Hospitals Should Exercise the Option to Enroll Kids in Medicaid through Presumptive Eligibility

Among many other provisions, the Affordable Care Act (ACA) gives hospitals the prerogative to make Medicaid presumptive eligibility (PE) decisions, regardless of whether the state has previously implemented PE. Presumptive eligibility allows states to train specific “qualified entities,” such as health care providers, schools, government agencies and community-based organizations, to screen for eligibility and temporarily enroll children and pregnant women in Medicaid or CHIP. Individuals determined presumptively eligible can secure covered health care services without delay while they complete the regular application process for ongoing coverage.

While 32 states use PE to enroll pregnant women, only 17 states use the option for children. These states already have a process in place that can be easily replicated in order to allow hospitals to make presumptive eligibility decisions. The ACA also allows states to use PE for adults (if they have implemented PE for either pregnant women or children), and hospitals can enroll anyone (children, pregnant women, parents and others adults) who qualifies under the new MAGI-based eligibility rules.

Do states that are not expanding Medicaid to adults have to allow hospitals to do presumptive eligibility? The short and definitive answer is yes. But it bears repeating – the only aspect of the law that was mitigated by the Supreme Court ruling is the Secretary’s power to impose financial penalties on states that do not expand Medicaid eligibility. This FAQ confirms in question #28 that all other provisions of the law stand, and that includes the hospital PE provision.

If we’re going to have super-duper real-time eligibility systems, do we need hospitals to do PE?  This continues to be one of the most frequent questions I am asked about PE going forward. The fact is there will be a period of transition when we are “breaking in” the new systems and connections to electronic data sources. It remains to be seen the extent to which real-time determinations will be possible and, because we are concerned about the adequacy of consumer assistance services, PE seems like a good way to help connect eligible individuals to coverage quickly.

Why should hospitals do presumptive eligibility if the state is not expanding Medicaid? PE is a tool that has proven to connect eligible children to coverage. And the fact is that 70% of uninsured children are currently eligible for Medicaid or CHIP. Four of the top five states with the largest numbers of uninsured children (AZ, FL, GA and TX) do not currently have presumptive eligibility for children. Deployed effectively, PE could be a great way to do outreach and connect uninsured children in these and other states to Medicaid and CHIP.

Where do states stand on implementing PE for hospitals as required by the ACA? As I’ve been reaching out to states and advocates to find out where the states stand on implementing PE for hospitals, I’ve encountered a mixed bag of responses. A few states say their hospitals aren’t interested in doing PE because the state’s real-time eligibility systems will be good to go on October 1 and they don’t need PE to get people enrolled quickly. Some states mistakenly believe this provision of the ACA is optional. But many states are moving forward, although some of them got a late start given that the final regulations on PE were not released until July 5, 2013.

What should state advocates do? Given that PE can be an effective tool for connecting uninsured children to Medicaid and CHIP, advocates may want to encourage their hospitals and hospital associations to get involved. There is no requirement for states to actively  “promote” the PE option to hospitals. And in some states, it may take active advocacy from hospitals and other stakeholders to get their state moving forward.

Regardless of where states stand on ACA implementation, it is important for child health advocates to keep coming back to the fact that with 70% of uninsured children currently eligible for Medicaid or CHIP, “kids don’t have to wait.” We should use all of the tools we have to continue our nation’s impressive progress in covering children.


Tricia Brooks
Tricia Brooks is a Senior Fellow at the Center for Children and Families