into MassHealth's eligibility systems based on the hospital's mistake. Services rendered to applicants erroneously approved by an HPE-trained CAC will not be paid for using HPE.
HPE determinations cannot be appealed. Applicants who are not eligible for HPE benefits should complete the full ACA-3 application.
Payment for Services Provided to Members Determined Eligible through HPE
Providers who provide services to MassHealth members determined eligible through HPE will be paid according to MassHealth fee-for-service rules for medically necessary covered services, if they submit claims for such services in compliance with all applicable administrative and billing and program requirements.
Members determined eligible through HPE may receive MassHealth Standard, MassHealth CarePlus, or MassHealth Family Assistance. Any services that are available fee-for-service for these coverage types are available to members determined eligible through HPE. (See 130 CMR 450.105 for a complete list of covered services by coverage type.) Individuals with HPE will not be assessed a premium. Premium assistance is not awarded during the presumptive eligibility period.
Managed care enrollment is not available to members determined eligible through HPE.
HPE coverage will not be retroactively terminated, even if the eligibility determination on the full application results in the member not being eligible for continued MassHealth coverage.
HPE Coverage Duration
HPE coverage starts on the day that the qualified hospital makes the presumptive eligibility determination, and ends on the last day of the month following the month that HPE was approved if a full application has not been submitted by that day; or, if a full application has been submitted by that date, then the HPE coverage ends on the date a determination is made based on the full application.
For example, if an applicant is determined to be eligible for coverage through HPE on March 15, 2020, then that is the first day of the HPE coverage period. The HPE coverage will end on April 30, 2020, if the individual has not submitted a full application by that date. If the individual submits a full MassHealth application by April 30, 2020, then the HPE coverage will continue until MassHealth makes an eligibility determination on the full application.
A member's HPE end date will vary depending on whether the member has submitted a full application and whether MassHealth has made a determination on that application. Therefore, it is particularly important that providers check EVS every day on which they furnish services, and every day of an inpatient hospital stay, to determine members' eligibility.
Proof of HPE Coverage
Applicants approved for coverage through HPE will receive an approval notice from the qualified hospital when the qualified hospital makes the HPE eligibility determination. The approval notice will include the HPE approval as well as the qualified hospital's name and contact information. In many cases, the approval notice provided by the qualified hospital will not include a member ID due to the lag time in getting the approval information into MassHealth systems.
MassHealth will also mail applicants approved through HPE a confirmation approval letter on MassHealth letterhead. This letter will contain the member ID.
Either the letter from the qualified hospital or the letter from MassHealth may be used as proof of coverage. Providers will also be able to verify coverage in EVS, once established. The EVS message for coverage determined through HPE will reflect fee-for-service coverage in MassHealth Standard, Family Assistance, or CarePlus.
No member ID cards will be provided for coverage determined through HPE. Members are directed to use the letter from the hospital or MassHealth as proof of coverage.
Questions
If you have questions about the information in this bulletin, please contact the MassHealth Customer Services Center at (800) 841-2900; email your inquiry to providersupport@mahealth.net; or fax your inquiry to (617) 988-8974.