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Presumptive Eligibility Federal RegulationsPresentation to: Qualified Hospitals that complete PresumptiveEligibility (PE) Medicaid applicationsPresented by: Memi Wilson0Date: August 2014

MissionThe Georgia Department of Community HealthWe will provide Georgians with access toaffordable, quality health care througheffective planning, purchasing and oversight.We are dedicated to A Healthy Georgia.1

QH’s Request For PEPer the Affordable Care Act (ACA), hospitals who meet the requirements ofparticipation will be given the opportunity to become Qualified Hospitals (QH)by competing PE Medicaid training. The training requirement is met by attending a presumptive workshop andsatisfactorily performing the training exercises. Upon completion of the training, each hospital certifies that all QHrequirements have been met by completing the QH enrollment form. Upon receipt of the enrollment form, the DCH Provider Enrollment Unit willadd the QH specialty code to the provider’s file and issue an approvalnotice to the provider showing the effective begin date for performing QHactivities.2

PE Hospital Application -UpdateDCH is currently working on the procedures andapplication that Hospitals will follow to requestbecoming a Qualified Hospital.This information will be shared with Hospitals onceeverything has been finalized. Please disregard anyprevious information regarding the Enrollment Wizardprocedures.3

§435.1110 Presumptive Eligibility (PE)Determined By HospitalsA Qualified Hospital (QH) is a hospital that: Participates as a Georgia Medicaid provider; Notifies DCH of its election to make PE determinations; Agrees to make PE determinations consistent with DCH’spolicies and procedures; Assists individuals in completing and submitting the fullHealthcare Coverage application and understanding anydocumentation requirements; and Has not been disqualified by DCH.4

Some QH Responsibilities Application to request PE accessMemorandum of Understanding agreementList of authorized personnel to complete PE applicationsMaking correct PE Medicaid determinationsCompleting PE Training; notification of periodic refresher PEtraining and new worker PE trainingPE Monitoring and cooperation with Quality ControlPE ReportsMeeting Performance StandardsPE Corrective action plans5

§435.1110 Disqualified HospitalDCH must take action, including, but not limited to,disqualification of a hospital as a qualified hospital if DCHdetermines that the hospital is not:1. Making, or is not capable of making, PE determinations in accordancewith applicable DCH policies and procedures; or2. Meeting the DCH standard.3. DCH may disqualify a hospital as a qualified hospital after it hasprovided the hospital with additional training or taken other reasonablecorrective action measures to address the issue.6

Where DCH Is With ACA Qualified Hospitals1. ACA PE Hospital materials have beensubmitted to CMS for final approval.2. GAMMIS is being programmed to updatePE Qualified Hospitals.Both of these important requirements must befinalized prior to moving forward with PE certificationfor Qualified Hospitals.7

What is Presumptive Eligibility Medicaid?A process that allows Georgia’s residents to be immediately enrolled inGeorgia’s Medicaid for a temporary period of time.An individual provides information about his or her taxable income, taxfiler status, household size, citizenship/immigration status, and residency.If they are eligible for Medicaid based on this information, a hospital shalldetermine that individual to be “presumptively eligible” for Medicaid.The individual is temporarily enrolled this interim period pending a finaladjudication of Medicaid eligibility by either the Right from the StartMedicaid (RSM) Project or the Division of Family and Children Services(DFCS) office.8

Goal and Purpose of PresumptiveEligibility Medicaid Goal: To provide Medicaid coverage prior to the fullMedicaid eligibility decision by RSM or DFCS, andto remove barriers to the availability of medicalservices and full Medicaid eligibility for all taxfiler/non tax filer household members. Purpose: To allow an applicant to knowimmediately if they are eligible. When eligible, theindividual can begin to receive medical services.9

What is a “Temporary Period of Time”?When an individual is approved for PE Medicaid theireligibility begins on the first day of the month of their PEapplication and ends no later than the last day of the followingmonth, or when a full Medicaid determination is made by RSMor DFCS, whichever occurs first. She applies 7/5/14, and is approved for PE Medicaid. Her PEMedicaid coverage begins 7/1/14 and ends no later than 8/31/14. If RSM or DFCS determine on 7/11/14 she is/is not eligible forMedicaid her PE Medicaid ends 7/31/14.10

Federal Regulations on Time PeriodFederal regulations allow only the first day of thePE period to begin with the PE disposition date.Due to DCH’s system it is automaticallyreverted back to the first day of the applicationmonth. This is currently being worked on andwill line up with federal regulations uponcompletion.11

Presumptive Eligibility MedicaidCategories §435.110Parent/Caretaker with Child(ren) §435.150Former FosterCare Medicaid §435.213Women’s Health Medicaid (Breastand/or Cervical Cancer) §435.1102 Children Under 19 Years of Age §435.1103 Pregnant Women12

Affordable Care ActTwo important regulations in the ACA: Taxable Income only is used to determine financialeligibility. Tax Filer or Non Tax Filer Status is used todetermine which individuals must be included in thebudget group.The ACA is based on IRS regulations.13

IncomeAppendix I –INCOME Chart reflects the IRSregulations regarding income. Income is either earned or unearned income. Only taxable income is used; not all income aperson receives is considered taxable. Taxableincome is required to be reported on a tax return,regardless if they expect to file a tax return or not.IRS names and definitions have been used for the Appendix I Income Chart14

