Noteworthy News

CMS Sets New Guidelines for Medicaid Presumptive Eligibility

law booksBeginning in calendar year 2014, states will be required to provide Medicaid coverage for individuals determined to be presumptively eligible for Medicaid regardless of whether the state has historically offered presumptive eligibility for such patients.

The new regulation, issued by the Centers for Medicare & Medicaid Services (CMS), applies to the actions of what it calls “qualified hospitals” – that is, hospitals that provide Medicaid services and notify their state Medicaid agency of their decision to make presumptive eligibility determinations in accordance with state Medicaid policies.

In return, states have the option of requiring these qualified hospitals to help such patients apply for Medicaid.  At the very least, recipients presumed to be eligible for Medicaid must be told how to apply for full benefits.

States may limit presumptive eligibility determinations to children and pregnant women and certain other specific populations, such as parents and caretaker relatives, other adults, former foster care recipients, women with breast or cervical cancer, and individuals seeking family planning services.

Currently, 14 states offer presumptive eligibility to children and pregnant women; two offer it only to children; and 17 offer it only to pregnant women.  States also have the option of permitting hospitals to make presumptive eligibility determinations for additional populations.

The new Medicaid policy should benefit many urban safety-net hospitals because of the large numbers of low-income patients they serve.

As part of this process, states are required to inform qualified hospitals about relevant state policies and procedures and how to fulfill their responsibilities as qualified hospitals.  If a state determines that a qualified hospital is not adhering to those policies and procedures, it may disqualify the hospital from its qualified status if additional training or other corrective measures fail to address the problem.

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