The Patient Protection and Affordable Care Act increases access to health insurance coverage for Americans in numerous ways. One of them involves the expansion of the presumptive eligibility policy, which allows states to authorize qualified entities such as hospitals, schools and federally qualified health centers to temporarily enroll patients in Medicaid or the Children's Health Insurance Program.
The presumptive eligibility policy previously applied only to children and pregnant women. As of January 2013, two-thirds of states used the policy for pregnant women, children or both, and it's widely seen as an effective way to enroll community members in Medicaid and CHIP through trusted organizations, according to a Health Affairs brief. After being temporarily enrolled, patients are encouraged to complete the regular application process.
Now, the PPACA has expanded the policy to permit hospitals that are Medicaid providers to enact presumptive eligibility even if their states haven't established programs based on the policy. The reform law also allows states that have already adopted presumptive eligibility for women or children to extend the policy to include adults eligible for Medicaid.
However, the PPACA requires states with presumptive eligibility programs to establish oversight mechanisms to ensure presumptive eligibility determinations are made in accordance with federal and state requirements. Depending on the state's regulations, this development could discourage hospitals from taking advantage of presumptive eligibility and helping uninsured patients get Medicaid coverage, according to Tricia Brooks, a senior fellow at the Center for Children and Families and a research associate professor at the Georgetown University Health Policy Institute in Washington, D.C.
Still, she says it's important that hospitals don't get discouraged by regulatory barriers because of how much they can benefit patients by getting them enrolled in Medicaid.
"I do think health providers play a very key role in connecting people to coverage, and the focus groups and research show, for the most part, individuals trust their hospitals, and they want to be assisted in a healthcare setting," says Ms. Brooks, who co-authored the Health Affairs brief. "To that extent, I think it's important that hospitals be key players."
According to a blog post Ms. Brooks wrote on the policy, some states have set reasonable standards for hospitals making presumptive eligibility determinations.
However, she says others have set the bar unreasonably high. Florida requires that 95 percent of individuals determined presumptively eligible fill out regular applications before the end of the presumptive eligibility period, which is the last day of the month following the month in which the presumptive eligibility determination was made. Additionally, the number of days between when the determination is made and the submission of a full application must be less than 10 days on average, and 97 percent of those determined temporarily eligible must be deemed qualified for regular, ongoing Medicaid coverage.
On top of that, required training for entities that enact presumptive eligibility "really does almost require hospitals to become experts on how to calculate income and household size," says Ms. Brooks. In her blog post, she equates
"We certainly have alerted CMS to the fact that some of these standards appear unreasonable," she says. "CMS needs to step in and not approve."
She advises hospitals not to just sit back and let their states enact unreasonable regulations. As long as CMS hasn't approved the state's presumptive eligibility rules, hospitals can voice concerns to CMS and urge the agency not to give the restrictions the green light. Providers can also negotiate with state officials.
"Sometimes you have to pull some of your clout," Ms. Brooks says. "Hospitals have great connections with their policymakers. I think it's really important for hospitals to arm themselves with the facts, not just to go to the state and say, 'What do you have in mind?'…but to really negotiate with the state, if the state's throwing up barriers."
Even if they decide they don't want to contend with the requirements for making PE determinations, Ms. Brooks recommends hospitals look into alternate options for helping people get Medicaid coverage. For instance, they can support community-based consumer assistance or train staff members as certified application counselors to assist people with enrollment. Doing so benefits both the patients and the hospital.
"If a hospital doesn't want to be directly involved in presumptive eligibility, I would certainly want them to examine what other opportunities they have to connect people with coverage," she says. "It's going to improve the bottom line."
More Articles on Medicaid:
HHS: 6.3M Deemed Eligible for CHIP, Medicaid Since Exchanges Launched
Hospitals in Red States Continue Push for Medicaid Expansion
Study: Predictions for 2014 and Beyond Based on Early Medicaid Expansions