Hospital Presumptive Eligibility Statement Of Interest (Page 3 of 4) in pdf

Hospital Presumptive Eligibility Statement Of Interest Page 3

Hospital Presumptive Eligibility (HPE) Qualified Entity Responsibilities and Agreement

I understand the responsibilities as a HPE Qualified Entity include:

•

Offering the HPE program to patients without health coverage or Medicaid;

•

Screening interested patients for income eligibility via the prescribed PE forms and guidelines;

•

Informing patients at the time of the HPE determination that they must file a Medicaid

application in order to obtain regular Medicaid coverage beyond the PE period;

•

Attesting that all individuals performing HPE are direct employees of the entity and do not

work as contractors or vendors of the hospital;

•

[Assisting patients in completing an application for Medicaid or subsidized insurance through

the state’s marketplace or healthcare.gov, if needed];

•

Providing with the HPE determination notice a written statement to applicants informing them

that they may file a regular Medicaid application regardless of eligibility for PE;

•

Notifying the [state agency] within five working days with the required information on those

patients eligible for HPE;

•

Attending HPE training and keeping current with changes affecting HPE through provider

bulletins, notices and/or further training.

I, (print name) _______________________________, agree to cooperate with [state agency] in

complying with the above Qualified Entity responsibilities. I am aware that if I do not comply

with these responsibilities and the PE guidelines as outlined in [state agency manual/regulations],

I may lose status as a Qualified Entity. I agree to notify the [State Agency] in writing of any

changes in application information at least [10] days prior to the effective date of the change.

Signature

Title of Authorized Agent

Date

Hospital Presumptive Eligibility Statement Of Interest Page 3