Starting Presumptive Eligibility in Your Hospital

Section Highlights

Using Presumptive Eligibility in Your Hospital

If your hospital participates in Medicaid, it is qualified to make presumptive eligibility determinations using the new statutory authority. Outpatient clinics operated by your hospital are also permitted to make PE determinations if the hospital itself is permitted. Your state does not need to expand Medicaid coverage in order for your hospital to make presumptive eligibility determinations. Your hospital can make presumptive eligibility determinations for any individual who is income-eligible for Medicaid based on your state’s Medicaid income eligibility guidelines.

How to Start Making Presumptive Eligibility Determinations

1. Review your state Medicaid agency’s policies and procedures on presumptive eligibility, if any exist.

2. Contact your state Medicaid agency to discuss and/or develop policies. Use the SPA template to guide the conversation.

3. Create an initial plan that ensures your hospital will follow those policies and procedures.

4. Notify the state Medicaid agency that your hospital intends to make presumptive eligibility determinations and agrees to make those determinations consistent with state policies and procedures. CMS has created a template to inform Medicaid agencies of hospitals’ intent, butsSome states have already created their own forms for hospitals. See: State-Specific HPE Policies for information about which forms are used in each state.

5. Agree to state terms and conditions on hospital presumptive eligibility and take any training required by the state. CMS has developed a template memorandum of understanding that states may use as a basis for their agreements with hospitals, but some states have created their own.

6. Roll out the new PE option in your hospital.

    • Establish a timeline for implementation.
    • Develop materials for hospital staff, such as training resources or instructions for working with patients.
    • If the state is not requiring training, train staff on presumptive eligibility, the basics of the Affordable Care Act, how eligibility determinations will work, and how this affects the work the hospital does (e.g., how other hospital programs, such as financial assistance, are affected). Many states have created training materials for hospitals and may require hospital staff to take the training (See: State-Specific HPE Policies), but it may be beneficial to augment the state training with additional hospital-specific training. This will ensure that staff understand the PE application process. Some states will use online applications, while others will use paper applications, and it is important to fully understand the process.
    • Identify and partner with enrollment assisters in your community, such as navigators, in-person assisters, certified application counselors, Medicaid eligibility workers, etc., who can help patients complete the full application process and enroll in ongoing coverage. Enroll America, through our Get Covered America campaign, has created a locator tool that identifies local assisters by ZIP code. This tool can help hospitals identify assisters in specific communities that may be able to help consumers needing assistance with the full application. If your hospital is interested in assisting consumers enroll in ongoing coverage by becoming a Certified Application Counselor (CAC) organization, our CAC Organization Toolkit provides information about the program, explains how to become a CAC organization, and identifies promising practices from successful CAC organizations.
    • Develop metrics to measure progress (see Tracking Performance below). While not all states require this, it can be a helpful tool to evaluate your hospital’s program.

Tip → It may be beneficial to work with other hospitals in your state when working to implement your presumptive eligibility in your hospital. Some of these hospitals may already be using hospital PE and may be able to help your hospital better understand the policies and processes.

Tracking Performance

It is important, and may be required by the state, for hospitals participating in the new presumptive eligibility program to develop metrics to track performance. Below is a list of possible topics your hospital may want to track:

  • The number of people that receive presumptive eligibility determinations
  • How many of those people complete a full application
    • Who is assisting those individuals fill out their applications?
    • Is the hospital referring these individuals to assisters or doing this internally?
    • What is the time frame between a PE determination and a full application being submitted?
  • The number of people that are ultimately found eligible for Medicaid
  • The costs and charges associated with delivering care for individuals during their temporary presumptive eligibility period
  • The number of PE determinations made in outpatient clinics and inpatient clinics
  • The number of PE individuals who receive follow-up care from the hospital

Tip → Create a working group to monitor these metrics and develop other metrics that your hospital will find useful to track.

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