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The New Opportunity for Hospitals


Starting in 2014, hospitals will have a new opportunity to better connect eligible patients to Medicaid. Using presumptive eligibility (PE), hospitals will be able to enroll patients and their families who are likely to be eligible in Medicaid immediately, without waiting for an eligibility determination from the state. A patient provides some basic information about his or her individual or family income and household size, and if the patient or family appears likely to be eligible for Medicaid based on this information, a hospital can determine that individual or family to be "presumptively eligible" for Medicaid. The hospital will get paid for the services provided, just as though the patient were already enrolled in Medicaid.

New Opportunity Starting in 2014

For years, states have had the option to use presumptive eligibility to connect pregnant women and children to Medicaid. The Affordable Care Act gives hospitals a unique new opportunity to use presumptive eligibility to connect all patients to Medicaid, as long as they appear to meet the state’s income guidelines for Medicaid eligibility. Hospitals in any state can elect to make these determinations—regardless of whether the state expands Medicaid eligibility or exercises the existing ability to allow presumptive eligibility for other populations or settings. Hospitals must agree to abide by state policies and procedures, but the choice to make presumptive eligibility determinations rests with each individual hospital, not with the state.

How will Presumptive Eligibility Work?

The figure below shows how an individual might go through the process of receiving care at a hospital that uses presumptive eligibility.

The patient provides basic information—name, contact information, date of birth, household size, and monthly income—to an intake worker at the hospital who then assesses “on the spot” whether the person has an income at or below Medicaid income eligibility guidelines for the state. If so, the intake worker can determine the individual or family to be presumptively eligible for Medicaid for a temporary period. PE determinations can be made by hospitals or by outpatient clinics operated by hospitals, which increases the number of access points for patients and their families.

PE periods will differ depending on whether an individual or family submits a full Medicaid application. If the individual or family submits a full application by the end of the month following the month a PE determination is made, the PE period will last until a full Medicaid determination is made. If the individual or family does not submit a full Medicaid application, the PE period will last until the end of the month following the month in which the presumptive eligibility determination is made. For example, if an individual is deemed presumptively eligible on March 10 and submits a full Medicaid application before April 30, the PE period will last until a full Medicaid determination is made (which may be after April 30). If that same individual does not submit a full Medicaid application, their PE period will last until April 30.

All services that are usually covered by Medicaid are covered during this temporary PE period (coverage for pregnant women only covers ambulatory care). During this time, hospitals will be paid—at regular Medicaid rates—for the services they provide, regardless of the ultimate Medicaid eligibility determination.

During the temporary eligibility period, individuals will also be able to receive treatment from other Medicaid providers after they leave the hospital (which could mean the difference between successful follow-up care and an unnecessary readmission). But it is critical—and may be a requirement, depending on state policies—that hospitals work with patients and their families to ensure they complete the full Medicaid application before their temporary eligibility period ends.

Presumptive Eligibility with Streamlined Enrollment

The Affordable Care Act ushers in new eligibility and enrollment requirements that will make it quicker and easier for many consumers to enroll in Medicaid. An online application and modernized eligibility systems may deliver real-time eligibility determinations for the first time in many states. While real-time determinations are not always possible, depending on the complexity of the case and a state's eligibility system, presumptive eligibility gives patients who are seeking care in a hospital the opportunity to enroll in Medicaid immediately. They can get the services they need while a full Medicaid determination—which could take weeks—is being processed. This also guarantees ensures that the hospital gets paid (at Medicaid rates) for all services rendered during the temporary eligibility period.

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