Promising State Approaches for Using Hospital Presumptive Eligibility

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February 2014

Most states have developed or are developing policies for using hospital presumptive eligibility (HPE) for Medicaid coverage. Although it is too early to assert that specific policies have led to increased enrollment, several promising practices have begun to emerge. Hospitals should work with state Medicaid agencies to develop HPE programs that meet the needs of consumers, hospitals, and states alike.

Develop High-Quality Training Materials

Many states have developed training materials to prepare hospitals to make accurate HPE determinations and to help hospitals understand state policies and procedures for HPE. The Centers for Medicare and Medicaid Services (CMS) has also created a template training that states can tailor with their own information..1 Hospitals may find it useful to work with their state to help develop HPE trainings that address their mutual needs.

High-quality training materials should include:

  • An explanation of how to collect and measure income information. HPE determinations are based on the consumer’s attestation of income, so training materials need not include explanations of how to calculate Modified Adjusted Gross Income (MAGI) or how to determine household size..2
  • A clear statement that consumers do not have to provide documentation of income, family size, residency, or immigration status in order to be determined presumptively eligible, and that HPE determinations cannot be held up pending this verification.
  • A description of who is required to take HPE training. Some states, such as Idaho, require each staff member who will be making HPE determinations to take HPE training. Other states, such as Iowa, require only certain staff members, such as hospital administrators, to take the training.
  • Instructions for providing temporary Medicaid cards to HPE individuals and families.
  • An explanation of whether hospitals are required to help patients complete the full Medicaid application, and if not, how hospitals can otherwise connect these patients to the full Medicaid application.
  • An overview of any performance standards that hospitals must meet, including consequences for hospitals that don’t meet those standards.

Establish Realistic Performance Standards

States can choose to create performance standards based on (1) the proportion of patients who have been determined to be presumptively eligible that complete the full Medicaid application, and (2) the proportion of those patients that complete the full Medicaid application and are found to be eligible for Medicaid.

While it is important for states to ensure that hospitals make accurate determinations and connect patients with ongoing Medicaid, it is equally important that states establish standards that are not so rigid that they dissuade hospitals from opting to make HPE determinations in the first place.

HPE is a new opportunity, and it will take time to figure out which performance standards are realistic. To do this, states should consider taking the following steps:

  • Start with a trial period and practical performance standards. After the initial implementation period, states can review how hospitals performed and adjust their standards to better align them with what hospitals can realistically achieve. Virginia will start with the expectation that hospitals connect 85 percent of HPE patients to the state’s Medicaid application and that 70 percent of those patients are found eligible for Medicaid. After HPE has been in place for six months, Virginia will revisit those benchmarks and adjust them if necessary.
  • Ramp up performance standards over time to allow hospitals to adjust to the new processes. Pennsylvania will start with requiring 80 percent of HPE patients to be found eligible for Medicaid. After the first year of implementation, the state will raise that standard to 95 percent.

Create Consumer-Friendly Policies

States should establish HPE policies that effectively connect consumers with coverage and needed health care services. Examples of actions states can take to make HPE consumer-friendly include:

  • Develop a summary of which services are covered and how to obtain services during the HPE period.3 that hospitals can give to patients when they receive an HPE determination. This summary should be written in plain language and should include important phone numbers, such as the Medicaid customer service hotline, and phone numbers for community partners that can provide assistance with the full Medicaid application.
  • Send notices to providers and pharmacists to explain that patients and customers who present temporary Medicaid cards are, in fact, covered by Medicaid. West Virginia’s Medicaid agency, the Bureau for Medical Services, sent a notice to all pharmacists about the temporary Medicaid cards and how consumers’ coverage works during HPE periods.4
  • Create HPE applications that are simple and straightforward, such as the applications that have been developed by Alabama and California.5
  • Allow at least one HPE period every 12 months. Many states, such as Kentucky and Montana, have adopted this policy. Requiring longer stretches of time between HPE periods (for example, two years) diminishes opportunities for ensuring that Medicaid-eligible consumers are receiving needed care even if their coverage lapses.

Enroll America has developed a toolkit that is designed to help hospital administrators understand presumptive eligibility and make the most of this unique opportunity. The tool kit is available online at



1 Centers for Medicare and Medicaid Services, Hospital Presumptive Eligibility: Training Template for Qualified Hospitals (Baltimore: CMS, 2014), available online here.

2 MAGI is used to make eligibility determinations for insurance affordability programs, including Medicaid.

3 HPE periods last until the last day of the month following the month in which the HPE determination was made, or when a full Medicaid determination is made, whichever comes first.

4 West Virginia’s Bureau for Medical Services Notice to Pharmacists is available online here.

5 Alabama’s HPE application is available online here. California’s HPE application is available online here.


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