Frequently Asked Questions

The hospital PE provision in the Affordable Care Act is just for Medicaid state plan and 1115 groups and does not apply to separate CHIP state plan or CHIP 1115 groups. However, hospitals can determine PE for CHIP if a state designates a hospital as a qualified entity under CHIP authorities. A state that covers children and pregnant women in a separate CHIP may elect to have certain qualified entities determine PE for them, and the state determines what types of entities may be qualified entities, which may include hospitals.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91616

Yes, hospital PE is not limited to patients of the hospital. Hospitals can assist with PE determinations for family members and may also enroll eligible individuals from the broader community.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91626

Per our regulations at 42 CFR 435.1103(a), pregnant women may have one PE period per pregnancy. If a woman is pregnant more than once in a calendar year, they may have more than one PE period in a calendar year due to the multiple pregnancies.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91631

In general, for individuals determined eligible under hospital PE, the benefits provided are the same as those provided under the eligibility group for which PE is determined. See 42 CFR 435.1103(a) and (c)(1)(ii), which specifies that covered benefits for pregnant women during a PE period are limited to ambulatory prenatal care, and benefits covered under family planning PE are limited to family planning services.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91641

If a state has elected to provide PE for individuals with breast or cervical cancer under section 435.1103(c)(2), it can limit qualified entities under that section to providers who conduct screenings for breast and cervical cancer under the state's CDC BCCEDP, and if it has done so, the state may limit hospitals that may determine PE for individuals with breast or cervical cancer on that basis to hospitals that conduct screenings under the state's BCCEDP. In states that do not opt to provide PE for individuals with breast or cervical cancer under section 435.1103(c), states similarly may limit hospitals' ability to determine PE for individuals with breast or cervical cancer under section 435.1110 to those that conduct screenings under the state' BCCEDP.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91651

When hospitals determine PE, they are subject to the same general rules set out for other qualified entities that may determine PE, including that they cannot "delegate the authority to determine presumptive eligibility to another entity." (See 42 CFR 435.1102(b)(2)(vi). However, they may implement PE with the support of third party contractors. For example, hospitals can rely on third party contractors to help staff their in-hospital PE operations, by staffing welcome desks, meeting with consumers, and helping them fill out PE applications as long as the hospital takes responsibility for the PE determinations that result. In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application.

Hospitals that conduct off-site, targeted outreach may also employ third party contractors to reach out to individuals who may be Medicaid eligible and assist them with a presumptive application and the single streamlined application at the individual's request. Hospitals must oversee such off-site outreach to ensure hospital accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. States should not unduly limit a hospital's ability to rely on third-party contractors as long as the hospital is not delegating its authority to determine presumptive eligibility to a third party and is meeting appropriate state-established performance standards.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB) 

FAQ ID:91656

Keeping track of all eligible providers is important to ensure ongoing training and that the providers have regular updates in policy as well as to review performance, implement performance standards and develop quality assurance measures. Some states maintain a centralized list of all providers who have completed the process for learning the state's policies and procedures; the state may wish, for example, to periodically review the list by calling all identified providers or settings and asking whether or not listed individuals are currently conducting PE determinations. It is important for states to ensure, over time, that hospital PE is functioning throughout the state.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91671

States have used a number of strategies to engage hospitals, such as reaching out to the state hospital association or local hospital groups, sending hospitals a letter of interest to get feedback on their plans to participate in the program, and inviting hospital representatives to teleconferences and webinars about the policy. CMS has also reached out to various hospital associations to advise them of this new provision and the federal guidance supporting it.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91681

The Medicaid statute provides several options for states to pay premiums for adults and children to purchase coverage through private group health plans, and in some case individual plans; in most cases, the statute conditions such arrangements on a determination that they are "cost effective." Cost effective generally means that Medicaid's premium payment to private plans plus the cost of additional services and cost sharing assistance that would be required would be comparable to what it would otherwise pay for the same services. Similar provisions also apply in the Children's Health Insurance Program (CHIP).

Under all these arrangements, beneficiaries remain Medicaid beneficiaries and continue to be entitled to all benefits and cost-sharing protections. States must have mechanisms in place to "wrap-around" private coverage to the extent that benefits are less and cost sharing requirements are greater than those in Medicaid. In addition under the statutory options in the individual market beneficiaries must be able to choose an alternative to private insurance to receive Medicaid benefits.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 40.01 KB)

FAQ ID:93841

Some states have expressed interest in section 1115 demonstrations to provide premium assistance for the purchase of QHPs in the Exchange. Under section 1115 of the Social Security Act, the Secretary may approve demonstration projects that she determines promote the objectives of the Medicaid program. HHS will consider approving a limited number of premium assistance demonstrations since their results would inform policy for the State Innovation Waivers that start in 2017. As with all such demonstrations, HHS will evaluate each proposal that is submitted and consider it on a case by case basis relative to this standard.

With regard to premium assistance demonstrations, HHS will consider states' ideas on cost effectiveness that include new factors introduced by the creation of Health Insurance Marketplaces and the expansion of Medicaid. For example, states may quantify savings from reduced churning (people moving between Medicaid and Exchanges as a result of fluctuating incomes) and increased competition in Marketplaces given the additional enrollees due to premium assistance. As with all demonstration proposals, the actuarial, economic, and budget justification (including budget neutrality) would need to be reviewed and, if approved, the program and budgetary impact would need to be carefully monitored and evaluated.

To ensure that the demonstrations further the objectives of the program and provide information in a timely way, HHS will only consider proposals that:

• Provide beneficiaries with a choice of at least two qualified health plans (QHPs).
• Make arrangements with the QHPs to provide any necessary wrap around benefits and cost sharing along with appropriate data; this would be done within the context of premium assistance, for example through a supplemental premium. This ensures that coverage is seamless, that cost sharing reductions are effectively delivered and that there is accountability for the payments made.
• Are limited to individuals whose benefits are closely aligned with the benefits available on the Marketplace, that is, individuals in the new Medicaid adult group who must enroll in benchmark coverage and are not described in SSA 1937(a)(2)(B)(an example of a population that is described in SSA 1937(a)(2)(B) is the medically frail). Marketplace plans were not designed to offer broader benefits and could experience unexpected adverse selection due to enrollment of groups that are described in SSA 1937(a)(2)(B).
• End no later than December 31, 2016. Starting in 2017, State Innovation Waiver authority begins which could allow a range of State-designed initiatives.

In addition, a state may increase the opportunity for a successful demonstration by choosing to target within the new adult group individuals with income between 100 and 133 percent of FPL. Medicaid allows for additional cost-sharing flexibility for populations with incomes above 100 percent of FPL; this population is more likely to be subject to churning and would be eligible for advance premium tax credits and Marketplace coverage if a state did not expand Medicaid to 133 percent of FPL.

Supplemental Links:

• This FAQ was released as part of a larger set. View the full set. (PDF, 40.01 KB)

FAQ ID:93846