Frequently Asked Questions

Real-time eligibility determinations make the role of PE different than it has been in the past. In situations in which the individual files a full application right away, the PE period would likely be considerably shorter-and eliminated altogether, as a practical matter, if a real-time determination is made. However, even with the most modernized systems, there invariably will be individuals for whom a real-time eligibility determination will not be possible. There also will be individuals who will not be comfortable with the online application, or ready with the information needed to complete a full online application and will instead opt to apply later or use a paper application. In such situations and for such individuals, PE remains a useful tool to facilitate prompt coverage and enrollment in the program. States have flexibility to in effect minimize the length of the PE periods by requiring that hospitals and other qualified entities assist individuals in submitting the single streamlined application online, as long as the individual is not required to submit the full application online as a condition of qualifying for PE.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91586

Yes. A simplified method of determining income (e.g., using use of gross income rather than or other simplified approximation of MAGI) per 42 CFR 435.1102(a) is permitted for all types of PE. Our regulations at 42 CFR 435.1102(a) discuss the use of simplified income methods and clearly state that full MAGI-based eligibility determinations cannot be used to determine PE. This requirement applies to all forms of PE, including hospital PE, per 42 CFR 435.1103(a) and 435.1110(a).

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FAQ ID:91591

Yes. A reasonable and simplified way of determining household composition for purposes of determining presumptive eligibility, including under hospital PE, would be to apply the rules for individuals who do not file taxes (i.e. the non-filer rules) as described at 42 CFR 435.603(f).

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FAQ ID:91596

At a minimum, states must implement hospital PE to ensure that hospitals are able to make PE determinations for all of the populations included in section 435.1102 and section 435.1103 (that is, all MAGI-eligible groups: pregnant women, infants, and children, parents and caretaker relatives, the adult group, if covered by the state, individuals above 133 percent of the Federal Poverty Level under age 65, if covered by the state, individuals eligible for family planning services, if covered by the state, former foster care children, and certain individuals needing treatment for breast or cervical cancer, if covered by the state). States may allow hospitals to determine PE for other groups, such as the aged, blind, and disabled, and those whose eligibility is established by section 1115 waiver authority. States permitting hospital PE for other groups are responsible for providing information on relevant state policies and procedures and information on how hospitals should fulfill their responsibilities in making presumptive eligibility determinations for such individuals.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91606

The hospital PE provision in the Affordable Care Act is just for Medicaid state plan and 1115 groups and does not apply to separate CHIP state plan or CHIP 1115 groups. However, hospitals can determine PE for CHIP if a state designates a hospital as a qualified entity under CHIP authorities. A state that covers children and pregnant women in a separate CHIP may elect to have certain qualified entities determine PE for them, and the state determines what types of entities may be qualified entities, which may include hospitals.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91616

Yes, hospital PE is not limited to patients of the hospital. Hospitals can assist with PE determinations for family members and may also enroll eligible individuals from the broader community.

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FAQ ID:91626

Per our regulations at 42 CFR 435.1103(a), pregnant women may have one PE period per pregnancy. If a woman is pregnant more than once in a calendar year, they may have more than one PE period in a calendar year due to the multiple pregnancies.

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FAQ ID:91631

In general, for individuals determined eligible under hospital PE, the benefits provided are the same as those provided under the eligibility group for which PE is determined. See 42 CFR 435.1103(a) and (c)(1)(ii), which specifies that covered benefits for pregnant women during a PE period are limited to ambulatory prenatal care, and benefits covered under family planning PE are limited to family planning services.

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FAQ ID:91641

If a state has elected to provide PE for individuals with breast or cervical cancer under section 435.1103(c)(2), it can limit qualified entities under that section to providers who conduct screenings for breast and cervical cancer under the state's CDC BCCEDP, and if it has done so, the state may limit hospitals that may determine PE for individuals with breast or cervical cancer on that basis to hospitals that conduct screenings under the state's BCCEDP. In states that do not opt to provide PE for individuals with breast or cervical cancer under section 435.1103(c), states similarly may limit hospitals' ability to determine PE for individuals with breast or cervical cancer under section 435.1110 to those that conduct screenings under the state' BCCEDP.

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• This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)

FAQ ID:91651

When hospitals determine PE, they are subject to the same general rules set out for other qualified entities that may determine PE, including that they cannot "delegate the authority to determine presumptive eligibility to another entity." (See 42 CFR 435.1102(b)(2)(vi). However, they may implement PE with the support of third party contractors. For example, hospitals can rely on third party contractors to help staff their in-hospital PE operations, by staffing welcome desks, meeting with consumers, and helping them fill out PE applications as long as the hospital takes responsibility for the PE determinations that result. In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third party contractors to assist individuals in completing and submitting the full application.

Hospitals that conduct off-site, targeted outreach may also employ third party contractors to reach out to individuals who may be Medicaid eligible and assist them with a presumptive application and the single streamlined application at the individual's request. Hospitals must oversee such off-site outreach to ensure hospital accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. States should not unduly limit a hospital's ability to rely on third-party contractors as long as the hospital is not delegating its authority to determine presumptive eligibility to a third party and is meeting appropriate state-established performance standards.

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FAQ ID:91656