Medicaid Presumptive Eligibility Coming to a Hospital Near You

Beginning in January 2014, hospitals that provide Medicaid services can begin making presumptive eligibility (PE) decisions giving temporary Medicaid (and/or CHIP) coverage to children, pregnant women, parents and adults covered under the Medicaid expansion. The Affordable Care Act permits this action without regard to whether the state has adopted PE as a policy (as 32 states have done so for pregnant women and 15 states have done for children in both Medicaid and CHIP).

So what is presumptive eligibility? As I wrote in this brief, presumptive eligibility is a state policy option that allows qualified entities to make on-the-spot, temporary eligibility decisions (based on an assessment of gross family income). With PE, eligible children and pregnant women get immediate access to medical services, potentially saving health care costs by nipping a problem in the bud with early treatment. Presumptive eligibility allows established community-based organizations, which often serve the lowest-income families, to enroll eligible children and pregnant women who have not been reached through other approaches. Temporary enrollment encourages families to follow through with the complete application process in order to keep coverage after the initial presumptive period.

Why do we need presumptive eligibility if we have new super-duper enrollment systems that determine eligibility in real time? This is 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.

How does the ACA expand presumptive eligibility? Before the ACA, PE was only available as a state option for children and pregnant women. Going forward, if a state has adopted PE for either pregnant women or children, it can offer it for parents and adults covered by Medicaid. Proposed regulations released in January provide more details on the expansion of PE to adults. When the final regulations are published, I’ll write more about best practices in implementing a presumptive eligibility programs (which I did in my former life as a CHIP director).

How will presumptive eligibility work for hospitals? The key difference is the hospital, not the state, can choose to do PE. Thus, states that do not currently have PE programs need to develop the procedures for making sure individuals determined presumptively eligible receive immediate, temporary coverage. Hospitals are required to follow the policies and procedures set by the state, and noncompliance can result in being disqualified as a presumptive entity. Furthermore, states have the option to require that hospitals assist with the full application process, including helping applicants understand any documentation requirements. Personally, I think this is an important step to providing more individuals with needed assistance through the eligibility and enrollment process.

How might states set up a presumptive eligibility oversight mechanism? There are two key measures to determining the effectiveness of presumptive eligibility. First, what percentage of applicants presumptively enrolled applies for ongoing coverage through the regular application process? Secondly, of those who apply, what percentage is determined eligible for ongoing coverage? Ideally 100% of individuals will apply for ongoing coverage, which can be accomplished if states require hospitals and other entities to assist the applicant with the regular application process. And, if hospitals and other entities are doing a good job of screening eligibility, most PE applicants should be determined eligible for ongoing coverage.

Stay tuned to Say Ahhh! for more details when the final regulations on presumptive eligibility are published. In the meantime, stakeholders could encourage hospitals to consider becoming PE sites and urge their states to expand presumptive eligibility to other qualified entities as another helpful way to help connect more consumers to coverage.

Tricia Brooks is a Research Professor at the Center for Children and Families (CCF), part of the McCourt School of Public Policy at Georgetown University.