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TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Final Rule
LSA Document #13-497(F)

DIGEST

Amends 405 IAC 1-1.5-1 to add presumptive eligibility determinations to the list of appealable actions. Adds 405 IAC 2-3.3 to allow hospitals to make presumptive eligibility determinations and include criteria for monitoring and sanctioning nonperforming hospitals. Effective 30 days after filing with the Publisher.



SECTION 1. 405 IAC 1-1.5-1 IS AMENDED TO READ AS FOLLOWS:

405 IAC 1-1.5-1 Scope

Authority: IC 12-15-21
Affected: IC 4-21.5-3

Sec. 1. (a) This rule governs the procedures for appeals to the office of Medicaid policy and planning (office) involving actions or determinations of reimbursement for all Medicaid providers.

(b) This rule governs the procedures for appeals to the office from the following actions or determinations:
(1) Setting rates of reimbursement.
(2) Any action based upon a final audit.
(3) Determination of change of provider status for purposes of setting a rate of reimbursement.
(4) Determination by the office that an overpayment to a provider has been made due to a year-end cost settlement.
(5) Any other determination by the office that a provider has been paid more than it was entitled to receive under any federal or state statute or regulation.
(6) The office's refusal to enter into a provider agreement.
(7) The office's suspension, termination, or refusal to renew an existing provider agreement.
(8) The office's revocation of a qualified hospital's presumptive eligibility provider status under 405 IAC 2-3.3-3.

(c) Notwithstanding subsections (a) and (b), this rule does not govern determinations by the office or its contractor with respect to the authorization or approval of Medicaid services requested by a provider on behalf of a recipient.

(d) Disputes relating to claims submitted to a managed care organization (MCO) by providers who are not under contract to the MCO, and who provide services to recipients in the risk-based managed care program are governed by 405 IAC 1-1.6.
(Office of the Secretary of Family and Social Services; 405 IAC 1-1.5-1; filed Oct 31, 1994, 3:30 p.m.: 18 IR 862; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Nov 10, 2004, 3:15 p.m.: 28 IR 815; errata filed Nov 15, 2004, 10:20 a.m.: 28 IR 970; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)


SECTION 2. 405 IAC 2-3.3 IS ADDED TO READ AS FOLLOWS:

Rule 3.3. Presumptive Eligibility Determinations by Qualified Hospitals


405 IAC 2-3.3-1 Definitions

Authority: IC 12-15-2.3-12; IC 12-15-21

Sec. 1. The following definitions apply throughout this rule:
(1) "Applicant" means an individual who has been determined presumptively eligible for Medicaid and has submitted an application.
(2) "Application" means an Indiana application for health coverage.
(3) "Office" refers to the office of the secretary of family and social services administration and its offices, divisions, or designee.
(4) "Presumptive eligibility period" means the period that begins on the day on which a qualified hospital makes a presumptive eligibility determination and ends on the earlier of the following:
(A) In the case of an applicant, the day that a decision is made on the application.
(B) In the case of a presumptively eligible individual, the last day of the month following the month in which a qualified hospital determined the individual to be presumptively eligible.
(C) In the case of an individual eligible under 405 IAC 10-4-1(a), the periods, as applicable, in accordance with 405 IAC 10-4-11(c) through 405 IAC 10-4-11(e).
(5) "Presumptively eligible individual" refers to a person who has been determined presumptively eligible by a qualified hospital but has not yet attained full Medicaid eligibility.
(6) "Qualified hospital" means a hospital that meets all of the following criteria:
(A) Participates as a Medicaid or waiver provider.
(B) Notifies the office of its intention to make presumptive eligibility determinations under this rule.
(C) Agrees to make presumptive eligibility determinations in accordance with applicable laws and policies.
(D) Agrees to assist an applicant or individual in completing and submitting an application during the presumptive eligibility period.
(E) Is not disqualified in accordance with section 3 of this rule.
(7) "Sufficiently complete" means an application that includes, at a minimum, an applicant's:
(A) name;
(B) date of birth;
(C) Social Security number;
(D) marital status;
(E) citizenship status;
(F) pregnancy status;
(G) presumptive eligibility recipient identification number;
(H) income;
(I) home address;
(J) mailing address;
(K) phone number;
(L) number of members in family; and
(M) signature.
(Office of the Secretary of Family and Social Services; 405 IAC 2-3.3-1; filed Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)


405 IAC 2-3.3-2 Presumptive eligibility determinations

Authority: IC 12-15-2.3-12; IC 12-15-21

Sec. 2. The office shall provide reimbursement for covered services during the presumptive eligibility period to an individual who is determined by a qualified hospital, on the basis of preliminary information, to be presumptively eligible.
(Office of the Secretary of Family and Social Services; 405 IAC 2-3.3-2; filed Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)


