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Oregon’s Hospital Presumptive Medical Eligibility Program

Oregon’s Hospital Presumptive Eligibility process

Learn how hospitals can help enroll people in the Oregon Health Plan.

Frequently asked questions

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Answer
Can any hospital in Oregon determine Hospital Presumptive Eligibility (HPE)?

​No. Only hospitals that have contacted the Oregon Health Authority (OHA), completed an application and signed an agreement with OHA to perform HPE determinations per OHA standards and rules may do so.​

Does the HPE process replace the OHP Hospital Hold process?

​No, HPE does not replace Hospital Hold.

There may be hospitals that do not participate in HPM that will continue to use Hospital Hold exclusively; and there may be an occasion when a Hospital may need to use Hospital Hold rather than HPE.

Will hospitals or providers be paid for services rendered during the HPE period even if a service is below the funding line on the Prioritized List?

​No. In order for a provider to be paid for a service rendered during the HPE period, the service must be a covered service under OHP.​

Is hospital presumptive eligibility (HPE) limited to patients only, or can hospitals make a PE decision for a person that walks into the hospital seeking assistance with enrollment?

Hospitals may make HPE determinations for a patient of the hospital or a community member, even if the individual has not used, and/or does not intend to use, hospital services.  


Can a HPE decision be made after the patient is discharged from the hospital (e.g., Emergency Department patients who come in overnight & discharge before regular business hours)?

​Yes, if the hospital submits the decision to OHA within 5 calendar days following the date of service. The date of service becomes the “Date of notice” on the Approval Notice, or proof of coverage, given to the patient.​

Can a HPE decision be backdated to a Date of Service within a certain time-frame (e.g., for recently discharged Emergency Department patients)?

Yes, if the hospital submits the decision to OHA within 5 calendar days following the date of service. This date becomes the “Date of notice” on the Approval Notice, or proof of coverage, given to the patient.

Is there a time frame under which the HPE form must be submitted by the hospital to OHP Customer Service?

​Yes, within 5 days of the HPE determination​.

Is an applicant’s, or applicant’s representative’s, signature required on the HPE application (OHP 7260)?

​A signature is highly preferable, but not absolutely required, for HPE.​

How long will it take for a hospital to get coverage info after the patient’s HPE paperwork has been faxed to OHP Customer Service?

​Hospitals or providers should check the Medicaid Management Information System (MMIS) within a week of submitting the required forms to determine if individuals are entered in MMIS as HPE-eligible clients.

Is the 5% MAGI disregard included for eligibility determination? (e.g. can patients with incomes between 133%-138% of the FPL be eligible for HPE?

​HPE determinations do not use the MAGI 5% disregard. They are based on straight household income.​

Can the individual have other health coverage (e.g., TPL or IHS) and still be HPE-eligible?

​Yes. As always, Medicaid would be the last payer if other insurance exists.​

When the person’s HPE eligibility has been approved, on what date does it take effect?

​HPE eligibility takes effect on the date the hospital makes the HPE eligibility decision. The HPM eligibility decision is an immediate determination so that the following all happens on the same date:

  • The HPE eligibility application (OHP 7260) is completed;
  • The hospital makes the eligibility determination;
  • The hospital gives the individual a notice of approval or denial.
This is generally prior to service delivery.
When and for whom are hospitals responsible for completing a Notice of Denial?

​All applicants who are denied HPE must receive a Notice of Denial, and all denials must be reported to OHP Customer Service within 5 working days of the denial.

If someone has a denial on file, will it exclude them from an HPE approval in the future, or can they simply re-apply at any time?

​A denied applicant may re-apply at any time.​

Are there any scenarios where HPE coverage would be terminated retroactively (for example, when a HPE decision is based on incorrect or incomplete information)?

​No, HPE will never be terminated retroactively. 

This is true even if OHP Customer Service later determines that the individual was not eligible based on information received by the hospital, or if the individual turns out to be ineligible for continued coverage (upon receipt of a completed Cover Oregon application).

 

Do hospitals have to help the HPE applicant complete the OHA 7210 (OHA/Cover Oregon application) for ongoing eligibility)?

Hospitals are only required to give the applicant the OHA 7210 and information on getting assistance with completing and submitting it (e.g., contact information for local Application Assisters).

However, ​since hospitals will be evaluated on the number of full applications completed by the individuals they approved for HPE, it is to their advantage to ensure the application is completed and submitted.


How does the hospital mark the OHA 7210 (OHA/Cover Oregon application) for ongoing coverage)?

When giving applicants the full 7210 application for ongoing coverage:

  • The hospital should clearly mark “Hospital Presumptive” at the top of the form for individuals approved for Hospital Presumptive coverage.
  • Individuals denied Hospital Presumptive coverage should get an unmarked 7210 application to comolete.
Does HPE cover all OHP services?

​HPM covers all services covered under OHP, including dental, vision and mental health, with one exception.

Exception:  Pregnant women are covered only for ambulatory care (all OHP-covered services) during the prenatal period. Labor and delivery are not covered. 

Are newborns born to HPE-eligible women considered Assumed Eligible Newborns (AEN)?

​No, these newborns are not deemed eligible. Only those born to mothers determined to be fully Medicaid-eligible are deemed AEN.

If the HPE-eligible pregnant woman has not been approved for full Medicaid eligibility by the time the newborn arrives, the hospital may make an HPE determination for the newborn.

Is retroactive coverage possible under the HPE decision process, or would the patient only have the possibility of retroactive coverage if they complete the full application?

​Retroactive coverage will only be available if the individual completes the full application and is determined eligible for Medicaid. Retroactive coverage will only be available for covered medical costs up to three months prior to the period of full eligibility.

Retroactive coverage does not apply to the HPE period.

Are HPE-eligible individuals entered as OHP open card for billing?

​Yes, HPE-eligible individuals will be fee-for-service (open card) and will not be enrolled into CCOs, or any managed care entity, until and unless determined fully eligible via a OHA 7210 application.​

Can an attendant/responsible party supply the information for a person?

​Yes.

Are hospital ancillary services covered for a hospital stay?

​Yes, all services provided by any enrolled OHP provider that are covered services under the person’s benefit package will be reimbursed.

Can hospitals pre-screen before actually starting the application?

Yes, to some extent. However, unless it is extremely clear that the individual would not be eligible, or does not wish to apply, everyone who comes in uninsured deserves the right to have an HPM application completed.

Can hospitals take the HPE application information over the phone?

This is not preferable, but allowable if the individual is indisposed and unavailable to apply in person. 


For more information about Hospital Presumptive Eligibility:

View the sources listed below. If you still have questions, email us at hpe.info@state.or.us.

Forms

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Description
OHP 7260 - PDF

​Application for Hospital Presumptive Eligibility

OHP 3263A - PDF

​Approval Notice for Hospital Presumptive Eligibility

OHP 3263B - PDF

​Denial Notice for Hospital Presumptive Eligibility

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Other Resources

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Hospital Presumptive Eligibility Roles and Responsibilities
Quick Guide to Income Eligibility for HPE Determinations
Webinar Slides - Hospital Presumptive Eligibility Process

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HPE announcements

  
  
Information about Hospital Presumptive Eligibility (HPE) for OHP pharmacies5/23/2014
Hospital Presumptive Eligibility (HPE) and Incarcerated Individuals4/25/2014
New Hospital Presumptive Eligibility process effective January 1, 20144/24/2014