A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the concept of presumptive eligibility in Medicaid. For many years, states were permitted to allow “qualified entities” (which includes hospitals) to presumptively enroll children and pregnant women into the Medicaid program. Once temporarily enrolled, families were encouraged to complete the formal enrollment process. As of last January, 33 states exercised this option, which anecdotal evidence has shown increases the likelihood of eventual enrollment. The Affordable Care Act (ACA) expands the role of hospitals in screening patients and in temporarily enrolling those who meet the appropriate income standard. As ACA implementation advances, presumptive eligibility seems likely to be an important tool in expediting access to coverage for uninsured low-income Americans.

Topics covered in this brief include:
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  • What’s in the law? The brief reviews the regulations released in July 2013 by the US Department of Health and Human Services. These guidelines state that hospitals that are Medicaid providers may make presumptive eligibility determinations, regardless of whether the state has adopted the policy or not.
  • What’s the debate? As states prepare to support hospital presumptive eligibility, some questions have surfaced. For example, does a state’s existing eligibility levels apply to all presumptive eligibility determinations? The brief points out that if a state has not opted to expand Medicaid, then the presumptive income eligibility will remain at the non-expansion level. The brief also describes how states set performance standards to ensure that qualified entities don’t misuse presumptive eligibility.
  • What’s next? The brief explains that states must file a Medicaid State Plan Amendment (SPA) for hospital presumptive eligibility. To assist them in navigating these relatively unchartered waters, CMS has created SPA templates and set timelines for operationalizing their programs. CMS has given states the option to establish standards that may be used to measure hospitals’ success in reaching eligible individuals. Despite the timeline and implementation challenges, presumptive eligibility offers all states a streamlined and expedited path to get eligible individuals covered.

About Health Policy Briefs. Health Policy Briefs are aimed at policy makers, congressional staffers, and others needing short, jargon-free explanations of health policy basics. The briefs, which are reviewed by experts in the field, include competing arguments on policy proposals and the relevant research supporting each perspective.

Sign up for an e-mail alert about upcoming briefs. The briefs are also available from the Robert Wood Johnson Foundation’s website. Please feel free to forward the briefs to any of your colleagues who are tracking health issues. And after you’ve taken a look, we welcome your feedback at: hpbrief@healthaffairs.org.