Children's Presumptive Eligibility (CPE) Training Module May 2025

Department of Health Care Services Children s Presumptive Eligibility (CPE) Provider Training May 2025

Table of Contents Module 1: Introduction & Background Module 2: Eligibility & Enrollment Rules Module 3: Application & Processing Module 4: Provider Responsibilities & Compliance Module 5: CPE Training Provider/Employee Acknowledgement

Module 1: Background

Module 1: Background A. What is Children s Presumptive Eligibility (CPE)? B. Key Benefits & Purpose C. Module 1 Quiz 4

A. What is Childrens Presumptive Eligibility? Children s Presumptive Eligibility (CPE) allows certain health care providers, known as Qualified Providers (QPs), to approve temporary, no cost health coverage for eligible applicants using an electronic application. Important: For this training, the insurance affordability application refers to the Single Streamlined Application (CCFRM 604). It is a single application that allows individuals to apply for both Medi-Cal and premium assistance through Covered California. Coverage is full-scope on a Fee-For-Service basis for up to 60 days. EXCEPTION: Deemed Infant Eligibility lasts up to 1 year. 5

B. Key Benefits & Purpose Purpose: CPE allows QPs to grant temporary coverage to uninsured children. Key Benefits: Determinations rely solely on the applicant's self-attestation of key information. Determinations do not require any proof or verification. Determination rely on a simplified application. Eligibility is granted in real-time to cover services needed right away.

Module 1 Quiz What is Children s Presumptive Eligibility? 1. Which is true about CPE coverage? A. It lasts up to 90 days. B. It s for children who already have Medi-Cal. C. Covered is limited-scope D. [None of the above] Key Benefits & Purpose 1. CPE applicants are required to provide proof such as pay stubs or identification? A. True B. [False] 7

Module 2: CPE Eligibility Requirements & CPE Income Chart

Module 2: Eligibility & Enrollment Rules A. Who is eligible? B. List of Medi-Cal PE Programs and PE enrollment Periods Permitted. C. Who Should be Included in Family Size? D. CPE Enrollment Period & Coverage E. Deemed Infant Eligibility F. Module 2 Quiz 9

A. Who is Eligible? To qualify for CPE, these must be true about the applicant: They have low monthly income based on household size They are a California resident. They do not currently have Medi-Cal. They have not received Presumptive Eligibility more than twice in the past 12 months And they are eligible in the following CPE group: CPE Group PE Enrollment Periods Permitted Children under 19 years old (FPL 0%-266%) 2 PE enrollment periods within the past 12 months

A. Who is Eligible? Children s Presumptive Eligibility Program 2025 Monthly Income Level The 2025 Federal Poverty Levels (FPLs) dollar values are rounded up to the next higher dollar amount. The 2025 FPL dollar values are valid through December 31, 2025, an are updated annually in January.

B. List of Medi-Cal PE Programs & PE Enrollment Periods Permitted PE has frequency restrictions. Child applicants cannot receive PE more than twice per 12 months. PE programs are listed below: Medi-Cal PE Programs Total PE Enrollment Periods Permitted Hospital PE- Children under 19 years old (FPL: 0%- 266%) 2 PE Enrollment Periods Hospital PE- Pregnant Individuals (FPL: 0%-213%) 1 PE Enrollment Period, per pregnancy CPE- Children under 19 years old (FPL 0%-266%) 2 PE Enrollment Periods Breast and Cervical Cancer Treatment Program (BCCTP) 1 PE Enrollment Period PE for Pregnant Women (FPL 0%-213%) 1 PE Enrollment Period, per pregnancy

C. Family Size Family refers to immediate family living in the home. Who should be included: The applicant The applicant s parents (only if the applicant is a minor) The applicant s siblings who are under the age of 19 (only if the applicant is a minor; siblings include biological, adopted or step siblings) The applicant s spouse (only if the applicant is an adult) Any unborn children of a household member (i.e., the number of expected babies count towards household size) Do not include other family or friends, even if they live in the home.

