Wash. Admin. Code § 182-505-0300

Current through Register Vol. 24-23, December 1, 2024

Section 182-505-0300 - Hospital presumptive eligibility

(1)Purpose. The hospital presumptive eligibility (HPE) program provides temporary Washington apple health coverage to HPE-eligible persons who enroll through an HPE-qualified hospital.

(2)HPE-eligible persons. To be HPE-eligible:

(a) A person must:

(i) Be younger than age 65; and

(ii) Meet the eligibility requirements for one or more of the following programs:

(A) Washington apple health for pregnant women (chapter 182-505 WAC);

(B) Washington apple health for kids (chapter 182-505 WAC);

(C) Washington apple health for foster care (chapter 182-505 WAC);

(D) Washington apple health for parents and caretaker relatives (chapter 182-505 WAC);

(E) Washington apple health for adults (chapter 182-505 WAC); or

(F) Family planning only services (chapter 182-532 WAC).

(b) A person must not:

(i) Be an apple health beneficiary;

(ii) Be a supplemental security income beneficiary; or

(iii) Have received HPE coverage within the preceding 24 months.

(3)HPE-qualified hospitals. To be HPE-qualified, a hospital must:

(a) Operate in Washington state;

(b) Submit a signed core provider agreement (CPA) to the agency;

(c) Submit a signed HPE agreement to the agency;

(d) Comply with the terms of the CPA and HPE agreements;

(e) Determine HPE eligibility using only those employees who have successfully completed the agency's HPE training;

(f) Agree to provide HPE-application assistance to anyone who requests it; and

(g) Agree to be listed on the agency's website as an HPE-application assistance provider.

(4)Limitations.

(a) An HPE-qualified hospital must attempt to help the person complete a regular apple health application before filing an HPE application. If the person cannot indicate whether they expect to file a federal tax return or be claimed as a tax dependent, the HPE-qualified hospital may treat the person as a nonfiler under WAC 182-506-0010(5)(c) for HPE purposes.

(b) HPE coverage begins on the earlier of:

(i) The day the HPE-qualified hospital determines the person is eligible; or

(ii) The day the HPE-qualified hospital provides a covered medical service to the person, but only if the hospital determines the person is eligible and submits the decision to the agency no later than five calendar days after the date of service.

(c) HPE coverage ends on the earlier of:

(i) The last day of the month following the month in which HPE coverage began; or

(ii) The day the agency determines the person is eligible for other apple health coverage.

(d) HPE coverage does not qualify a person for continuous eligibility under WAC 182-504-0015.

(e) If HPE coverage is based on pregnancy, the pregnant person is eligible for HPE coverage only once for that pregnancy.

(f) The HPE program covers only those services included in the programs listed in subsection (2)(e) of this section, except that pregnancy-related services are limited to ambulatory prenatal care.

(g) A child born to a person with HPE coverage is ineligible for apple health under WAC 182-505-0210(2). An HPE-qualified hospital must complete a separate HPE determination for the newborn child.

Wash. Admin. Code § 182-505-0300

Adopted by WSR 15-06-039, Filed 2/26/2015, effective 3/29/2015

Amended by WSR 17-12-018, Filed 5/30/2017, effective 6/30/2017

Amended by WSR 23-11-007, Filed 5/4/2023, effective 6/4/2023