Common use of Presumptive Eligibility- HIP Clause in Contracts

Presumptive Eligibility- HIP. Individuals determined presumptively eligible for HIP before 1/1/2019 in accordance with 42 CFR §435.1110 will be enrolled with an MCE for a presumptively eligible period, which begins on the day a qualified hospital, qualified provider or other authorized entity makes a determination that the individual is presumptively eligible. Individuals determined EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK presumptively eligible on 1/1/2019 and after, will be in the Fee for Service program During the member’s presumptively eligible period, the Contractor shall provide health benefits equivalent to the HIP Basic plan benefits, as described in Exhibit 6 of this Contract. The member will not be provided a POWER Account during the presumptively eligible period; however, the member will be subject to copayments for services as set forth in Section 4.1.2. The Contractor shall reduce reimbursement to providers for services rendered to a presumptively eligible member by the amount of the individual’s required copayment. The presumptive eligibility period will continue in accordance with the requirements in the HIP MCE Policies and Procedures Manual but should not be longer than (1) the last day of the month following the start of the presumptive eligibility period for individuals who do not file an application; (2) the day of the IHCP application denial for individuals that file an application but are not found eligible for coverage; or (3) for individuals that file an IHCP application and are found eligible for HIP the first day of the month following the determination of eligibility. Individuals determined presumptively eligible for HIP (Adult PE) will not have a break in coverage if they are found eligible for Medicaid through the IHCP application process. Once found eligible, presumptively eligible members will be enrolled in the applicable HIP Plan. This enrollment will coincide with the end of the presumptive eligibility period and begin the 1st day of the month following the end of the presumptive eligibility period. Presumptively eligible members who made a fast track payment during the standard fast track process will be enrolled in HIP Plus. Presumptively eligible members who have not made a fast track payment will be enrolled in HIP Basic and will have the opportunity to pay to move to HIP Plus as detailed below. Members who are determined eligible under the Adult PE eligibility category during their presumptively eligible period are moved to the HIP Basic category when their full IHCP application is approved:  Members transitioned from Adult PE who make a POWER Account payment within sixty (60) days from the date they filed their IHCP application, or their anchor date, will be enrolled in HIP Plus effective the first day of the month after payment is received.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame who have household income equal to or less than 100% of the federal poverty level (FPL), will stay enrolled in HIP Basic. These members are not eligible to buy in to HIP Plus until eligibility redetermination or the application of rollover.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame and who have household incomes greater than 100% FPL will be terminated from HIP effective at the end of the month, following required adverse action timelines. The Contractor shall comply with the policies and procedures set forth in HIP MCE Policies and Procedures Manual. The Contractor shall be required to comply with the requirements set forth in the document as of the effective date of the Contract.

Presumptive Eligibility- HIP. Individuals determined presumptively eligible for HIP before 1/1/2019 in accordance with 42 CFR §435.1110 will be enrolled with an MCE for a presumptively eligible period, which begins on the day a qualified hospital, qualified provider or other authorized entity makes a determination that the individual is presumptively eligible. Individuals determined EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK presumptively eligible on 1/1/2019 and after, will be in the Fee for Service program During the member’s presumptively eligible period, the Contractor shall provide health benefits equivalent to the HIP Basic plan benefits, as described in Exhibit 6 of this Contract. The member will not be provided a POWER Account during the presumptively eligible period; however, the member will be subject to copayments for services as set forth in Section 4.1.2. The Contractor shall reduce reimbursement to providers for services rendered to a presumptively eligible member by the amount of the individual’s required copayment. The presumptive eligibility period will continue in accordance with the requirements in the HIP MCE Policies and Procedures Manual but should not be longer than (1) the last day of the month following the start of the presumptive eligibility period for individuals who do not file an application; (2) the day of the IHCP application denial for individuals that file an application but are not found eligible for coverage; or (3) for individuals that file an IHCP application and are found eligible for HIP the first day of the month following the determination of eligibility. Individuals determined presumptively eligible for HIP (Adult PE) will not have a break in coverage if they are found eligible for Medicaid