405 IAC 2-3.3-3 Presumptive eligibility performance standards and sanctions

Sec. 3. (a) A qualified hospital shall meet the following performance standards with regard to an applicant's application during the following time periods in order to make presumptive eligibility determinations: (1) Between the effective date of this rule and December 31, 2015, as follows: (A) Eighty percent (80%) of presumptively eligible individuals from a qualified hospital shall complete and submit an application before the end of the presumptive eligibility period. (B) Seventy-five percent (75%) of applications submitted for applicants will be sufficiently complete. (C) Ninety percent (90%) of the applicants who complete and submit an application shall be determined eligible for a Medicaid program. (2) Beginning January 1, 2016, as follows: (A) Ninety-five percent (95%) of presumptively eligible individuals from a qualified hospital shall complete and submit an application before the end of the presumptive eligibility period. (B) Ninety percent (90%) of applications submitted for applicants will be sufficiently complete. (C) Ninety-five percent (95%) of the applicants who complete and submit an application shall be determined eligible for a Medicaid program. (b) The office shall periodically review a qualified hospital's application submissions and assess its performance. The office shall initiate the following actions if its review of a qualified hospital's performance indicates it fails to meet the performance standards in subsection (a) during any given calendar quarter: (1) The office shall issue a written warning to the qualified hospital and require the qualified hospital to submit a ninety (90) day corrective action plan within thirty (30) days of its receipt of the written warning if: (A) it is the qualified hospital's first offense; or (B) eighteen (18) months or more have passed since the occurrence of a first or subsequent offense. (2) If a second offense occurs within eighteen (18) months of the date of a first or subsequent offense, the office will revoke the qualified hospital's presumptive eligibility status for a period of one (1) year. (3) If a third or subsequent offense occurs within eighteen (18) months of the date of the second or subsequent offense, the office will revoke the qualified hospital's presumptive eligibility status for a period of three (3) years. (c) The office shall revoke a qualified hospital's status for two (2) years if it fails to comply with one (1) or more of the terms of a corrective action plan during the period of the corrective action plan. (d) Subject to subsection (e), a hospital whose presumptive eligibility status has been revoked under this section may reapply for reinstatement of its presumptive eligibility status only after the sanction period has passed. (e) The office may consider a hospital's written request for reinstatement of its presumptive eligibility status prior to the passing of the sanction period. The office may consider lifting the sanction if the hospital demonstrates one (1) or more of the following circumstances: (1) The hospital has experienced a change of ownership. (2) The hospital has provided adequate assurances that it is sufficiently capable of preventing the issues that resulted in the office's decision to revoke its presumptive eligibility status. (3) A sufficient amount of time passed between the cited offense and a prior offense. (4) The office determines that lifting the sanction is in the best interests of the Medicaid program. (f) A qualified hospital may be referred to the office's program integrity division or the Indiana Medicaid fraud control unit for appropriate action if the office's review suggests potential fraud, waste, or abuse.