Current through March 20, 2024
Authority: IC
12-15-2.3-12; IC
12-15-21
Affected: IC 12-15-2.3
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.
