Report Title:

Medicaid Presumptive Eligibility



Requires the department of human services to provide presumptive eligibility to medicaid or QUEST eligible waitlisted patients. (SD1)



S.B. NO.



S.D. 1
















     SECTION 1.  The legislature finds that it is in the State's best interest to ensure that waitlisted patients receive appropriate medical care by authorizing the department of human services to apply medicaid presumptive eligibility to qualified waitlisted patients.  Presumptive eligibility means that the department of human services shall make a preliminary or "presumptive determination" to authorize medical assistance in the interval between application and the final medicaid eligibility determination based on the likelihood that the applicant will be eligible.

     On average, there are two hundred and as many as two hundred seventy-five, medically-complex patients waitlisted daily for long term care in acute care hospital settings across our State.  Waitlisted patients are those who are deemed medically ready for discharge and no longer in need of acute care services, but who cannot be discharged due to various barriers, and therefore must remain in the higher cost hospital setting.  Discharge timeframes for waitlisted patients range from days to over a year.  This creates a poor quality of life for the patient, presents an often insurmountable dilemma for providers and patients, and engenders a serious financial drain on acute care hospitals with ripple effects felt throughout other health care service sectors.

     Regulatory and government mandates create barriers to transferring waitlisted patients.  One such barrier is the delay in completing medicaid eligibility determinations for waitlisted patients.  Senate Concurrent Resolution No. 198, Session Laws of Hawaii 2007, (SCR 198) requested the Healthcare Association of Hawaii to conduct a study of patients in acute care hospitals who are waitlisted for long term care, and to propose solutions to the problem.  The following is an excerpt from the SCR 198 final report to the legislature addressing the critical problem of waitlisted patients and the regulatory/government barrier of a medicaid eligibility determination:

     "[H]awaii State Medicaid eligibility/re-eligibility determinations:

     (1)  Presumptive eligibility/re-eligibility:  The waitlist task force is very concerned about the amount of time it takes to complete the medicaid eligibility and re-eligibility process.  Staff within hospitals, nursing facilities, etc. report spending a significant amount of time assisting families with medicaid applications, following up with families to ensure their compliance in submitting the required documentation to support the application, hand carrying applications to the medicaid eligibility office, following up with eligibility workers on the status of applications, etc.  They report that hand-carried applications are often misplaced, the time clock for eligibility does not start until the application is located within the department of human services, family members may be non-compliant in completing the necessary paperwork since the patient is being cared for safely and the facility has no option for discharging the patient, and the providers believe that they have taken on a beneficiary services role of assisting consumers that should be assumed by the department of human services.  The medicaid eligibility and re-eligibility application process in Hawaii is obsolete and unable to handle the current volume.  It relies on a paper-driven system that receives a high volume of applications per day.  Delays in processing applications in a timely manner translate to delays in access to care for medicaid beneficiaries.  Acute care hospitals report that in many cases they have not been able to transfer patients to long term care because the delay in making a determination of medicaid eligibility resulted in too long a delay in placement in a nursing facility or home and community based setting.  By the time the medicaid eligibility was approved, the bed in the long term care facility/setting was taken by someone else.  The direct labor hours involved in following up on the process negatively impact providers across the continuum.  Many have hired outside contractors to assist in the application process. 

     (2)  Shifting responsibility for consumer assistance in completing the medicaid application from the provider of service to the department of human services:  Providers have taken on the role of consumer services representatives when patients/families need to submit applications for medicaid eligibility or to reapply for eligibility.  Often, providers end up spending hours to days "tracking down" required documentation to include with the medicaid application and it has become labor intensive.  Many have hired external organizations to assist in this process.  Delays by patients/families in completing medicaid applications result in bad debt and charity care incurred by providers, and they have no recourse but to hold the family members accountable and/or discharge the patient due to non-payment; and

     (3)  Non-compliance by family members/guardians in completing medicaid eligibility/re-eligibility applications:  In other states, such as Nevada, legislation has been passed to impose financial penalties on family members/guardians who did not actively participate in completing/submitting documentation for medicaid eligibility/re-eligibility determinations when fraudulent activity was suspected."

     The purpose of this Act is to require the department of human services to provide presumptive eligibility to medicaid or QUEST eligible waitlisted patients as has been done for pregnant women and children nationwide.

     SECTION 2.  Chapter 346, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§346-    Presumptive eligibility under medicaid or QUEST for waitlisted patients.  (a)  The department shall presume that a waitlisted patient applying for medicaid or QUEST coverage is eligible for coverage; provided that the applicant is able to show proof of:

     (1)  An annual income at or below the maximum level allowed under federal law or the medicaid section 1115 waiver approved for Hawaii, as applicable;

     (2)  Confirmation of waitlisted status as certified by a health care provider licensed in Hawaii; and

     (3)  Meeting the level of care requirement for institutional or home and community based long term care as determined by a physician licensed in Hawaii.

The presumption shall apply immediately upon application.  The patient or guardian shall be notified within forty-five days of the application of eligibility for continuing coverage under either medicaid or QUEST.

     Waitlisted patients who are presumptively covered by medicaid or QUEST shall be deemed eligible for services and shall be processed for coverage under the State’s qualifying medicaid or QUEST program.

     (b)  If the waitlisted patient is later determined to be ineligible for medicaid or QUEST after receiving services during the presumptive eligibility period, the department shall disenroll the waitlisted patient and notify the provider and the plan, if applicable, of disenrollment by facsimile transmission or e-mail.  The department shall provide reimbursement to the provider or the plan for the time in which the waitlisted patient was enrolled."

     SECTION 3.  The department of human services shall submit a report no later than twenty days prior to the convening of the 2011 regular session of findings and recommendations to the legislature regarding the costs and other issues related to presumed eligibility.

     SECTION 4.  New statutory material is underscored.

     SECTION 5.  This Act shall take effect on July 1, 2008; and shall be repealed on June 30, 2011.