D. CPE Enrollment Period & Coverage CPE provides full-scope coverage on a Fee-For-Service basis for up to 60 days. CPE applications are not subject to periodicity and can be accepted during any type of health care visit. The CPE enrollment period cannot be backdated for any reason; however, the end date can change.

D. CPE Enrollment Period & Coverage The CPE enrollment period begins on the day the applicant is determined eligible through the CPE portal. The CPE Enrollment Period ends, either: 1. On the last day of the following month in which determined eligible for CPE - if the individual did not file an insurance affordability application prior to their CPE Enrollment Period end date, OR 2. If an insurance affordability application is filed prior to the CPE Enrollment Period end date, on the day the eligibility determination is made. IMPORTANT: The submission of an insurance affordability application during the CPE enrollment period impacts its end date. This means the CPE period can be shortened or extended depending on when a determination is made on the insurance affordability application (i.e. approved or denied). 15

D. CPE Enrollment Period & Coverage Example: Without an Insurance Affordability Application When an applicant is approved for CPE but doesn t submit an insurance affordability application, the CPE enrollment period ends on the last day of the following month. CPE is approved July 3 CPE ends August 31 July August 16

D. CPE Enrollment Period & Coverage Example 1: With an Insurance Affordability Application When an applicant is approved for CPE and submits an insurance affordability application, the CPE enrollment period ends the day a determination is made on the insurance affordability application (i.e. approved or denied). Insurance affordability application is submitted August 4. Application processed August 25. CPE ends August 25. CPE is approved July 3. July August 17

D. CPE Enrollment Period & Coverage Example 2: With an Insurance Affordability Application When an applicant is approved for CPE and submits an insurance affordability application, the CPE enrollment period ends the day a determination is made on the insurance affordability application (i.e. approved or denied). July August September Insurance affordability application is submitted August 30. Application processed September 3. CPE ends September 3. CPE is approved July 3. 18

E. Deemed Infant Eligibility Deemed Infant eligibility provides full-scope Medi-Cal coverage to certain young children until their first birthday. The CPE portal allows QPs to establish Deemed Infant eligibility when certain conditions are met (see next slide). When the optional Deemed Infant questions are left blank, partially completed or are completed but the applicant does not qualify for Deemed Infant eligibility, the system will always provide a CPE determination. Deemed Infant eligibility questions are optional and do not impact ability to apply for CPE. Eligibility Criteria Frequency Restrictions Deemed Infant under 1 year of age (mother had active Medi-Cal eligibility in the month the infant was born) N/A- Deemed Infant coverage lasts until the infant is 1 year of age 19

E. Deemed Infant To qualify for Deemed Infant eligibility, these things must be true about the child applicant: The child is under one year of age during the CPE application process. The child was born to a mother who was an active Medi-Cal member at time of birth. The family has completed the following optional questions: Mother s first name Mother s last name Mother s date of birth Mother s social security number or Client Identification Number (CIN) 20

F. Module 2 Quiz Who is Eligible? 1. Applicants must be a California resident to qualify for CPE? A. [True] B. False 2. How many times can a child receive Presumptive Eligibility per 12 months? A. Once B. [Twice] C. No limit

F. Module 2 Quiz Who is Eligible? 3. Who should not be included in family size? A. The 15-year-old applicant B. The 15-year-old applicant s parents C. The 15-year-old applicant s unborn child D. [The 15-year-old applicant s best friend, who is like a sister]

F. Module 2 Quiz CPE Enrollment Period 1. Submission of an insurance affordability application during the CPE enrollment period has no impact on its end date. A. True B. [False] 2. CPE is approved July 4th, and the family does not submit an insurance affordability application. When does CPE end? A. July 3. B. [August 31] C. September 2 D. September 31

F. Module 2 Quiz CPE Enrollment Period 3. CPE is approved July 4th,and the family submits an insurance affordability application on July 8th. The County approves Medi-Cal on July 18th. When does CPE end? A. July 8 B. [July 18] C. July 31 D. August 31

