What is Presumptive Eligibility?
With presumptive eligibility (PE), an individual can be temporarily enrolled in Medicaid immediately if it appears they are eligible. When an individual provides a hospital with a few basic pieces of information (about their income and household size), a PE determination can be made.
The Affordable Care Act brings many opportunities for hospitals to become even more active in enrolling people in the health coverage they need.One of these opportunities allows hospitals to enroll patients and their families who are likely to be eligible in Medicaid for a temporary “presumptive eligibility” period using a vastly simplified application.
As part of our ongoing commitment to provide enrollment stakeholders like hospitals the tools they need to maximize the number of Americans who enroll in health coverage, Enroll America has put together this toolkit, which is designed to help hospital administrators understand and make the most of this unique opportunity.
We hope that this toolkit provides hospital administrators with information and guidance on implementing the presumptive eligibility option. Hospitals have always played and continue to play an important role in connecting patients to health care and health coverage. Hospitals are invaluable partners in the effort to maximize the number of people who enroll in reliable, comprehensive health coverage.
What do the federal rules allow hospitals to do?
- The Affordable Care Act and subsequent regulations allow qualified hospitals (those that accept Medicaid) to make presumptive eligibility determinations.
- Qualified hospitals may determine an individual to be presumptively eligible for Medicaid on the basis of basic, preliminary information asked of the individual.
- Hospitals can elect to make presumptive eligibility determinations regardless of whether the state in which the hospital operates has opted to use presumptive eligibility more broadly.
- Hospitals can elect to make presumptive eligibility determinations regardless of whether the state in which the hospital operates has elected to expand its Medicaid program to adults with incomes up to 133 percent of the poverty level.
In this Toolkit:
- State HPE policies (updated: 8/2016)
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Last Updated: September 2016
Originally Published: August 2013