Presumptive eligibility (PE) has been a Medicaid policy option that enables qualified entities (e.g., hospitals, FQHCs, etc.) to determine eligibility and temporarily enroll eligible individuals into Medicaid or the Children’s Health Insurance Program (CHIP). This policy allows individuals to receive immediate coverage for needed health care services and sets them on the path for continued coverage. However, the Affordable Care Act (ACA) now gives hospitals the authority to decide whether to participate in PE.
While states are obligated to allow hospitals that participate in Medicaid to conduct PE determinations, they have the authority to oversee the quality of hospitals’ PE determinations. This issue brief, “Establishing Performance Standards for Hospital-Based Presumptive Eligiblity: Considerations for State Medicaid Agencies,” prepared by Manatt Health Solutions with support from the State Health Reform Assistance Network, describes the flexibility available to states to establish performance standards and discusses approaches states may want to consider as they develop standards. For additional information on hospital PE, check out the following resources:
