The Access to Care Report (#20) / Medicaid presumptive eligibility

November 21, 2013

health-care-lawThis is installment #20 in a continuing series of Access to Care Reports.

Access to care may be improved through expansion of the concept of presumptive eligibility (PE) for Medicaid program assistance.

The concept is based on allowing hospitals to estimate when individuals may be eligible for Medicaid, based on limited information that may be collected from patients.

A “toolkit for hospitals” for PE has been posted at Enroll America is encouraging hospitals to consider PE as a way to maximize health coverage for individuals with limited income.

Starting in 2014, the Affordable Care Act (ACA) gives hospitals in all states a “unique new opportunity” to expand the use of PE.

Temporary eligibility can be estimated based on monthly income, and lasts to the “end of the month following the month in which the…(PE) determination was made”.

This new opportunity for eligibility determination is possible because the expanded Medicaid program under the ACA makes Modified Adjusted Gross Income (MAGI) the central test for eligibility.

Through PE, time is allowed for a full Medicaid application to be processed.

The hospital is paid for services at Medicaid rates during the temporary period, so long as the hospital follows specified procedures.

Hospitals are required to work with state Medicaid agencies, which in turn are required to submit amendments to state plans specifying how the PE option will take effect.

This feature applies even in states that have chosen not to expand their Medicaid programs.

Improved patient care can result from immediate eligibility for hospital benefits and care after discharge from the hospital.

Improved hospital efficiency can result from allowing temporary eligibility for Medicaid to be established in a simplified way.

And simplified determination of patient eligibility, combined with enhanced efficiency for hospitals, can help achieve improved access to care for affected patients.

If hospitals are able to quickly establish temporary eligibility for Medicaid, and know that they will be paid, they will be more welcoming to patients who do not have alternative health care coverage.

And if efficiency of administration and treatment is improved, individual patients will experience this as improved access.

Numerous legal issues are raised by this PE opportunity. Hospitals will require advice about implementing the new option, and in dealing with state agencies.

Patients and family may often need advice that explains the use of this option, with follow-up to assure that both temporary and long-term Medicaid eligibility is established, when appropriate.

More on related ACA and access to care topics, with wide-ranging discussions of funding sources for care, may be found in a recent book by the authors that describes implementation of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.