F. Module 2 Quiz Deemed Infant 1. The mother s information must be completed for a CPE determination? A. True B. [False] 2. Deemed Infant coverage is distinct from Presumptive Eligibility? A. [True] B. False

Module 3: Application & Processing

Module 3: Application & Processing A. Step-By-Step: How to Submit an CPE Application B. Approval & Denial Process C. Module 3 Quiz

A. Step-By-Step: How to Submit an CPE Application The CPE enrollment application is located within the Medi-Cal Provider Portal website. Access the Provider Portal by opening: https://provider-portal.apps.prd.cammis.medi-cal.ca.gov/login Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 28

A. Step-By-Step: How to Submit an CPE Application Enter your email and password. Authorized CPE staff will use their authorized login credentials. Then click Log In Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 29

A. Step-By-Step: How to Submit a CPE Application Once logged in, navigate to the Transaction Center and then the "Enrollment section. Find and select Children s Presumptive Eligibility to access the CPE enrollment transaction. Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 30

A. Step-By-Step: How to Submit a CPE Application The QP must submit the CPE application electronically through the Medi-Cal Provider Portal to obtain a real-time determination. The provider may issue a hard copy of the Children s Presumptive Eligibility Pre-Enrollment Worksheet (DHCS 4073) to reference when completing the electronic application; or verbally ask the questions. In either scenario, the data-collected information must match the applicant s responses exactly as they are communicated. Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 31

A. Step-By-Step: How to Submit an CPE Application 32

A. Step-By-Step: How to Submit a CPE Application QPs must ensure confidentiality and take steps to protect patient privacy during the application process. CPE QPs who assist with the application process are responsible for ensuring that: CPE application questions are understood The CPE Application Summary is complete, reviewed and signed before submission. Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 33

A. Step-By-Step: How to Submit a CPE Application Once data collection is complete, the applicant s responses are summarized on an Application Summary, which must be reviewed and signed by the applicant prior to submission. If keying errors occurred, or the applicant indicates the Application Summary is not accurate, the QP must navigate to the impacted screen(s), correct the information, and generate a new Application Summary for review. Once the CPE enrollment transaction is submitted, an eligibility determination is returned in real-time. Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 34

A. Step-By-Step: How to Submit a CPE Application IMPORTANT: The Application Summary stands as the only valid form of the application and must be reviewed and signed prior to submission giving the opportunity to review data entries for accuracy and ensure their attestation is are correct. 35

A. Step-By-Step: How to Submit a CPE Application Applicant Take-Home Materials In addition to a verbal explanation of the CPE determination, QPs must give all applicants the following items: A paper copy of the insurance affordability application A paper copy of the determination. Immediate Need Eligibility document for approvals and existing Medi- Cal coverage; Response message for denials. A signed copy of their CPE Application Summary. Accessing the Provider Portal Data Collection and Entry Reviewing and Submitting the Application 36

B. Approval & Denial Process Immediate Need Eligibility Document (Approvals) Response Message (Denials) 37

B. Approval & Denial Process RETAIN Signed copy of the Application Summary in patient file Signed copy of the Immediate Need Eligibility document PRINT Two copies of the Application Summary Two copies of the Immediate Need Eligibility document. Have the applicant sign both APPROVAL PROCESS EXPLAIN PRINT ISSUE RETAIN ISSUE Signed copy of their Application Summary and Immediate Need Eligibility document A paper copy of the insurance affordability application. EXPLAIN Eligibility decision CPE enrollment period Frequency of enrollment and scope of coverage. 38

B. Approval & Denial Process RETAIN Signed copy of the Application Summary in patient file Copy of the response message PRINT Two copies of the Application Summary and have the applicant sign both. Two copies of the response message. These do not need a signature DENIAL PROCESS EXPLAIN PRINT ISSUE RETAIN ISSUE Signed copy of the Application Summary and copy of the response message. A paper copy of the insurance affordability application. EXPLAIN Eligibility decision Reason for denial Applicant may still be eligible for continued coverage and should submit an insurance affordability application. 39

