Financing Presumptive Eligiblity

Hospitals already play an active role in connecting their patients to Medicaid when applicable. There are several reasons that presumptive eligibility makes financial sense for hospitals, even though hospitals may already being actively enrolling eligible patients in Medicaid.

Section Highlights:

Improved Patient Care

Presumptive eligibility allows patients to get additional Medicaid-covered benefits after they are discharged from the hospital, often before a full Medicaid determination has been made. This increases the likelihood that patients will receive needed follow-up care after they are treated in the hospital, and it decreases the likelihood of costly readmissions.


Presumptive eligibility streamlines hospitals’ enrollment work, saving the hospital time it might otherwise spend working with patients to identify a funding stream for their care. With millions more Americans now eligible for Medicaid, increasing efficiency will be essential. Making enrollment decisions for marketplace coverage may be more complex and require greater investment in resources. Simplifying Medicaid enrollment may also free up time to provide enrollment assistance to patients who are eligible for marketplace coverage.

Further, many states are struggling to efficiently enroll eligible consumers in Medicaid coverage due to large volumes of applicants and difficulty transferring consumers’ applications from marketplaces to state Medicaid agencies. Presumptive eligibility can alleviate part of this problem by temporarily enrolling consumers in coverage during a presumptive eligibility period before they enroll in ongoing coverage. This allows consumers to receive the care they need in a timely manner.

Predictability in Reimbursement for the Hospital

Hospitals must meet state accuracy standards to remain eligible to perform presumptive eligibility determinations. In turn, Medicaid payments made during the presumptive eligibility period cannot be recouped by the state Medicaid agency, regardless of a person or family’s ultimate Medicaid eligibility determination. The hospital can also begin receiving payment for an individual’s care immediately, rather than waiting for a full Medicaid determination.

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