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Medi-Cal Hospital Presumptive Eligibility Will Assist Hospitals with the Expected Surge in Uninsured

Medi-Cal Hospital Presumptive Eligibility (HPE)


Since March 12, almost 4 million Californians have filed for unemployment (nearly 20% of workers in the state). With the recent increase in unemployed, an increase in uninsured can be expected.


Local hospitals can manage and decrease this surge in uninsured with the help of the Medi-Cal Hospital Presumptive Eligibility Program.


HPE allows hospitals to provide temporary Medi-Cal coverage to patients likely to qualify for Medi-Cal based on patient-attested preliminary information. Through HPE, the patient can access Medicaid and the provider can be compensated without having to wait for the application to be fully processed.


What is Hospital Presumptive Eligibility (HPE)?


The Hospital Presumptive Eligibility (HPE) program was established by the Patient Protection and Affordable Care Act (ACA) and implemented by the Department of Health Care Services (DHCS) on January 1, 2014. This program gives qualified individuals immediate access to temporary, no-cost Medi-Cal services for up to 2 months while they apply for permanent Medi-Cal or other health coverage. This is a benefit for the patient and the hospital; the patient can move forward with treatments needed while eligibility is processed, and the hospital is ensured reimbursement for services provided.


Additionally, the hospital has an opportunity to assist families in gathering the documents needed to complete the full application to extend coverage beyond the limited scope of 60 days. This benefits both parties in the long term. Patients may obtain permanent coverage and the hospital can reduce frequent uninsured visits by helping repeat patients gain insurance for future services rendered.


How are HPE Determinations Made?


Each determination is based on the applicant’s self-attestation of income, household size, and state residency. The hospital enters this information into the HPE Application Web Portal and receives the HPE determination in real time. This can easily be completed at registration or at bedside during a screening process for an uninsured patient.


HPE Enrollment Period Start and End Dates


The HPE enrollment period begins on the day the patient is determined eligible for HPE (the date the application is submitted through the HPE Application Web Portal). Coverage ends either:


  • On the last day of the month following the month in which eligibility was determined, if the patient does not submit an insurance affordability application before the HPE end date.

  • If the patient does submit an insurance affordability application before the HPE end date, it ends the day that the insurance affordability application is approved or denied.


How to Participate as an HPE Provider in California


A hospital must become qualified in the state of California to participant as an HPE provider. The hospital must notify DHCS of its election to participate, agree to terms and conditions established by DHCS, and ensure its staff members complete the HPE training program. Gaining access to the HPE Application Web Portal takes no more than 24 hours.


COVID-19 Flexibilities


Due to the COVID-19 emergency, DHCS has approved the following flexibilities:


  • HPE providers may utilize telephonic applicant signatures for HPE applications.

  • An Authorized Representative may act on behalf of the applicant by providing the required information for enrollment and using an Authorized Representative form.

According to the DHCS website, HPE providers must follow this procedure for telephonic signatures:

  1. “Read the consent language aloud to the individual/Authorized Representative as it is stated on the signature page of the HPE Application: By signing, I declare that what I say below is true and correct.

  • I have read and understood this HPE Medi-Cal Application.

  • The information I provided is true, correct, and complete.

  • I understand that I must complete and submit the insurance affordability application by the end of my PE period in order to be eligible for continued coverage.

  • I have received the insurance affordability application.

2. Ask that the individual/Authorized Representative verbally acknowledge their consent

3. In the signature line, type “Verbal consent – COVID-19”

4. Be sure to document and keep documentation for all verbal consent obtained”

The Surge in Uninsured: Are You Ready?


Managing the greater number of uninsured patients will require additional work and reporting, so hospitals may wish to utilize vendor partners to execute the HPE program. These vendors must be certified and trained in Medi-Cal Hospital Presumptive Eligibility.


The advocates at Golden State Advocates Eligibility are experts in Medi-Cal Hospital Presumptive Eligibility. Contact us today to learn more about Medi-Cal Hospital Presumptive Eligibility, the new COVID-19 flexibilities, and how we can assist you with this program.

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