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.