Sec. 1.5. (a) The office of the secretary shall establish the following:
(1) Performance standards for providers to use in making presumptive eligibility determinations.
(2) An appeals process for a provider that disputes a determination that a presumptive eligibility standard was violated.
The office of the secretary shall limit presumptive eligibility determination to qualified providers.
(b) A provider shall do the following when making a presumptive eligibility determination:
(1) Notify the office of the secretary of each presumptive eligibility determination not later than five (5) business days after the date of the determination.
(2) Assist individuals whom the provider determines are presumptively eligible with completing and submitting a full Medicaid application.
(3) Notify the applicant in writing and on all relevant forms with plain language and large print that if the applicant:
(A) does not file a full Medicaid application with the office of the secretary before the last day of the following month, presumptive eligibility will end on that last day; and
(B) files a full Medicaid application with the office of the secretary before the last day of the following month, presumptive eligibility will continue until an eligibility determination is made concerning the application.
(c) The office of the secretary shall use the following performance standards to establish and ensure accurate presumptive eligibility determinations by a qualified provider:
(1) Determine whether each presumptive eligibility determination received from the provider complied with the time requirement set forth in subsection (b)(1).
(2) Determine whether the office of the secretary received before the expiration of each presumptive eligibility period the full application from the individual determined by the provider to be presumptively eligible.
(3) Determine whether each applicant who was determined by the provider to be presumptively eligible was determined to be eligible for Medicaid after the full application was received.
(d) Each single violation by a provider of any of the performance standards under subsection (c) counts as one (1) violation for the presumptive eligibility determination. Each subsequent violation of a performance standard is an additional violation for purposes of this section.
(e) For the first violation of a presumptive eligibility standard under this section that a provider receives in a calendar year, the office of the secretary shall notify the provider in writing not later than five (5) days after the determination of a violation is made. The notice must include the following:
(1) A description of the standard that was not met and an explanation of why the provider did not meet the standard.
(2) Notice that a second finding on noncompliance with a standard will result in a requirement that the provider's applicable staff participate in mandatory training on provider presumptive eligibility rules and standards that is performed by the office of the secretary.
(3) A description of the available appeal procedures that the provider may use to dispute the finding of a violation of presumptive eligibility standards.
(f) If the office of the secretary determines that a provider has failed to meet any of the presumptive eligibility standards under this section in any presumptive eligibility determination by the provider for a second time within a twelve (12) month period of a first violation, the office of the secretary shall notify the provider in writing not later than five (5) days after the determination that a second violation has occurred. The written notice must include the following:
(1) A description of the standard that was not met and an explanation of why the provider did not meet the standard.
(2) Notice that the provider's applicable staff must participate in mandatory training on provider presumptive eligibility rules and standards that is performed by the office of the secretary, and information concerning the date, time, and location of the training by the office.
(3) A description of the available appeal procedures that the provider may use to dispute the finding of a violation of presumptive eligibility standards.
(4) Notice that a third violation by the provider of a presumptive eligibility standard within a twelve (12) month period from the second violation will result in the provider no longer being qualified to make presumptive eligibility determinations.
If a provider appeals a finding of a violation of presumptive eligibility standards described in this subsection, the provider must provide clear and convincing evidence during the appeals process that the standard was met by the provider.
(g) If the office of the secretary determines that a provider has failed to meet any of the presumptive eligibility standards under this section in any presumptive eligibility determination by the provider for a third time within a twelve (12) month period of the second violation by the provider, the office of the secretary shall notify the provider in writing not later than five (5) days from a determination that a presumptive eligibility standard was violated by the provider for the third time. The written notice must include the following:
(1) A description of the standard that was not met and an explanation of why the provider did not meet the standard.
(2) A description of the available appeal procedures that the provider may use to dispute the finding of a violation of presumptive eligibility standards.
(3) Notice that, effective immediately from receipt of the notice, the provider is no longer qualified to make presumptive eligibility determinations for the Medicaid program.
(h) If a provider appeals a finding of a violation of presumptive eligibility standards described in subsection (g), the provider must provide clear and convincing evidence during the appeals process that the standard was met by the provider.
As added by P.L.126-2025, SEC.7. Amended by P.L.122-2026, SEC.58.
