This Memorandum of Understanding (“MOU”) is effective as of _____ (date signed by HHSC) between the State of Texas Health and Human Services Commission (“HHSC”) and [Hospital name] (“Hospital”). It shall remain in effect unless terminated in accordance with the policies and procedures outlined in Sections IV and V.
I. Introduction and Purpose
Under Section 2202 of the Patient Protection and Affordable Care Act of 2010 and
Federal regulations at 42 CFR 435.1110, qualified hospitals may determine certain individuals presumptively eligible (“PE”) for Medicaid,
subject to federal and state requirements. By conducting PE determinations in accordance with this provision, the hospital can assist eligible
individuals in securing temporary Medicaid coverage on a timely basis and facilitating enrollment in ongoing coverage.
When conducting PE determinations, the Hospital will evaluate an individual's eligibility using
financial and non-financial eligibility criteria established by HHSC for the following Medicaid categories: children, parents and caretaker relatives,
pregnant women, and individuals under age 26 who were in foster care at age 18 or older.
The purpose of this MOU is to set forth the roles, responsibilities, and other terms for the Hospital
to conduct Medicaid PE determinations and facilitate enrollment in ongoing coverage, as well as HHSC’s roles and responsibilities in supporting and overseeing these activities.
II. HHSC Responsibilities
In general, HHSC will support the Hospital in conducting PE determinations by providing training, oversight, and approving
corrective action measures where relevant. HHSC will provide PE Medicaid coverage to individuals based on the Hospital’s proper determinations of presumptive eligibility as long
as they were conducted in accordance with HHSC policies and procedures. HHSC will not hold the Hospital financially responsible if an individual is found ineligible for Medicaid
based on a full eligibility determination.
A. TRAINING AND ASSISTANCE
HHSC will provide initial and ongoing training and technical assistance to the Hospital,
including responding to the Hospital’s questions regarding the appropriate policies and procedures to use when conducting PE determinations.
B. PERFORMANCE STANDARDS AND OVERSIGHT
In accordance with federal regulations at 42 CFR § 435.1110(d), HHSC has adopted the following performance standards for PE determinations which the Hospital must meet:
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95% of individuals who are determined presumptively eligible by qualified Hospitals submit a regular application.
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95% of presumptive eligibility determinations by qualified Hospitals and corresponding regular Medicaid applications are electronically submitted within one working day.
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100% of presumptive eligibility determinations by qualified Hospitals and corresponding regular Medicaid applications are electronically submitted within five working days.
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97% of individuals are determined presumptively eligible by a qualified Hospital are determined eligible for Medicaid based on the submission of a regular application for Medicaid.
If the Hospital fails to meet HHSC’s performance standards, HHSC may:
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notify the Hospital;
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provide the Hospital additional training;
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provide technical assistance to the Hospital in developing and implementing a corrective action plan, and provide approval of the corrective action plan;
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provide the timeline within which the Hospital must achieve improved results that meet HHSC’s performance standards; or
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Terminate this MOU.
HHSC will evaluate Hospital compliance with HHSC’s performance standards using automated reports at regular intervals.
Hospitals will be notified if they are not complying with HHSC’s performance standards.
C. HHSC SERVICES AND SUPPORT
HHSC will provide:
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the Hospital with the forms and access to IT systems required to conduct PE determinations;
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the Hospital with the policy and process for submitting PE determinations and applications for health care coverage to HHSC;
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an HHSC staff member that will serve as the point of contact for the Hospital and update the Hospital if the staff member changes.
III. Hospital Responsibilities
The Hospital will conduct PE determinations for Medicaid in accordance with all policies and procedures
provided by HHSC and in accordance with all applicable laws, rules, and regulations. All PE determinations are the responsibility of the Hospital, including
any assistance provided by contractors or vendors of the Hospital.
