N.D. Admin. Code 75-02-02.1-24.4

Current through Supplement No. 395, January, 2025

Section 75-02-02.1-24.4 - Hospital presumptive eligibility

1. For purposes of this section, "qualified hospital" means a hospital or hospital-owned physician practice or clinic that:

a. Is a Medicaid provider;

b. Notifies the department of its election to make presumptive eligibility determinations; and

c. Has been approved by the department to make presumptive eligibility determinations under this section.

2. The department may provide Medicaid benefits during a period of presumptive eligibility, prior to a determination of Medicaid eligibility, to the following individuals:

a. Children through the month they turn nineteen years of age;

b. Former foster care children through the month they turn twenty-six years of age, who were enrolled in Medicaid and were in foster care when they turned eighteen years old;

c. Parents and caretaker relatives of children through the month the children turn nineteen years of age;

d. Pregnant women; and

e. Medicaid expansion group ages nineteen through sixty-four, from the month following the month they turn nineteen years of age through the month prior to the month they turn sixty-five years of age.

3. An applicant shall apply for presumptive eligibility coverage at a qualified hospital. Applicants do not need to be hospitalized. Presumptive eligibility determinations may be made only by qualified hospital employees who are trained and certified to determine presumptive eligibility.

4. The application for presumptive eligibility must be signed by the applicant, an authorized representative, or if the applicant is incompetent or incapacitated and has not designated an authorized representative, someone acting responsibly for the applicant.

5. The presumptive eligibility determination is based on the information reported by the applicant and verification is not required. The applicant shall provide all information the qualified hospital needs to determine presumptive eligibility.

6. Applicants shall attest to each of the following for each household member requesting presumptive eligibility:

a. United States citizen, United States national, or eligible immigrant status;

b. North Dakota residency;

c. Gross income amount;

d. Whether or not the applicant is currently enrolled in Medicaid; and

e. That the applicant does not have any other health insurance coverage that meets minimum essential coverage, as defined in section 5000A(f) of subtitle D of the Internal Revenue Code, as added by section 1401 of the Affordable Care Act, and implementing regulations.

7. MAGI-based methodology must be used to determine presumptive eligibility.

8. The presumptive eligibility period begins on the day the presumptive eligibility determination is made and ends the earlier of:

a. If a Medicaid application has been submitted, the day on which a decision is made on that application; or

b. If a Medicaid application has not been submitted, the last day of the month following the month the presumptive eligibility determination was made.

9. Individuals, excluding pregnant women, are eligible for one period of presumptive eligibility per calendar year. Pregnant women are eligible for presumptive eligibility coverage once per pregnancy.

10. Presumptive eligibility coverage does not include the three-month prior period.

11. An individual may not appeal presumptive eligibility determinations.

12. Qualified hospitals shall:

a. Make presumptive eligibility determinations for applicants without Medicaid or other health care coverage;

b. Assure timely access to care while the presumptive eligibility determination is being made;

c. Ensure all employees assisting in and completing presumptive eligibility determinations follow department regulations and policies for presumptive eligibility determinations;

d. Provide the applicant with notice of the presumptive eligibility determination;

e. Inform applicants at the time of the presumptive eligibility determination that applicants must submit an application for Medicaid to obtain Medicaid coverage beyond the presumptive eligibility period;

f. Assist applicants in completing and submitting an application for Medicaid and children's health insurance program or subsidized insurance through the federally facilitated marketplace;

g. Meet the performance standards as set forth in subsection 13;

h. Ensure all employees assisting in and completing presumptive eligibility applications and determinations attend all presumptive eligibility policy training provided by the department and stay current with changes, including the following:

(1) Participate in all in person, telephone conference, webinar, and computer-based presumptive eligibility training sessions; and

(2) Read all information provided regarding updates and changes to presumptive eligibility policies and regulations; and

i. Provide verification to the department upon request that all employees assisting in and completing presumptive eligibility applications and determinations have completed the training set forth in subdivision h.

13. Qualified hospitals shall meet the following performance standards:

a. Ninety-five percent of applicants are not enrolled in Medicaid at the time the presumptive eligibility determination is made;

b. Ninety percent of applicants determined presumptively eligible by the qualified hospital submit a Medicaid application during the presumptive eligibility period; and

c. Eighty-five percent of applicants that are determined presumptively eligible and submit a Medicaid application during the presumptive eligibility period are determined eligible for Medicaid.

14. Qualified hospitals that do not meet the performance standards set forth in subsection 13 for three consecutive months are required to participate in additional training or other reasonable corrective action measures, or both, provided by the department. If the qualified hospital continues to fail to meet the performance standards for an additional two consecutive months after the training or other corrective action measures, the department will disqualify the qualified hospital.

N.D. Admin Code 75-02-02.1-24.4

Adopted by Administrative Rules Supplement 2016-361, July 2016, effective 7/1/2016.

Amended by Administrative Rules Supplement 2022-387, January 2023, effective 1/1/2023.

General Authority: NDCC 50-06-16, 50-24.1-04

Law Implemented: NDCC 50-24.1-37; 42 U.S.C. 1396 a(e)