through the IHCP application process. Once found eligible, presumptively eligible members will be enrolled in the applicable HIP Plan. This enrollment will coincide with the end of the presumptive eligibility period and begin the 1st day of the month following the end of the presumptive eligibility period. Presumptively eligible members who made a fast track payment during the standard fast track process will be enrolled in HIP Plus. Presumptively eligible members who have not made a fast track payment will be enrolled in HIP Basic and will have the opportunity to pay to move to HIP Plus as detailed below. Members who are determined eligible under the Adult PE eligibility category during their presumptively eligible period are moved to the HIP Basic category when their full IHCP application is approved:  Members transitioned from Adult PE who make a POWER Account payment within sixty (60) days from the date they filed their IHCP application, or their anchor date, will be enrolled in HIP Plus effective the first day of the month after payment is received.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame who have household income equal to or less than 100% of the federal poverty level (FPL), will stay enrolled in HIP Basic. These members are not eligible to buy in to HIP Plus until eligibility redetermination or the application of rollover.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame and who have household incomes greater than 100% FPL will be terminated from HIP effective at the end of the month, following required adverse action timelines. The Contractor shall comply with the policies and procedures set forth in HIP MCE Policies and Procedures Manual. The Contractor shall be required to comply with the requirements set forth in the document as of the effective date of the Contract.

Presumptive Eligibility- HIP. Individuals determined presumptively eligible for HIP before 1/1/2019 in accordance with 42 CFR §435.1110 will be enrolled with an MCE for a presumptively eligible period, which begins on the day a qualified hospital, qualified provider or other authorized entity makes a determination that the individual is presumptively eligible. Individuals determined EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK presumptively eligible on 1/1/2019 and after, will be in the Fee for Service program During the member’s presumptively eligible period, the Contractor shall provide health benefits equivalent to the HIP Basic plan benefits, as described in Exhibit 6 of this Contract. The member will not be provided a POWER Account during the presumptively eligible period; however, the member will be subject to copayments for services as set forth in Section 4.1.2. The Contractor shall reduce reimbursement to providers for services rendered to a presumptively eligible member by the amount of the individual’s required copayment. The presumptive eligibility period will continue in accordance with the requirements in the HIP MCE Policies and Procedures Manual but should not be longer than (1) the last day of the month following the start of the presumptive eligibility period for individuals who do not file an application; (2) the day of the IHCP application denial for individuals that file an application but are not found eligible for coverage; or (3) for individuals that file an IHCP application and are found eligible for HIP the first day of the month following the determination of eligibility. Individuals determined presumptively eligible for HIP (Adult PE) will not have a break in coverage if they are found eligible for Medicaid through the IHCP application process. Once found eligible, presumptively eligible members will be enrolled in the applicable HIP Plan. This enrollment will coincide with the end of the presumptive eligibility period and begin the 1st day of the month following the end of the presumptive eligibility period. Presumptively eligible members who made a fast track payment during the standard fast track process will be enrolled in HIP Plus. Presumptively eligible members who have not made a fast track payment will be enrolled in HIP Basic and will have the opportunity to pay to move to HIP Plus as detailed below. Members who are determined eligible under the Adult PE eligibility category during their presumptively eligible period are moved to the HIP Basic category when their full IHCP application is approved:  ▪ Members transitioned from Adult PE who make a POWER Account payment within sixty (60) days from the date they filed their IHCP application, or their anchor date, will be enrolled in HIP Plus effective the first day of the month after payment is received.  ▪ Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame who have household income equal to or less than 100% of the federal poverty level (FPL), will stay enrolled in HIP Basic. These members are not eligible to buy in to HIP Plus until eligibility redetermination or the application of rollover.  ▪ Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame and who have household incomes greater than 100% FPL will be terminated from HIP effective at the end of the month, following required adverse action timelines. The Contractor shall comply with the policies and procedures set forth in HIP MCE Policies and Procedures Manual. The Contractor shall be required to comply with the requirements set forth in the document as of the effective date of the Contract.

