ACA Extends Medicaid Presumptive Eligibility and Expands Hospital Role

Health Affairs has issued a Health Policy Brief regarding the expansion of the Medicaid policy that allows states to authorize certain qualified entities (such as federally qualified health centers, hospitals, and schools) to screen for Medicaid or the Children’s Health Insurance Program (CHIP) eligibility based on gross income and temporarily enroll eligible children, pregnant women, or both. According to the brief, under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), presumptive eligibility is extended beyond children and pregnant women, and the role of hospitals in determining presumptive eligibility is expanded. Specifically, states that have adopted the policy for children or pregnant women now have flexibility to extend it to parents and adults. In addition, hospitals may now make presumptive eligibility determinations for low-income people, even if the state does not have an established program.

State Adoption

As of January 1, 2013, Health Affairs reports that 33 states were using presumptive eligibility for pregnant women, children, or both. One state, Kansas, was using it for children only. Sixteen states were using it for pregnant women only. And sixteen states and the District of Columbia were using it for both.

Qualified Entity

Under 42 CFR 435.1101, a “qualified entity” means an entity that is determined by the state to be capable of making determinations of presumptive eligibility for children, and that:

  • furnishes health care items and services under Medicaid and CHIP;
  • is authorized to determine eligibility of a child to participate in a Head Start program;
  • is authorized to determine eligibility of a child to receive child care services;
  • is authorized to determine eligibility of an infant or child to receive assistance under the special nutrition program for women, infants, and children;
  • is authorized to determine eligibility of a child for medical assistance under the Medicaid state plan, or eligibility of a child for child health assistance under the State CHIP program;
  • is an elementary or secondary school;
  • is a state or tribal child support enforcement agency;
  • is an organization that provides emergency food and shelter; or
  • is any other entity the state so deems, as approved by the Secretary of HHS.

Important Questions Considered

Regarding implementation of the hospital presumptive eligibility, Health Affairs provides information on several questions being discussed by the states, including:

  • Can hospitals enroll adults with income up to 138 percent of the poverty level, regardless of whether a state has opted to expand Medicaid?
  • Why can’t qualified entities delegate their presumptive eligibility authority to another entity?
  • Will a state be responsible for 100 percent of the cost of services for someone enrolled presumptively but determined ineligible when they apply for ongoing coverage?
  • How can states protect against bad actors that could misuse presumptive eligibility?
  • How does presumptive eligibility add value when high-performing eligibility and enrollment systems can determine eligibility in real time?

New Considerations

Finally, Health Affairs provides a list of matters that states that should consider, including:

  • States must file a Medicaid State Plan Amendment (SPA) for hospital presumptive eligibility.
  • States have tight time frames for operationalizing hospital presumptive eligibility.
  • States are weighing the use of standards.
  • States may want to consider partnering with navigator groups or health care associations in developing training.
  • Technology-based enrollment solutions are needed to maximize the effectiveness of presumptive eligibility programs.