WagesWagesEmployee Compensation includes what will be asked about regarding working. Some receive aPaycheck and others are paid in cash (such as a day laborer). Self employment iscalculated using total monthly gain minus their self employment expenses to determine themonthly taxable income to begin with.Example: She is self employed and earns 10,000 monthly. She has 8,000 in self employmentexpenses monthly. We take 10,000 – 8,000 2,000 is our starting point of taxable income.15

Wages: In-KindWe do not count In-Kind types as part of their financialeligibility determination.She lives with a family that provides her room andboard in exchange for watching their children afterschool. Her compensation is room and board only.16

Child SupportChild support can be received one of three ways: Directly from the absent parent From the Division of Child Support Services From a court system (any state)Regardless of how they receive child support, and of theamount, none of the child support is counted as it is considerednon-taxable income per IRS regulations.17

Unemployment Compensation Benefits (UCB) andWorker's Compensation Benefits (WCB)UCB is different than WCB18

Social Security Administration (SSA)IncomeSupplemental Security Income (SSI), this income also comes with Medicaid (300 aidcategory codes), and Retirement, Survivors and Disability Insurance (RSDI).RSDI is received by individuals that are either retired, or if they lost a spouse/parent, orby disabled individuals. Disabled Individuals that receive RSDI will begin to receiveMedicare after two years (regardless of their age). SSI income will not be included inthe budget, but the individual is counted in the budget group.19

Non-taxable Income TypesBenefits received by individuals are not alwaysincluded in the budget because they are considerednon-taxable income. ly shows the old names so 104 will show LIM Adult, but Appendix CClass of Assistance (COA), has the new names that will show on GAMMIS once it has been updated. OnceGAMMIS is updated a mandatory training will be available for Qualified Hospitals to complete.41

Dually Eligible If the beneficiary is receiving P4HB aid categories 180 or 181 or ifthey are receiving Q-Track Medicaid (600-662), continue with theirPE Medicaid. These Medicaid categories are limited Medicaid andPE Medicaid has more coverage for them. Unlike full Medicaid thatis better than temporary Medicaid of PE Medicaid. If the beneficiary is on PE WHM or WHM contact ARROWHEAD sothey can handle their case. SSI beneficiaries will need to have their pregnancy informationupdated on GAMMIS. Continue to use the SSI Pregnancy Form; theform and procedures are located in the PE Manual.Detailed information will be covered in the GAMMIS training.42

Questions?Before we move on are there anyquestions regarding definitions, or medicalverification of pregnancy, and/or duallyeligible procedures?43

Net Taxable Income ChartTitle or Chapter Slideand(use as needed; feel free to delete)Deductions44

Parent/Caretaker with Child(ren) Limit45

PE Pregnancy 220% FPL Table46

Children Under 19 Years of Age Limit47

Pre-Tax DeductionsPre-tax deductions are removed from gross income before taxes areapplied. The most common types are health Insurance, dentalinsurance, vision insurance, etc. Not every income amount deductedfrom gross income is considered a pre-tax. Line 1 on the W2 form iswhat is entered on Line 7 of the tax return form 1040.48

1040 Deductions49

5% Federal Poverty Level Deduction50

PresumptiveTitle or Chapter SlideEligibility(use as needed; feel free to delete)MedicaidCategories51

§435.110 Parent/Caretaker with Child(ren)Provides Medicaid coverage for Parent(s) orCaretaker(s) with at least one qualifying child. Tax Filer or Non Tax Filer Status Exceptions per ACA Net Taxable Income must be at or below limit GA Resident Citizen or Qualified Immigrant52

§435.1102 Children Under 19 Years of AgeProvides Medicaid coverage for a child(ren) under 19years of age. Tax Filer or Non Tax Filer Status Exceptions per ACA Net Taxable Income must be at or below limit GA Resident Citizen or Qualified Immigrant53

§435.1103 Pregnant WomenProvides Medicaid coverage for a pregnant woman. Tax Filer or Non Tax Filer Status Exceptions per ACA Net Taxable Income must be at or below limit GA Resident Citizen or Qualified Immigrant Pregnancy is not medically verified Can only be PE approved once per pregnancy54

§435.150 Former FosterCare MedicaidProvides Medicaid coverage for individuals that have aged out ofFoster Care at 18 years of age or older. Former Foster Care Medicaid began January 1, 2014. Foster Care is not limited receipt in Georgia only. The individual must be under 26 years of age. No income or asset test required. They will be the only one included in their budget group. Taxfiler/Non Tax Filer status is not considered. If they have otherfamily members, such as a child, these individuals areconsidered for another type of Medicaid.55

§435.213 Women’s Health Medicaid(Breast and/or Cervical Cancer) Georgia provides PE for women with breast and/or cervical cancerbut is limited to Qualified Providers who conduct screenings forbreast and cervical cancer under GA’s Centers for Disease Controland Prevention (CDC) National Breast and Cervical Cancer EarlyDetection Program (BCCEDP). Georgia limits Qualified Hospitals that may determine PE for womenwith breast and/or cervical cancer on that basis to hospitals thatconduct screenings under GA’s BCCEDP. The Department of Public Health (DPH) is charged with the CDCBCCEDP program. Once a Qualified Hospital is certified by theDPH, they will be trained to complete PE Women’s Health Medicaid(WHM).56

Federally Facilitated Marketplace (FFM)Applicants for health coverage in Georgia, who are childless adultsbetween the ages of 19-64 years of age, should be guided to applydirectly at the FFM to prevent any delay with their selection.https://www.healthcare.govAvailable 24/7 By Phone:1-800-318-2596TTY: 1-855-889-432557