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 provider 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, 2016, the following:
(A)
Eighty percent (80%) of presumptively eligible individuals from a qualified
provider shall complete and submit an application before the end of the
presumptive eligibility period.
(B)
Seventy-five percent (75%) of applications submitted for an applicant 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, 2017, the following:
(A) Ninety-five percent (95%) of
presumptively eligible individuals from a qualified provider shall complete and
submit an application before the end of the presumptive eligibility
period.
(B) Ninety percent (90%) of
applications submitted for an applicant 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 provider's application submissions and assess its performance. The
office shall initiate the following actions if its review of a qualified
provider's performance indicates it fails to meet the performance standards in
subsection (a):
(1) The office shall issue a
written warning to the qualified provider and require the qualified provider 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 provider'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 provider'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
provider's presumptive eligibility status for a period of three (3)
years.
(c) The office
shall revoke a qualified provider'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 subdivision (1), a provider
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. The office may consider a provider's written
request for reinstatement of its presumptive eligibility status prior to the
passing of the sanction period if the provider demonstrates one (1) or more of
the following circumstances:
(1) The provider
has experienced a change of ownership.
(2) The provider 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.
(e) A qualified provider 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.
