Adds to existing law to establish provisions regarding hospital presumptive eligibility determinations.

LEGISLATURE OF THE STATE OF IDAHO Sixty-eighth Legislature Second Regular Session - 2026 IN THE HOUSE OF REPRESENTATIVES HOUSE BILL NO. 845 BY HEALTH AND WELFARE COMMITTEE AN ACT1 RELATING TO MEDICAID; AMENDING CHAPTER 2, TITLE 56, IDAHO CODE, BY THE AD-2 DITION OF A NEW SECTION 56-276, IDAHO CODE, TO ESTABLISH PROVISIONS RE-3 GARDING MEDICAID PRESUMPTIVE ELIGIBILITY DETERMINATIONS BY QUALIFIED4 HOSPITALS, TO PROVIDE PERFORMANCE STANDARDS, AND TO PROVIDE FOR VIOLA-5 TIONS, NOTICE, AND RIGHTS OF APPEAL; AND DECLARING AN EMERGENCY AND PRO-6 VIDING AN EFFECTIVE DATE.7

Be It Enacted by the Legislature of the State of Idaho:8

SECTION 1. That Chapter 2, Title 56, Idaho Code, be, and the same is9 hereby amended by the addition thereto of a NEW SECTION, to be known and des-10 ignated as Section 56-276, Idaho Code, and to read as follows:11 56-276. MEDICAID PRESUMPTIVE ELIGIBILITY -- QUALIFIED HOSPITAL PER-12 FORMANCE STANDARDS -- VIOLATIONS. (1) The director shall limit presumptive13 eligibility determination to qualified hospitals.14 (2) A hospital making a presumptive eligibility determination shall:15 (a) Notify the department of each presumptive eligibility determina-16 tion no later than five (5) business days after the date of the determi-17 nation;18 (b) Assist individuals who the hospital determines are presumptively19 eligible with completing and submitting a full medicaid application;20 (c) Notify the applicant in writing, on all relevant forms, with plain21 language and in large print, that:22 (i) The applicant's presumptive eligibility will end on the last23 day of the following month if the applicant does not file a full24 medicaid application with the department before the last day of25 the following month; and26 (ii) The applicant's presumptive eligibility will continue until27 an eligibility determination is made by the department concerning28 the application if the applicant files a full medicaid application29 with the department before the last day of the following month; and30 (d) Comply with all other regulations and standards required pursuant31 to subsection (3) of this section.32 (3) The department shall:33 (a) Establish performance standards for hospitals to use in making34 presumptive eligibility determinations in compliance with the require-35 ments of subsection (2) of this section;36 (b) Establish an appeals process for a hospital that disputes a deter-37 mination that a presumptive eligibility standard was violated; and38 (c) Use the following performance standards to establish and ensure ac-39 curate presumptive eligibility determinations by a qualified hospital:40

2 (i) Determine whether each presumptive eligibility determina-1 tion received from the hospital complied with the time requirement2 set forth in subsection (2) of this section;3 (ii) Determine whether the department received the full applica-4 tion from the individual determined by the hospital to be presump-5 tively eligible before the expiration of each presumptive eligi-6 bility period; and7 (iii) Determine whether each applicant who was determined by the8 hospital to be presumptively eligible was determined to be eligi-9 ble for medicaid after the full application was received.10 (4) Each violation by a hospital of any of the performance standards set11 forth in subsection (3) of this section counts as one (1) violation for the12 presumptive eligibility determination. Each subsequent violation of a per-13 formance standard is an additional violation for purposes of this section.14 (5) For the first violation of a presumptive eligibility standard un-15 der this section that a hospital receives in a calendar year, the depart-16 ment shall notify the hospital of the violation in writing no later than five17 (5) days after the determination of a violation is made. The notice must in-18 clude:19 (a) A description of the standard that was not met and an explanation of20 why the hospital did not meet the standard;21 (b) Notice that a second violation by the hospital of a presumptive el-22 igibility standard will result in a requirement that the hospital's ap-23 plicable staff participate in mandatory training on hospital presump-24 tive eligibility rules and standards that is performed by the depart-25 ment; and26 (c) A description of the appeal procedures available to the hospital27 to dispute the finding of a violation of presumptive eligibility stan-28 dards.29 (6) If the department determines that a hospital has failed to meet any30 of the presumptive eligibility standards under this section in any presump-31 tive eligibility determination by the hospital for a second time within a32 twelve (12) month period of a first violation, the department shall notify33 the hospital of the violation in writing no later than five (5) days after34 the determination that a second violation has occurred. The notice must in-35 clude:36 (a) A description of the standard that was not met and an explanation of37 why the hospital did not meet the standard;38 (b) Notice that the hospital's applicable staff must participate in39 mandatory training on hospital presumptive eligibility rules and stan-40 dards that is performed by the department, and information concerning41 the date, time, and location of the training;42 (c) A description of the appeal procedures available to the hospital43 to dispute the finding of a violation of presumptive eligibility stan-44 dards; and45 (d) Notice that a third violation by the hospital of a presumptive eli-46 gibility standard within a twelve (12) month period from the second vi-47 olation will result in the hospital no longer being qualified to make48 presumptive eligibility determinations.49

3 (7) If the department determines that a hospital has failed to meet any1 of the presumptive eligibility standards under this section in any presump-2 tive eligibility determination by the hospital for a third time within a3 twelve (12) month period of the second violation by the hospital, the depart-4 ment shall notify the hospital of the violation in writing no later than five5 (5) days from a determination that a presumptive eligibility standard was6 violated by the hospital for the third time. The notice shall include:7 (a) A description of the standard that was not met and an explanation of8 why the hospital did not meet the standard;9 (b) A description of the appeal procedures available to the hospital10 to dispute the finding of a violation of presumptive eligibility stan-11 dards; and12 (c) Notice that, effective immediately upon receipt of the notice, the13 hospital is no longer qualified to make presumptive eligibility deter-14 minations for the medicaid program.15 (8) If a hospital appeals a finding of a violation of presumptive eli-16 gibility standards set forth in subsection (3) of this section, the hospital17 must provide clear and convincing evidence during the appeals process that18 the standard was met by the hospital.19

SECTION 2. An emergency existing therefor, which emergency is hereby20 declared to exist, this act shall be in full force and effect on and after21 July 1, 2026.22