For years, states have had the option to use presumptive eligibility (PE) to connect pregnant women and children to Medicaid. Hospitals were often key to implementing PE for those populations. Starting in January 2014, the Affordable Care Act gives qualified hospitals a unique new opportunity to connect other populations to Medicaid coverage. Under this new PE authority, hospitals will be able to immediately enroll patients who are likely eligible under a state's Medicaid eligibility guidelines for a temporary period of time. An individual provides information about his or her income and household size, and (at state option) information regarding citizenship, immigration status, and residency, and if they appear to be eligible for Medicaid based on this information, a hospital shall determine that individual to be "presumptively eligible" for Medicaid. The individual is temporarily enrolled, and health care providers (not just hospitals) will receive payment for services provided during this interim period pending a final adjudication of Medicaid eligibility by the state Medicaid agency. Like other forms of PE, hospital PE aims to:
- Assure timely access to care while a final eligibility determination is made; and
- Promote enrollment (beyond the interim PE period) in ongoing Medicaid coverage by offering additional channels through which individuals can apply.
The choice to make PE determinations rests with each individual hospital (not with the state) and is not dependent on whether the hospital (or the state) operates PE for other populations.
- This FAQ was released as part of a larger set. View the full set. (PDF, 151.09 KB)