Presumptive Eligibility Toolkit for Hospitals

By Liz Hagan

The Affordable Care Act offers many new opportunities for providers to connect patients to health care and health coverage. As we’ve talked about before, one of these opportunities gives hospitals an easier pathway to using presumptive eligibility to connect patients to Medicaid. Our new toolkit, at, is designed to help hospitals learn about the new option and take the steps to begin using it.

With presumptive eligibility (PE), people who appear to be eligible can be temporarily enrolled in Medicaid immediately by a “qualified entity,” like a hospital, health care provider, or school. After collecting a few basic pieces of information about a person (like income and household size), the qualified entity can make a simple, temporary eligibility determination.

A number of states having been using PE for pregnant women and/or children for years, but starting in 2014, states can allow PE to be used for any person who appears to be eligible for Medicaid based on income (see state eligibility guidelines). Additionally, any hospital that participates in Medicaid can use PE for all patients who appear to be eligible for Medicaid (based on income) starting in January 2014, regardless of the state in which they are operating. A hospital simply has to inform the state of its intent to make PE determinations and work with the state to establish acceptable policies and procedures.

Our toolkit provides the critical information that hospitals need to understand the new presumptive eligibility option, the legal authority behind it, how to start using it, key financing concepts, and best practices to ensure the temporary eligibility period is followed by full, ongoing enrollment in coverage.


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