Presumptive Eligibility Toolkit Updated

By Liz Hagan

Our Presumptive Eligibility Toolkit has been updated to reflect some exciting new developments!

In case you haven’t already checked it out, our toolkit goes over the new opportunity for hospitals to use presumptive eligibility to quickly and temporarily enroll patients in Medicaid who are likely eligible. Hospital presumptive eligibility seems to be getting more attention elsewhere, too; State Health Reform Assistance Network recently released an issue brief that looks at how states can develop policies and procedures for implementing hospital presumptive eligibility.

Presumptive eligibility is a great start to getting patients enrolled into coverage, because patients in a health care setting—like a hospital—are naturally thinking about their health care and how to pay for it. What’s good is that presumptive eligibility is allowed in any hospital that participates in Medicaid, regardless of the state.

The presumptive eligibility period lasts until the end of the following month in which an individual or family was temporarily enrolled in coverage. Individuals and families are encouraged to officially apply to be enrolled in Medicaid. However, as many of you know, for a variety of reasons, that doesn’t always happen prior to someone going to the hospital. But, in the meantime, by using presumptive eligibility for likely eligible patients, hospitals are reimbursed for the cost of care and individuals are protected from paying large medical bills out of pocket.  It is critical that hospitals work with patients to connect them to ongoing coverage, and not just temporarily, so patients can continue to receive the care they need.

Here are the big takeaways from this most recent update to the toolkit:

  1. Outpatient clinics that hospitals operate are permitted to make presumptive eligibility determinations.
  2. Whole families can be deemed presumptively eligible for Medicaid. This means that families—and not just individuals within a family—can be temporarily enrolled in Medicaid and receive the care they need. As noted above, it is critical that these families are connected to ongoing Medicaid beyond the temporary presumptive eligibility period.
  3. As it currently stands, eligibility vendors cannot make presumptive eligibility determinations on a hospital’s behalf. However, the Centers for Medicare and Medicaid Services has said that they may issue sub-regulatory guidance to allow eligibility vendors, in some fashion, to make presumptive eligibility determinations.

We will continue to update the toolkit as we receive new information. Stay tuned!

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