405 IAC 2-3.3-3 Presumptive eligibility performance standards and sanctions

Authority: IC 12-15-2.3-12; IC 12-15-21
Affected: IC 12-15-2.3

Sec. 3. (a) A qualified hospital shall meet the following performance standards with regard to an applicant's application during the following time periods in order to make presumptive eligibility determinations:
(1) Between the effective date of this rule and December 31, 2015, as follows:
(A) Eighty percent (80%) of presumptively eligible individuals from a qualified hospital shall complete and submit an application before the end of the presumptive eligibility period.
(B) Seventy-five percent (75%) of applications submitted for applicants will be sufficiently complete.
(C) Ninety percent (90%) of the applicants who complete and submit an application shall be determined eligible for a Medicaid program.
(2) Beginning January 1, 2016, as follows:
(A) Ninety-five percent (95%) of presumptively eligible individuals from a qualified hospital shall complete and submit an application before the end of the presumptive eligibility period.
(B) Ninety percent (90%) of applications submitted for applicants will be sufficiently complete.
(C) Ninety-five percent (95%) of the applicants who complete and submit an application shall be determined eligible for a Medicaid program.

(b) The office shall periodically review a qualified hospital's application submissions and assess its performance. The office shall initiate the following actions if its review of a qualified hospital's performance indicates it fails to meet the performance standards in subsection (a) during any given calendar quarter:
(1) The office shall issue a written warning to the qualified hospital and require the qualified hospital to submit a ninety (90) day corrective action plan within thirty (30) days of its receipt of the written warning if:
(A) it is the qualified hospital's first offense; or
(B) eighteen (18) months or more have passed since the occurrence of a first or subsequent offense.
(2) If a second offense occurs within eighteen (18) months of the date of a first or subsequent offense, the office will revoke the qualified hospital's presumptive eligibility status for a period of one (1) year.
(3) If a third or subsequent offense occurs within eighteen (18) months of the date of the second or subsequent offense, the office will revoke the qualified hospital's presumptive eligibility status for a period of three (3) years.

(c) The office shall revoke a qualified hospital's status for two (2) years if it fails to comply with one (1) or more of the terms of a corrective action plan during the period of the corrective action plan.

(d) Subject to subsection (e), a hospital whose presumptive eligibility status has been revoked under this section may reapply for reinstatement of its presumptive eligibility status only after the sanction period has passed.

(e) The office may consider a hospital's written request for reinstatement of its presumptive eligibility status prior to the passing of the sanction period. The office may consider lifting the sanction if the hospital demonstrates one (1) or more of the following circumstances:
(1) The hospital has experienced a change of ownership.
(2) The hospital has provided adequate assurances that it is sufficiently capable of preventing the issues that resulted in the office's decision to revoke its presumptive eligibility status.
(3) A sufficient amount of time passed between the cited offense and a prior offense.
(4) The office determines that lifting the sanction is in the best interests of the Medicaid program.

(f) A qualified hospital may be referred to the office's program integrity division or the Indiana Medicaid fraud control unit for appropriate action if the office's review suggests potential fraud, waste, or abuse.
(Office of the Secretary of Family and Social Services; 405 IAC 2-3.3-3; filed Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)


405 IAC 2-3.3-4 Administrative appeals

Authority: IC 12-15-2.3-12; IC 12-15-21
Affected: IC 4-21.5-3

Sec. 4. (a) A qualified hospital may appeal the office's revocation of its presumptive eligibility status under the provisions of 405 IAC 1-1.5.

(b) The following actions are not sanctions and are not appealable:
(1) The office's decision to issue a warning to a qualified hospital and to require a corrective action plan.
(2) The office's decision not to exercise its discretion to lift a hospital's request for reinstatement under section 3(e) of this rule.
(Office of the Secretary of Family and Social Services; 405 IAC 2-3.3-4; filed Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)


LSA Document #13-497(F)
Notice of Intent: 20131106-IR-405130497NIA
Proposed Rule: 20150805-IR-405130497PRA
Hearing Held: August 27, 2015
Approved by Attorney General: August 31, 2015
Approved by Governor: September 8, 2015
Filed with Publisher: September 14, 2015, 2:07 p.m.
Documents Incorporated by Reference: None Received by Publisher
Small Business Regulatory Coordinator: Jennifer Porter, FSSA Office of Medicaid Policy and Planning, Indiana Government Center South, 402 West Washington Street, Room W374, Indianapolis, IN 46204, (317) 234-0774, jennifer.porter@fssa.in.gov

Posted: 10/14/2015 by Legislative Services Agency

DIN: 20151014-IR-405130497FRA
Composed: Feb 02,2023 1:14:16PM EST
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