A. PROCEDURES FOR CONDUCTING PRESUMPTIVE ELIGIBILITY DETERMINATIONS
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The Hospital must have sufficient technology available to support staff completion of training,
the electronic submission of PE determinations, and the electronic submission of associated applications for regular Medicaid.
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The Hospital will not delegate the authority to make PE determinations to another entity.
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The Hospital will provide services without discrimination on the grounds of race, color,
national origin, age, sex, religion, or disability.
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The Hospital will comply and make PE determinations in accordance with all HHSC policies and procedures.
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The Hospital will keep current with changes affecting PE through provider bulletins, notices, and/or further training.
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The Hospital will provide a point of contact and update the HHSC designated staff member if the point of contact changes.
B. TRAINING
The Hospital will require all staff that conduct Medicaid PE determinations to successfully complete HHSC-provided training.
It will keep a record of this training for HHSC to review as requested. Upon HHSC request, the Hospital will provide the state with the name, title, and contact information for staff
that complete the training.
C. CONFIDENTIALITY OF INFORMATION
When conducting PE determinations, the Hospital will take all measures necessary to safeguard client and HHSC confidential
information and will comply with all state, federal, and HHSC rules and regulations regarding data privacy and security, including, without limitation, the Health Insurance Portability and
Accountability Act (HIPAA) and Medicaid confidentiality standards.
D. CONFLICTS OF INTEREST
All Hospital staff must avoid conflict of interests or the appearance of impropriety. Staff is not allowed to make presumptive eligibility determinations if the individual is a relative
(by blood or marriage), roommate, dating companion, co-worker, supervisor, friend, acquaintance, or volunteer or staff at the Hospital.
In cases with a potential conflict of interest, staff may provide the patient with a paper application and information about other options on how and where to apply for benefits.
E. DEVELOPING AND COMPLYING WITH PERFORMANCE STANDARDS
The Hospital will comply with the performance standards in II(B) of this MOU. If HHSC data indicates that the Hospital is not meeting HHSC’s
performance standards, the Hospital must:
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participate in additional training;
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develop and implement a corrective action plan, subject to HHSC approval;
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meet HHSC’s performance standards after implementation of its approved corrective action plan and within the timeline specified by HHSC; or
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adhere to any other reasonable request of HHSC to comply with the requirements of II(B) of this MOU of the PE Medicaid program.
IV. Potential for Disqualification
HHSC may disqualify the Hospital from conducting PE determinations if HHSC determines: 1) that the Hospital is not making, or is not capable of making,
proper PE determinations in accordance with federal and state law and regulations; 2) if the Hospital remains unable to meet the performance standards established by HHSC in section II (B) of this MOU; or
3) the Hospital no longer participates in Medicaid. There may be additional reasons that result in the disqualification of a Hospital.
If the Hospital is disqualified from making PE determinations,
it will not have any bearing on whether the Hospital can participate in Medicaid or on any agreements other than this
one between the Hospital and HHSC.
V. Termination of this Memorandum of Understanding
The Hospital may withdraw from conducting PE determinations and
terminate this Memorandum of Understanding upon 30 days written notice to HHSC.
HHSC may terminate this agreement with 30 days written notice if
HHSC disqualifies the Hospital from conducting PE determinations in accordance with Section IV. HHSC may immediately
terminate this MOU if, in its reasonable determination, HHSC determines that the Hospital is intentionally misrepresenting
program eligibility requirements; is negligent in determining eligibility; or is fraudulently submitting PE determinations
for the Hospital’s own financial gain or other purpose.
VI. Signatures
The terms of this MOU are not intended to alter, amend, or
rescind any provisions of federal or state law. Any provision of this MOU that conflicts with Federal or
state law will be null and void.
By entering your name below, you are signing this
form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.
Please provide an electronic signature on this document and submit. When HHSC has signed the MOU, a pdf version will be emailed for your records.
If you have questions about this MOU, please contact OSS_QHQE_PE@hhsc.state.tx.us.