Hospital Presumptive Eligibility Program
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On January 1, 2014, the Hospital Presumptive Eligibility Program (HPE) was implemented. The HPE Program provides qualified individuals immediate access to temporary, no-cost Medi-Cal while applying for permanent Medi-Cal coverage or other health coverage. To qualify for HPE, individuals must meet the rules below.
- Have income below the monthly limit for household size.
- Be a California resident.
- Not already have Medi-Cal.
- If not pregnant, have not received PE Enrollment benefits from any Medi-Cal PE Program up to the maximum limitation allowed within the past 12 months of applying. If pregnant, have not had a PE Enrollment during the current pregnancy of applying.
And, be eligible in one of the following HPE groups below:
- Children under 19 years old
- Parents and Caretaker Relatives
- Pregnant Women (benefits are limited to ambulatory prenatal services.)
- Former Foster Youth between ages 18 to 26 years old, who were in foster care in any state on their 18th birthday or older. (No income limit)
- Adults between ages 19-64, not pregnant, not in Medicare, and not eligible for any group stated above.
To apply for HPE benefits, an individual must visit a hospital that is a qualified HPE Provider. The HPE Provider submits the individual’s information via the HPE Medi-Cal Application online portal and eligibility is determined in real-time.
The HPE enrollment period begins on the date the individual is determined eligible for HPE, which is the day the HPE Medi-Cal Application is submitted via the online portal.
To obtain coverage prior to the HPE start date, individuals must apply for full scope Medi-Cal and mark the box that indicates the individual has medical expenses in the last three months and needs help to pay.
Inquiries regarding the HPE Program may be directed to: DHCSHospitalPE@dhcs.ca.gov
Providers & Partners
Hospital Presumptive Eligibility (HPE) Flexibilities due to COVID-19Due to the ongoing Public Health Crisis, DHCS is approving immediate enrollment flexibilities for PE providers to limit potential exposure to COVID-19.
Hospital Presumptive Eligibility (HPE) Enrolling Providers can utilize telephonic signatures for HPE Applications, noting in the case file “COVID-19 protocol.” If the individual is not at the hospital and not experiencing an urgent health event which requires immediate care, providers should suggest to the individual to apply online using the Covered CA portal
to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative form for the HPE applicant, allowing an individual acting on behalf of the applicant, to provide the required information to assist with the enrollment of the individual in HPE, thereby minimizing direct contact with the individual and promoting physical distancing.
In order to accept a telephonic signature, the following procedure must be followed:
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
New Policy Changes to the Hospital Presumptive Eligibility Program
As California continues to respond to the COVID-19 Public Health Emergency (PHE), the Hospital Presumptive Eligibility (HPE) Program will temporarily expand PE coverage to a new coverage group of individuals who are 65 or older and whose income is below 138 percent of the Federal Poverty level (FPL) effective immediately. This new coverage group is referred to as the “Aged” HPE group. This coverage group is allowed two (2) periods of PE in a twelve-month period and will be assigned aid code 7D. This expansion will be in effect through the end of the PHE. This change is effective immediately and will be in effect through the end of the PHE.
DHCS is also expanding presumptive eligibility periods through HPE for adults that are age 19 years and over. HPE will now provide two (2) periods of presumptive eligibility in a twelve-month period for adults age 19 and over.
DHCS has received federal approval on these new policy changes through California State Plan Amendment 20-0024.
It is critical that HPE Providers monitor the Hospital PE Program
Medi-Cal website for future articles and materials scheduled to publish during May and June 2020.
Questions concerning HPE expansion should be sent to DHCSHospitalPE@dhcs.ca.gov
HPE Provider Lists
To apply for HPE benefits, an individual must visit a hospital that is a qualified HPE Provider. The Qualified HPE Providers list is below. Providers, if your hospital is not listed and it should, please call (916) 552-9472.
If you have any questions, please call the Telephone Service Center: (800) 541-5555 (outside of California, please call (916) 636-1980)
(Monday - Friday, 8:00 A.M. to 5:00 P.M.)
- Option 1: for Provider
- Option 2: for Hospital Presumptive Eligibility
- Option 3: for the Technical Help Desk