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 ACT	1
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 QUALIFIED	4
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 is	9
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 presumptive	13
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 presumptively	19
eligible with completing and submitting a full medicaid application;	20
(c) Notify the applicant in writing, on all relevant forms, with plain	21
language and in large print, that:	22
(i) The applicant's presumptive eligibility will end on the last	23
day of the following month if the applicant does not file a full	24
medicaid application with the department before the last day of	25
the following month; and	26
(ii) The applicant's presumptive eligibility will continue until	27
an eligibility determination is made by the department concerning	28
the application if the applicant files a full medicaid application	29
with the department before the last day of the following month; and	30
(d) Comply with all other regulations and standards required pursuant	31
to subsection (3) of this section.	32
(3) The department shall:	33
(a) Establish performance standards for hospitals to use in making	34
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; and	38
(c) Use the following performance standards to establish and ensure ac-	39
curate presumptive eligibility determinations by a qualified hospital:	40

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(i) Determine whether each presumptive eligibility determina-	1
tion received from the hospital complied with the time requirement	2
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; and	7
(iii) Determine whether each applicant who was determined by the	8
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 set	11
forth in subsection (3) of this section counts as one (1) violation for the	12
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 five	17
(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 of	20
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; and	26
(c) A description of the appeal procedures available to the hospital	27
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 any	30
of the presumptive eligibility standards under this section in any presump-	31
tive eligibility determination by the hospital for a second time within a	32
twelve (12) month period of a first violation, the department shall notify	33
the hospital of the violation in writing no later than five (5) days after	34
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 of	37
why the hospital did not meet the standard;	38
(b) Notice that the hospital's applicable staff must participate in	39
mandatory training on hospital presumptive eligibility rules and stan-	40
dards that is performed by the department, and information concerning	41
the date, time, and location of the training;	42
(c) A description of the appeal procedures available to the hospital	43
to dispute the finding of a violation of presumptive eligibility stan-	44
dards; and	45
(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 make	48
presumptive eligibility determinations.	49

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(7) If the department determines that a hospital has failed to meet any	1
of the presumptive eligibility standards under this section in any presump-	2
tive eligibility determination by the hospital for a third time within a	3
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 five	5
(5) days from a determination that a presumptive eligibility standard was	6
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 of	8
why the hospital did not meet the standard;	9
(b) A description of the appeal procedures available to the hospital	10
to dispute the finding of a violation of presumptive eligibility stan-	11
dards; and	12
(c) Notice that, effective immediately upon receipt of the notice, the	13
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 hospital	17
must provide clear and convincing evidence during the appeals process that	18
the standard was met by the hospital.	19
SECTION 2. An emergency existing therefor, which emergency is hereby	20
declared to exist, this act shall be in full force and effect on and after	21
July 1, 2026.	22

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