As we approach the Winter Olympics, I was thinking about how the world’s elite athletes achieve such high standards of performance. It’s a rarity that such athletes emerge from the unknown at the top of their fields. It takes training, coaching, assessing, testing new techniques, making adjustments and, over time with lots of practice, top performance develops. While it’s a stretch to put hospital presumptive eligibility in the same league as the Olympics, the analogy illustrates that it’s not realistic to expect hospitals to be at the top of their game as they get started in making presumptive eligibility (PE) determinations. Which is why I raised concerns in this blog about the standards that Florida was proposing. Since then, I’ve gotten questions about what reasonable standards might be.
First of all, it’s important to note that states are not required to set standards. However, standards will establish expectations for hospital performance and, most importantly, help ensure that people who are determined presumptively eligible not only receive temporary coverage for urgent and acute needs but also are connected to ongoing coverage. So I’ll cast my vote for standards, as long as they are reasonable and don’t discourage hospitals from participating.
Federal guidance and experts are in agreement when it comes to the most relevant measurements. The top two measurements include the proportion of PE applicants who 1) file a regular Medicaid application and 2) are found eligible for ongoing Medicaid. States are also considering other measurements. For example, Florida’s proposed standards included the average amount of time between the presumptive determination and the submission of the full Medicaid application. Other measurements might be verifying that the individual is not currently enrolled in Medicaid or checking for prior PE determinations in states that set reasonable limits on the number of PE periods an individual can have in a specified timespan.
There’s no cookie cutter approach to setting standards. A variety of factors could impact the ability of hospitals to meet standards depending on how states operationalize the policy. A state’s Medicaid verification plan could still require individuals to provide paper documentation, which is a known barrier to getting through the eligibility process. Setting a high standard (such as Florida proposed that 97% of PE applicants who submit a full application would be determined eligible) will be more difficult if states don’t have streamlined processes for determining eligibility.
It’s important for states to have the ability to capture and report data needed for oversight. State systems need to be able to track PE submissions and connect PE to the regular Medicaid application and eligibility process. Without good data that is systematically collected, it will be difficult for states to monitor hospital performance. Keeping manual records is not cost-effective or necessarily accurate, and having hospitals track and submit their own data is not the best way for states to exercise their oversight responsibility.
Establishing a baseline is a good starting point before setting standards. Given that there are so many new things in Medicaid – eligibility based on new MAGI rules for counting income and household size; new eligibility systems that may need refinement; hospitals tackling PE for the first time – it will be helpful for states to collect data to see what the baseline statistics look like. Given that there is a lot of dust yet to settle on new processes and systems, collecting baseline data for the first six months or even a year seems reasonable.
Use baseline data to establish standards that promote achievable performance levels and improvement over time. Baseline data allows states to base benchmarks on actual experience. For example if 80% of hospitals are submitting full applications for 80% of PE applicants, then 80% seems a fair standard and sets a goal for underperforming hospitals. In this example, states that want to encourage higher performance might think about raising the bar to 85% for the next reporting cycle.
States and hospitals should take a collaborative approach. Hospital presumptive eligibility benefits both the state and the hospital. By connecting people who are eligible for Medicaid with urgently needed services, hospitals may be able to stop a health problem from becoming worse and requiring more expensive treatment that would ultimately be covered through retroactive Medicaid. In turn, hospitals receive reimbursement for delivering those services. And most importantly, individuals get the care and coverage they need, a goal that we all share. By working together, states and hospitals can find common ground in how standards are used to measure performance and encourage improvement over time.
New tools can help states in implementing hospital presumptive eligibility. CMS recently released additional guidance on hospital presumptive eligibility and a new toolkit for states. Our friends at Enroll America also recently updated their toolkit, which includes links to state resources. And if you’re just looking for an overview of hospital presumptive eligibility and other recent changes to the state option to allow other qualified entities to use presumptive eligibility determinations for not only children and pregnant women but others as well, check out this brief I wrote for Health Affairs.
