§ 12-15-4-1.5 — Establishment of performance standards for hospitals concerning presumptive eligibility; requirements; standards; violations; notice; loss of qualification

Indiana § 12-15-4-1.5

• Jurisdiction: Indiana
• Art. 15: MEDICAID
• Ch. 4: Application for Assistance

Text

5. (a) The office of the secretary shall
establish the following:
(1) Performance standards for hospitals to use in making
presumptive eligibility determinations.
(2) An appeals process for a hospital that disputes a determination
that a presumptive eligibility standard was violated.
The office of the secretary shall limit presumptive eligibility
determination to qualified hospitals.
(b) A hospital shall do the following when making a presumptive
eligibility determination:
(1) Notify the office of the secretary of each presumptive
eligibility determination not later than five (5) business days after
the date of the determination.
(2) Assist individuals whom the hospital determines are
presumptively eligible with completing and submitting a full
Medicaid application.
(3) Notify the applicant in writing and on all relevant forms with
plain language and large print that if the applicant:
(A) does not file a full Medicaid application with the office of
the secretary before the last day of the following month,
presumptive eligibility will end on that last day; and
(B) files a full Medicaid application with the office of the
secretary before the last day of the following month,
presumptive eligibility will continue until an eligibility
determination is made concerning the application.
(c) The office of the secretary shall use the following performance
standards to establish and ensure accurate presumptive eligibility
determinations by a qualified hospital:
(1) Determine whether each presumptive eligibility determination
received from the hospital complied with the time requirement set
forth in subsection (b)(1).
(2) Determine whether the office of the secretary received before
the expiration of each presumptive eligibility period the full
application from the individual determined by the hospital to be
presumptively eligible.
(3) Determine whether each applicant who was determined by the
hospital to be presumptively eligible was determined to be
eligible for Medicaid after the full application was received.
(d) Each single violation by a hospital of any of the performance
standards under subsection (c) counts as one (1) violation for the
presumptive eligibility determination. Each subsequent violation of a
performance standard is an additional violation for purposes of this
section.
(e) For the first violation of a presumptive eligibility standard under
this section that a hospital receives in a calendar year, the office of the
secretary shall notify the hospital in writing not later than five (5) days
after the determination of a violation is made. The notice must include
the following:
(1) A description of the standard that was not met and an
explanation of why the hospital did not meet the standard.
(2) Notice that a second finding on noncompliance with a
standard will result in a requirement that the hospital's applicable
staff participate in mandatory training on hospital presumptive
eligibility rules and standards that is performed by the office of
the secretary.
(3) A description of the available appeal procedures that the
hospital may use to dispute the finding of a violation of
presumptive eligibility standards.
(f) If the office of the secretary determines that a hospital has failed
to meet any of the presumptive eligibility standards under this section
in any presumptive eligibility determination by the hospital for a
second time within a twelve (12) month period of a first violation, the
office of the secretary shall notify the hospital in writing not later than
five (5) days after the determination that a second violation has
occurred. The written notice must include the following:
(1) A description of the standard that was not met and an
explanation of why the hospital did not meet the standard.
(2) Notice that the hospital's applicable staff must participate in
mandatory training on hospital presumptive eligibility rules and
standards that is performed by the office of the secretary, and
information concerning the date, time, and location of the training
by the office.
(3) A description of the available appeal procedures that the
hospital may use to dispute the finding of a violation of
presumptive eligibility standards.
(4) Notice that a third violation by the hospital of a presumptive
eligibility standard within a twelve (12) month period from the
second violation will result in the hospital no longer being
qualified to make presumptive eligibility determinations.
If a hospital appeals a finding of a violation of presumptive eligibility
standards described in this subsection, the hospital must provide clear
and convincing evidence during the appeals process that the standard
was met by the hospital.
(g) If the office of the secretary determines that a hospital has failed
to meet any of the presumptive eligibility standards under this section
in any presumptive eligibility determination by the hospital for a third
time within a twelve (12) month period of the second violation by the
hospital, the office of the secretary shall notify the hospital in writing
not later than five (5) days from a determination that a presumptive
eligibility standard was violated by the hospital for the third time. The
written notice must include the following:
(1) A description of the standard that was not met and an
explanation of why the hospital did not meet the standard.
(2) A description of the available appeal procedures that the
hospital may use to dispute the finding of a violation of
presumptive eligibility standards.
(3) Notice that, effective immediately from receipt of the notice,
the hospital is no longer qualified to make presumptive eligibility
determinations for the Medicaid program.
(h) If a hospital appeals a finding of a violation of presumptive
eligibility standards described in subsection (g), the hospital must
provide clear and convincing evidence during the appeals process that
the standard was met by the hospital.

Legislative History

As added by P.L.126-2025, SEC.7.