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Hospital Based Presumptive Eligibility
Frequently Asked Questions

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How to Handle Transfers between hospitals

Q. What happens if a person is determined presumptively eligible in West Virginia and then is transferred to a hospital out of the state?

A. As long as the hospital is a contracted Medicaid hospital, the member will still be covered.

Q. Can patients transferred to a hospital from Mildred Bateman or Sharpe hospital be eligible for presumptive Medicaid determination?

A. Yes they may be. BMS encourages acute care hospitals that regularly get these types of transfers to enter into an agreement with Mildred Bateman and/or Sharpe about who is responsible for completing the full Medicaid application.

HBPE for Incarcerated Individuals

Q. Are the authorized hospital employees responsible for determining incarcerated indivduals presumptively eligible?

A. No, as of May 21, 2014.  The prison will complete all Medicaid applications for incarcerated individuals when they return to the prison.

Eligibility Guidelines

Q. Is the income amount on the HBPE application gross income?

A. Yes, the income amount is gross and will be updated on the application prior to January.

Q. Can authorized hospital employees ask additional clarifying questions to assist the applicant in determining income or the number of individuals in their household?

A.Yes, you may want to clarify the types of income that is countable and what is not countable.Non countable income includes Temporary Assistance to Needy Families (TANF) and other government case assistance, Supplemental Security Income (SSI), child support, veterans benefits, worker’s compensation payments, proceeds from life insurance, accident insurance or health insurance, federal tax credits and federal income tax refunds, gifts and loans, and inheritances.  

You may also want to clarify that a household includes members of the immediate family who lives with the patient such as spouse, children (including stepchildren and adopted) but does not include other relatives or friends.

Q. If a patient is a member of one of the presumptive eligibility groups (pregnant women, former WV foster children under age 26 or has breast and cervical cancer but has an income in excess of the federal poverty guidelines for their household size will they still be considered presumptively eligible?

A. For pregnant women the summary chart in the WV inRoads presumptive eligibility portal will show if they are within the allowable income range.  If the summary screen shows their income is not within guidelines you will probably make a decision not to make them presumptively eligible.

Former WV foster children under the age of 26 are eligible for presumptive eligibility despite income level.

Women who are in the Breast and Cervical Cancer who are part of the Centers for Disease Control program administered by the Office of Maternal, Child and Family Health are eligible despite income level. If you have a woman who comes in that is part of that program or has applied I would determine her eligible. If a woman comes in with both of these cancers is not part of this program you can determine her eligible and refer her to the program. The referral to the program will keep you from having a negative impact on your numbers.

Q. The training states that HBPE should only be offered to individuals who do not have any other health care coverage and are WV Residents, AND are a member of one or more of the eligible groups. But, the training also states that we should not ignore patients that already have Medicare and that AHE’s should go ahead with the PE determination. Is this the case? If so, do we go ahead with PE with Medicare patients and what about patients with commercial insurance?

A. People may have insurance and still qualify for Medicaid if they fall into the right groups and income levels. If someone within the eligibility group indicates that they have insurance but it won't cover their care you can do a PE on them.

Q. I was under the understanding that a “flat” FPL percentage of 138%, discount included, was used for all income groups. has percentages that vary across the individual groups. Which numbers do we use?

A. The system is programmed with the correct numbers for all of the groups so you do not need to worry about that. Some groups, for example pregnant women and children, can have an income greater than 138% of FPL and still be eligible for Medicaid.

HBPE services and locations

Q. Can hospital presumptive eligibility be used for outpatient services or only inpatient?

A. Presumptive eligibility may be used for both outpatient and inpatient services; expect for incarcerated individuals must be an inpatient for 24 hours before a presumptive eligibility determination is made.

Q. Can we select the specific types of patients in which to determine presumptive eligibility, such as those patients being seen in the emergency room and walk in self pays that don’t require authorizations?

A. Yes you may

Q. Can a hospital do presumptive eligibility determinations for patients in a continuous care center?

A. No.

When to bill for HBPE services

Q. In the case of a car accident, hospital employees are asked to wait 60 days before billing for services.  Is this still the case with hospital based presumptive eligibility?

A. No. The patient will be covered immediately and the hospital may bill immediately.

Q. Can we backdate hospital presumptive eligibility coverage 24 hours? This would cover instances where the individual comes in goes into surgery immediately late at night and is not determined PE until early the next morning.

A. You can now backdate a HBPE 24 hours.


Q. Can authorized hospital employees print out the Privacy Practice for the Medicaid application and give it to the patient for reference rather than reading it aloud?

A. Yes, printing the Privacy Practice and giving it to the patient is an acceptable substitute to reading it aloud. However, AHEs must do one or the other.

