Issue Briefs | Jan 30, 2014

Establishing Performance Standards for Hospital-based Presumptive Eligibility

Manatt Health Solutions – Jocelyn Guyer

The Affordable Care Act (ACA) allows hospitals to use preliminary information to enroll people who appear eligible for Medicaid into coverage on a temporary basis. The goal of this “presumptive eligibility” (PE) option for hospitals is to quickly and efficiently enroll eligible people into Medicaid while insuring immediate health care costs are covered. While presumptive eligibility is not a new concept in Medicaid, the ACA for the first time gives hospitals – rather than states – the authority to decide whether to participate in PE. This issue brief, prepared by Manatt Health Solutions (Manatt), describes the flexibility available to states to establish training and performance standards for hospitals conducting PE determinations, and discusses approaches states may want to consider as they develop standards. It is based on Manatt’s review of federal law and regulations, as well as interviews with several state officials and other experts from states that currently operate hospital-based presumptive eligibility programs