E. Continuation of Benefits Prior to leaving the office, QPs must provide the applicant/family with a paper copy of the insurance affordability application (CCFRM 604). Help with its completion should be offered and must provided whenever asked. Individuals must submit an insurance affordability application before their PE period end date to evaluate for eligibility beyond the PE enrollment period end date. Always encourage applicant/family to apply for continued coverage regardless of determination outcome (i.e. approval or denial). 40

E. Continuation of Benefits Individuals can apply for Medi-Cal online, in person, via phone, via fax and through mail. Information on ways to apply can be found here. Ways to Apply for Medi-Cal Individuals may complete an application via phone and sign using a telephonic signature by contacting their county Medi-Cal office. Office information can be found here. County Offices (ca.gov) Always encourage applicant/family to apply for continued coverage regardless of determination outcome (i.e. approval or denial). 41

Module 3 Quiz Data Collection and Entry 1. What s Children s Presumptive Eligibility Pre-Enrollment Worksheet number? A. [DHCS 4073] B. DHCS 4007 C. DHCS 4003 2. When filling out the electronic CPE application, the QP must data collect applicant information and responses A. [Exactly as they are communicated by the applicant, either verbally or in writing] B. Exactly as they appear in patient records C. Neither A nor B 42

Module 3 Quiz Data Collection and Entry 3. Which of the following must be given to each CPE applicant, regardless of the determination outcome? A. A copy of the applicant s signed Application Summary B. A verbal explanation of the determination C. A paper copy of the Immediate Need Eligibility Document (approved; signed) or response message (denied; unsigned) D. [A, B and C] Continuation of Benefits 1. Applicants and their families can only apply for continuing coverage such as Medi-Cal via paper or online application? A. True B. [False] 43

Module 4: Provider Responsibilities & Compliance

Module 4: Provider Responsibilities & Compliance A. Provider Participation Requirements B. Corrective Actions & Consequences for Non-Compliance C. Resources D. Module 4 Quiz

A. Provider Participation Requirements To enroll as a Qualified Provider, providers, clinics or other organizations must electronically complete and sign the Children's Presumptive Eligibility Provider Application and Agreement (DHCS 7025) and agree to comply with all applicable CPE requirements, policies and federal regulations.

A. Provider Participation Requirements To enroll as a QP, organizations must: 1) Already be an enrolled Medi-Cal provider. 2) Have a medical license number. 3) Have a National Provider Identifier (NPI) number. 4) Provide a Federal Employer ID Number (EIN) or Taxpayer Identification Number (TIN). 5) Electronically acknowledge and accept Medi-Cal POS Network/Internet Agreement. 6) Complete the web-based CPE provider training. 7) Ensure only trained employees, including employees of associated clinics, perform PE eligibility determinations for CPE applicants. 8) Assist the applicant with completion of the CPE application.

A. Provider Participation Requirements Associated Clinic(s) Requirements A QP can also use the electronic Children's Presumptive Eligibility Provider Application and Agreement (DHCS 7025) to permit eligible, associated clinics within their organization to participate in CPE. Associated Clinic(s) Requirements Training and Certification Requirements Maintaining Records 48

A. Provider Participation Requirements Associated Clinic(s) Requirements Once approved, the QP takes full responsibility of associated clinic(s) they permitted to participate in CPE and must ensure the rules below are implemented: The QP is responsible for CPE determinations made at participating associated clinics; All CPE determinations must be made by CPE-trained associated clinic employees who adhere to all CPE rules and guidelines; The QP must maintain a current list of associated clinics permitted to make CPE determinations and CPE-trained employees conducting determinations at those clinics. Associated Clinic(s) Requirements Training and Certification Requirements Maintaining Records 49

A. Provider Participation Requirements Each employee participating in the CPE must: Complete and pass the required CPE training located in the Medi- Cal Learning Portal. Stay updated on CPE changes which are communicated through provider bulletins, notices and/or additional training programs. The Medi-Cal Subscription Service (MCSS) allows staff to sign up for bulletins and other communicates. Who Can Participate Training and Certification Requirements Maintaining Records 50