Q.  If an individual has applied for Medicaid at the Federally-Facilitated Marketplace (or and has not yet received a determination from the State; can authorized hospital employees help the individual apply for presumptive eligibility?

A. Yes.  If the individual is not a current member of Medicaid and has not been determined presumptive eligibility in the past 12 months, they can apply for hospital based presumptive eligibility.

Q. If no one is at the hospital that can make a presumptively eligible decision, for example over the weekend or in the evening, would I still do a presumptive eligibility determination or can I just do the full application?

A. You may do the full application at any time.

Q. If a person is found ineligible for PE, is there a way to enter the full application so a client can obtain a denial letter (for our charity program) and that way they will automatically get referred to the Market Place since health care coverage is mandatory as of 1/1/2014?

A. Just because they are not determined PE does not prevent them from doing a full Medicaid application.

Q. We have clinics that are Hospital Based Clinics owned by the hospital, can we still do PE with them?

A. If they are inside the hospital you can still do PE.

Q. Authorized Representative (AR) is an individual who has been authorized under West Virginia State Law to authorize the determination of medical care or to elect or revoke the election of hospice on behalf of a terminally ill individual who is mentally or physically incapacitated. Is a spouse/close family member an automatic authorized representative? Does the AR, have to present proof from the State as being an AR? Are we supposed to rely on self-attestation for this as well?

A. A spouse, parent, legal guardian or representative can be an authorized representative.  The AR does not have to present proof to the state that they are an AR. You do rely on self-attestation and you may ask the patient if he/she is capable of answering.

Q. When we submit the full Medicaid Application, does that count as “finished”? As far as the performance measures are concerned, do we need to continue with any and all follow-up questions and fix all of those for the process to be considered completed and not to count negatively against us?

A. Your responsibility for that application ends when you push the submit button on the full Medicaid application.

Q.Where is the referral program for the Breast and Cervical Cancer located on the dashboard?

A. It is under Learn More About.

Q. Is there a number that we can call to verify if the patient already has WV Medicaid, or that the process of obtaining WV Medicaid has already started?

A. In order to determine if someone already has Medicaid you need to call Molina at 1-888-483-0793. To determine if someone is in the process of getting WV Medicaid you need to contact the local DHHR office. 

Q. When I try to get a precertification/prior authorization for services for a PE member I am told that the person is not a member. What should I do?

A. It takes anywhere from 24 to 72 hours to get the person into the system so you will need to ask for a courtesy review. If you are unfamiliar with this process, contact APS Health Care at 304-343-9663.


Q. What are some common administrative denial examples?

A. Someone you know has been determined PE in the last 12 months even if they say they haven’t.  Based on your experience with the person you expect they are not being truthful with you.

Q. Is the patient denied PE if that individual is not a US citizen regardless of WV residency?

A. In order to be determined presumptively eligible a patient must be a US citizens or a qualified alien.  An eligible (qualified) alien is one who is:

  • An alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act (INA) and was admitted before August 22, 1996;
  • An alien who is granted asylum under section 208-INA eligible for 7 years from entry to United States;
  • A refugee who is admitted to the United States under section 207-INA including immigrants who have been certified by the U.S. Department of Health and Human Services to be victims of a severe form of trafficking in persons in accordance with the victims of Trafficking and Violence Protection Act of 2000 (P.L.106-386) eligible for 5 years from entry to United States;
  • An alien who is paroled into the United States under section 212(d)(5) of INA for a period of at least 1 year, eligible for 7 years from date of status;
  • An alien whose deportation is being withheld under section 243(h) of INA eligible for 7 years from date of status;
  • An alien who is granted conditional entry pursuant to section 203(a)(7) and section 274a.12(a)(3) of INA, eligible for 7 years from entry;
  • Pregnant women and children 18 and under who are lawfully admitted for permanent residence.
  • Amerasian immigrant under 584 of FOEFRPAA 1988 entered the United States within last 5 years (participation limited to 7 years from entry into the United States;
  • Is a Cuban or Haitian entrant under section 501(e) of REAA 1980 and entered the United States within last 5 years, participation limited to 7 years from entry;
  • Honorably discharged veterans, their spouses, and unmarried dependent children;
  • An alien who is active duty in the United States Armed Forces, other than duty for training, their spouses, and unmarried dependent children;
  • An alien who is lawfully admitted to the United States on or after August 22, 1996 and has been a qualified alien for more than 5 years.
  • An alien who is a battered spouse or battered child of/or is a veteran or on active duty in the United States Armed Forces, or spouse or unmarried dependent child of the veteran or person on active duty. The non-abusive parent of a battered child may also be eligible. Likewise, a child of a battered parent may be eligible.
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