DPSS ePolicy

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The Hospital Presumptive Eligibility (HPE) program was implemented on January 1, 2014.  HPE provides temporary, zero Share of Cost (SOC) Medi-Cal benefits for up to 60 days based on self-attested information collected by the hospital.

Qualified hospitals can determine Presumptive Eligibility (PE) for certain Medi-Cal eligible populations based on preliminary information to ensure uninsured individuals have access to medical care.

The Patient Protection and Affordable Care Act (ACA) of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, required implementation of the HPE program effective January 1, 2014.  HPE is administered by qualified hospitals and not the Department of Public Social Services.

Terms and Descriptions

Insurance Affordability Programs (IAP)

Term used to refer to the following healthcare programs:

1. Medi-Cal (MAGI and Non-MAGI) 
2. Children’s Health Insurance Program (CHIP) 
3. Advance Premium Tax Credit (APTC) 
4. Cost-Sharing Reduction (CSR)

Qualified Hospital

A hospital that participates as a HPE provider under the State plan or a demonstration waiver under Section 1115 of the Social Security Act.

Hospital Presumptive Eligibility Medi-Cal Application (DHCS 7022)

One page application that includes the individual’s self-attested information and can only be submitted online via the HPE portal.  The application may not be submitted in paper format.

Hospital Presumptive Eligibility (HPE) Portal

An interface (portal) developed between the qualified hospitals and Medi-Cal Eligibility Data System (MEDS) to have an HPE eligibility determination completed in real-time.

The eligibility requirements to qualify for the HPE program are:

HPE Eligibility

1. Individual must be a California resident;
2. Not currently enrolled in an Insurance Affordability Program (IAP); and
3. Meet the income and household composition requirements for one of the ACA eligibility groups:
   1. Children, ages 0 up to 19 years, 
   2. Parent/Caretaker Relatives, 
   3. Pregnant women, and 
   4. New Adults, ages 19-64, not pregnant, not enrolled in Medicare, and not eligible for any other mandatory group. 
   5. Former foster care children between the ages of 18-26 who were receiving foster care on his/her 18th birthday.

HPE Enrollment

The HPE is limited to one enrollment per a 12-month period.  The 12-month enrollment period begins in the month determined eligible for the HPE.

There are two exceptions for the HPE enrollment:

1. A 60-day period can be extended if the customer is pending a Medi-Cal application approval/denial decision from the County, or 
2. The HPE 12-month period is for a pregnant woman.  Pregnant women are permitted to receive more than one 12-month HPE period per pregnancy for ambulatory prenatal services.

Below are the stages to be completed for the HPE enrollment:

Stage 1:  Hospital Representative
Required Action:

• Processes DHCS 7022 and approves HPE.
• Provides a Single Streamlined Application (SSApp) to the customer prior to leaving the hospital. 

Stage 2:  Applicant
Required Action:

• Completes SSApp.
• Submits completed SSApp to the County no later than the last day of the following month in which HPE was granted. 

Note:  The HPE Enrollment period will end if the HPE applicant does not submit an SSApp prior to the  end of their 60-day enrollment period.

HPE Application

The HPE Medi-Cal application (DHCS 7022) can only be submitted online via the Hospital PE portal.  Authorized hospital personnel are required to submit the HPE Medi-Cal application via the online process.  Paper HPE Medi-Cal applications are not accepted.

The HPE Medi-Cal application is a one-page document and is based entirely on the individual’s self-attestation.  The application includes information about the individual’s:

1. Residency;
2. Income; and
3. Family size.

HPE Limitations

Enrollment limitations have been established for certain Presumptive Eligibility (PE) programs that include HPE.  The enrollment limitation is the maximum number of times a customer can enroll in HPE during a 12-month period.  The enrollment limit is determined by the customer’s coverage group.

The enrollment agency for these programs validate whether the customer has exceeded the enrollment limitation.  If the customer has exceeded the enrollment period limitation, they will be denied HPE benefits.  The enrolling agency will encourage the customer to submit a SSApp.

The 12-month enrollment limit for each coverage group is shown below:

• Enrollment Limit – One
  • Former Foster Youth (FFY):  (age 18-25 who were in foster care)
  • Parents and caretaker relatives
  • New adult group
     
• Enrollment Limit – Two
  • Children aged 0 -19
     
• Enrollment Limit – One per pregnancy
  • Pregnant women

HPE Benefits on MEDS

MEDS displays the following information:

• For HPE Begin Date, MEDS displays the customers application date.  The 60-day Medi-Cal eligibility time-period begins the date MEDS is updated.  
  
  Example:  Customer applied on December 15^th and received HPE with aid code P3.  MEDS special segment screens (INQ1, INQ2, or INQ3) display aid code P3 and INQD displays the December 15^th date on the AE-EFF-DATE.
  
  
• For HPE End Date, MEDS displays the termination based on when HPE expires which is 60 days from the date HPE began.  
  
  Example:  HPE began on December 15^th; the 60^th day is February 13^th.  MEDS will show a term date on the MEDS special segment screens (INQ1, INQ2, INQ3) as February 13^th, and benefits will not be available after the 13^th.

Note:  MEDS is programmed to automatically terminate all HPE benefits for individuals who reach the 60-day limit unless MEDS has a record of a pending Medi-Cal application (INQP screen).  When a Medi-Cal application is opened in the Leader Replacement System (LRS) for an HPE individual, eligibility staff shall ensure that an AP-18 application transaction is sent to and posted in MEDS with the date of application to continue PE benefits until a final eligibility determination is made for ongoing eligibility (approval or denial).

HPE Aid Codes

There are 10 HPE aid codes.  Below is the list of aid codes, FPL limits, and Level of Benefits.

Aid Codes:  P1
HPE FPL:  Infants age 0 -1, at or below 208%
Level of Benefits:  Full Scope

Aid Codes:  P2
HPE FPL:  Parent, Caretaker Relative, at or below125%
Level of Benefits:  Full Scope

Aid Codes:  P3
HPE FPL:  Adults, at or below 138%
Level of Benefits:  Full Scope

Aid Codes:  P4
HPE FPL:  Pregnant women, at or below 213%
Level of Benefits:  Limited Scope

Aid Codes:  H6
HPE FPL:  Infants age 0-1, above 208% up to and including 266%
Level of Benefits:  Full Scope

Aid Codes:  H7
HPE FPL:  Children age 1-6, at or below 142%
Level of Benefits:  Full Scope

Aid Codes:  H8
HPE FPL:  Children age 6-19, at or below 133%
Level of Benefits:  Full Scope

Aid Codes:  H9
HPE FPL:  Children age 1-6, above 142% up to and including 266%
Level of Benefits:  Full Scope

Aid Codes:  H0
HPE FPL:  Children age 6-19, above 133% up to and including 266%
Level of Benefits:  Full Scope

Aid Codes:  4E
HPE FPL:  Former Foster Care Children up to age26 (no incoming screening)
Level of Benefits:  Full Scope

HPE beneficiaries will not receive a Benefit Identification Card (BIC).  The Hospital Presumptive Eligibility Response (HPER) card will act as the Immediate Need Eligibility document to receive temporary covered Medi-Cal services such as, doctor visits, hospital care, and some prescription drugs.  The customer must present the HPER card to a Medi-Cal provider for services rendered during the HPE eligibility period.  The customer will only receive a BIC if they apply and are determined eligible for Medi-Cal benefits.

Note:  Below is a sample of the HPER card the hospital issues.