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Defining Presumptive Eligibility

Presumptive Eligibility is a term that's synonymous with Medicaid. If you know about Medicaid, you ought to know about Presumptive Eligibility (PE), especially if there are children or pregnant women in your family.

By definition, PE is a policy that permits qualified entities to make temporary eligibility decisions. It is a process that offers short-term healthcare coverage for those with limited incomes and who are not eligible for Medicaid.

PE is a boon for pregnant women and children because it allows community-based organizations to reach out to them and get immediate access to medical services. Individuals who are temporarily enrolled are encouraged to follow the complete application process to keep the coverage after the initial presumptive period.

CoverMe's Hospital Presumptive Eligibility compliance tool allows you to make PE determinations in real-time and makes Medicaid more accessible for the individual. To understand the importance of PE, we need to explore how the policy has evolved over the years.

PE: A Peek Into History

PE was first established as an option to extend ambulatory services for pregnant women and was available only in states that selected it. However, in 1997, Congress extended the option to children when the Children's Health Insurance Program (CHIP) was enacted. Later on, in 2010, the Affordable Care Act (ACA) allowed states to extend PE to parents, caretaker relatives, and other adults covered by the state's Medicaid program. This new option helped states establish more coordinated family-based coverage.

In addition, the Affordable Care Act allows hospitals that offer Medicaid services to make presumptive eligibility decisions regardless of whether the state has adopted it. In 2014, the 133% Federal Poverty Level (FPL) was set as the new national income eligibility floor for Medicaid.

Thanks to ACA, states across the US have ample flexibility in implementing PE. As long as Presumptive Eligibility is made on a state-wide basis, states have the freedom to:

  • Determine which coverage groups to enroll and which qualified entities to use
  • Use automated or manual processes to implement PE
  • Determine how often an individual can be presumed eligible for PE
  • Determine how quickly the providers verify information

Key Requirements For Implementing PE In Hospitals

As far as states are concerned, hospital participation in PE is optional. However, states bear some responsibilities such as:

  • Developing procedures to ensure that people determined as presumptively eligible should receive immediate and temporary coverage.
  • Providing the right mechanism for hospitals to become qualified for Presumptive Eligibility
  • Taking action against hospitals and healthcare providers who do not meet the standards or follow the established policies.
  • Providing training for qualified hospitals in all the procedures concerning Presumptive Eligibility

Hospitals, on the other hand, are also responsible for:

  • Following all policies, rules, and procedures set by the state for PE
  • Participating in the Medicaid program to qualify for PE
  • Notifying the state of its intentions to make PE determinations
  • Agreeing to comply with all the rules and regulations
  • Avoiding delegating PE determinations to non-hospital staff

Eligibility for individuals applying for PE

Hospital Presumptive Eligibility is not limited to patients. The policy also includes family members, children, caretaker relatives, adults, and other individuals whose eligibility is based on income.

Eligibility criteria for hospitals

To qualify for PE determinations, a hospital should fulfill the following criteria:

  • Participate as a provider under the state plan or a Section 1115 demonstration
  • Notify the agency of its election to make PE determinations
  • Be compliant with the policies and procedures
  • Meet the standards set by the Medicaid agency

The PE rules also allow hospitals to partner with third parties to conduct PE activities, as long as the procedures are done only by qualified hospital staff. Off-site PE activities are also allowed, as long as a qualified hospital maintains the responsibility for determining PE.

List of key federal requirements to be fulfilled by states and qualified entities:

For the state:

  • Provide application forms for qualified entities
  • Train them to assist applicants in filling the forms
  • Ensure the qualified entity is fulfilling its responsibilities

For qualified entities:

  • Provide the written notification for the eligibility determination or denial
  • Provide the individual with the regular application
  • Educate individuals about the end date of the coverage if the application is not filed.
  • Notify the state within five days of the PE determination

Now that we have the key requirements covered let's move on to the application process.

The Application Process For Presumptive Eligibility

States can develop and administer the PE application process used by hospitals. However, they must develop a standardized process for determining PE. Additionally, states are not required to use a written application. Instead, they may use verbal screening questions or an online portal to collect the information.

The qualified hospital collects and records all necessary information to determine PE, regardless of the process used. Depending on the state's requirements, either a single, streamlined application or a PE-specific application can be used.

Once a state adopts PE and establishes the policy in the hospitals across the state, it needs to set up an oversight mechanism to determine the effectiveness. There are two key measures to measure the effectiveness:

1. Determining the number of presumptively enrolled applicants applying for ongoing coverage through the regular application process.
2. Determining the percentage eligible for ongoing coverage.

Fortunately, nearly all the applicants will apply for ongoing coverage if the hospitals assist them with the regular application process. As long as the screening process is effective, accurate, and consistent, most PE applicants will be determined eligible for ongoing coverage.

However, is the process as easy as we assume it to be? Not likely. States are facing immense challenges such as:

  • Short timeframes to implement PE.
  • Limited experience in setting benchmarks for PE
  • Limited human resources to develop and deliver training
  • Lack of technology-based enrollment solutions

Simplifying & Streamlining PE With CoverMe

Presumptive Eligibility does have its challenges and complexities. Despite the drawbacks, it offers a quick and effective path for insurance coverage. It provides the quickest access to reach out to children and pregnant women who urgently need healthcare services.

As a prominent healthcare coverage and finance marketplace, CoverMe offers cutting-edge automation and in-depth data to get patients covered under PE. Request a demo to understand the benefits of CoverMe's PE tool.

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