Presumptive Eligibility- HIP. Individuals determined presumptively eligible for HIP before 1/1/2019 in accordance with 42 CFR §435.1110 will be enrolled with an MCE for a presumptively eligible period, which begins on the day a qualified hospital, qualified provider or other authorized entity makes a determination that the individual is presumptively eligible. Individuals determined EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK The presumptively eligible on 1/1/2019 and after, applicant will be in able to select an MCE at the Fee for Service program time of the presumptive eligibility determination. If an applicant fails to select a MCE at the time of the presumptive eligibility determination, the State will auto-assign the applicant to an MCE according to the State’s auto-assignment methodology. During the member’s presumptively eligible period, the Contractor shall provide health benefits equivalent to the HIP Basic plan benefits, as described in Exhibit 6 of this Contract. The member will not be provided a POWER Account during the presumptively eligible period; , however, the member will be subject to copayments for services as set forth in Section 4.1.2. The Contractor shall reduce reimbursement to providers for services rendered to a presumptively eligible member by the amount of the individual’s required copayment. The Within one (1) business day of receiving the presumptively eligible file, the Contractor shall send an invoice to the presumptively eligible member for a ten dollar ($10.00) initial fast track POWER Account prepayment in accordance with Section 4.6.2. This initial “fast track” invoice shall notify the presumptively eligible member that the prepayment is an optional payment that is fully refundable if the individual is determined not to be eligible for HIP. Further, the initial fast track invoice shall also include a prominent notice stating in substance that the individual has the right to select another MCE before the first payment is made. Within ten (10) business days of receiving the presumptive eligibility period file, the Contractor shall have the member fully enrolled in all systems. The Contractor will provide the members the full array of Basic benefits, including dental for 19 and 20 year olds, and process prior authorization requests. The Contractor shall also conduct outreach to presumptively eligible members in order to encourage the member to complete the IHCP application within the member’s presumptive eligible period. The Contractor shall work with their authorized presumptive eligibility providers to ensure that presumptively eligible members are provided information at the time of the presumptive eligibility determination regarding the HIP program, the difference between HIP Plus and HIP Basic, and the importance of completing the IHCP application and of paying the initial ten dollar ($10.00) initial fast track POWER Account prepayment in order to maintain HIP benefits. Such education should also encourage members to include their unique presumptive eligibility RID number on their IHCP application. Within two (2) business days of receiving the presumptive eligibility file, the Contractor shall have the presumptively eligible member loaded into their system and be able to identify that member as being under their coverage. The Contractor must assure that within five (5) business days of receiving the presumptively eligible file, that member will be fully open in the pharmacy benefit manager system and able to receive services at a point of sale pharmacy with no manual intervention. The Presumptive Eligibility Period will continue in accordance with the requirements in the HIP MCE Policies and Procedures Manual but should not be longer than (1) the last day of the month following the start of the presumptive eligibility PE period for individuals who do not file an application; (2) the day of the IHCP application denial for individuals that file an application but are not found eligible for coverage; or (3) for individuals that file an IHCP application and are found eligible for HIP the first day of the month following the determination of eligibility. Individuals determined presumptively In the case of members who make a fast track POWER account prepayment to the Contractor during their presumptive eligibility period but who are not eligible for HIP (Adult PE) will not have a break in coverage if they HIP, the Contractor is responsible for refunding this payment to the member within 10 calendar days of the termination of the presumptive eligibility prepayment. For members that are found eligible for Medicaid through HIP and make a fast track POWER account prepayment the IHCP application processcontractor is to apply this payment in accordance with Section 4.6.2. Once found eligible, presumptively eligible members The Contractor will be enrolled in required to process all payments, notify the applicable HIP Plan. This enrollment will coincide with the end State of the receipt of payment, and reconcile any POWER Account overpayments or underpayments resulting from a fast track POWER Account prepayment received from a member during their presumptive eligibility period in accordance with the process and begin the 1st day of the month following the end of the presumptive eligibility period. Presumptively eligible members who made a fast track payment during the standard fast track process will be enrolled in HIP Plus. Presumptively eligible members who have not made a fast track payment will be enrolled in HIP Basic and will have the opportunity to pay to move to HIP Plus as detailed below. Members who are determined eligible under the Adult PE eligibility category during their presumptively eligible period are moved to the HIP Basic category when their full IHCP application is approved:  Members transitioned from Adult PE who make a POWER Account payment within sixty (60) days from the date they filed their IHCP application, or their anchor date, will be enrolled in HIP Plus effective the first day of the month after payment is received.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame who have household income equal to or less than 100% of the federal poverty level (FPL), will stay enrolled established in HIP Basic. These members are not eligible to buy in to HIP Plus until eligibility redetermination or the application of rollover.  Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame and who have household incomes greater than 100% FPL will be terminated from HIP effective at the end of the month, following required adverse action timelinesSection 4.6.2. The Contractor shall comply with the policies and procedures set forth in HIP MCE Policies and Procedures Manual. The Contractor shall be required to comply with the requirements set forth in the document as of the effective date of the Contract.

Presumptive Eligibility- HIP. Individuals determined presumptively eligible for HIP before 1/1/2019 in accordance with 42 CFR §435.1110 will be enrolled with an MCE for a presumptively eligible period, which begins on the day a qualified hospital, qualified provider or other authorized entity makes a determination that the individual is presumptively eligible. Individuals determined EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK presumptively eligible on 1/1/2019 and after, will be in the Fee for Service program During the member’s presumptively eligible period, the Contractor shall provide health benefits equivalent to the HIP Basic plan benefits, as described in Exhibit 6 of this Contract. The member will not be provided a POWER Account during the presumptively eligible period; however, the member will be subject to copayments for services as set forth in Section 4.1.2. The Contractor shall reduce reimbursement to providers for services rendered to a presumptively eligible member by the amount of the individual’s required copayment. The presumptive eligibility period will continue in accordance with the requirements in the HIP MCE Policies and Procedures Manual but should not be longer than (1) the last day of the month following the start of the presumptive eligibility period for individuals who do not file an application; (2) the day of the IHCP application denial for individuals that file an application but are not found eligible for coverage; or (3) for individuals that file an IHCP application and are found eligible for HIP the first day of the month following the determination of eligibility. Individuals determined presumptively eligible for HIP (Adult PE) will not have a break in coverage if they are found eligible for Medicaid through the IHCP application process. Once found eligible, presumptively eligible members will be enrolled in the applicable HIP Plan. This enrollment will coincide with the end of the presumptive eligibility period and begin the 1st day of the month following the end of the presumptive eligibility period. Presumptively eligible members who made a fast track payment during the standard fast track process will be enrolled in HIP Plus. Presumptively eligible members who have not made a fast track payment will be enrolled in HIP Basic and will have the opportunity to pay to move to HIP Plus as detailed below. Members who are determined eligible under the Adult PE eligibility category during their presumptively eligible period are moved to the HIP Basic category when their full IHCP application is approved:  ▪ Members transitioned from Adult PE who make a POWER Account payment within sixty (60) days from the date they filed their IHCP application, or their anchor date, will be enrolled in HIP Plus effective the first day of the month after payment is received.  ▪ Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame who have household income equal to or less than 100% of the federal poverty level (FPL), will stay enrolled in HIP Basic. These members are not eligible to buy in to HIP Plus until eligibility redetermination or the application of rollover.  ▪ Members transitioned from Adult PE who do not make a POWER Account payment in the 60-day time frame and who have household incomes greater than 100% FPL will be terminated from HIP effective at the end of the month, following required adverse action timelines. The Contractor shall comply with the policies and procedures set forth in HIP MCE Policies and Procedures Manual. The Contractor shall be required to comply with the requirements set forth in the document as of the effective date of the Contract.