CHA News Article

ACA Offers New Opportunities for Hospitals Through Presumptive Eligibility

Starting in January 2014, the Affordable Care Act (ACA) gives hospitals a unique new opportunity to use presumptive eligibility to connect all patients to Medicaid, as long as they appear to meet the state’s income guidelines for Medicaid eligibility.Hospitals in any state can elect to make these determinations, regardless of whether the state expands Medicaid eligibility or exercises the existing ability to allow presumptive eligibility for other populations or settings. Hospitals must agree to abide by state policies and procedures, but the choice to make presumptive eligibility determinations rests with each individual hospital, not with the state.

In California, Senate Bill X1 1 (Chapter 4, Statutes of 2013) implements the Hospital Presumptive Eligibility (HPE) Gateway Program, as prescribed in the ACA. CHA has been working with the California Department of Health Care Services (DHCS) to develop and implement the program, which gives hospitals qualified under the state plan or those with a Medicaid 1115 demonstration waiver the option as qualified entities to make presumptive eligibility determinations. 

Under the HPE Gateway Program, qualified hospitals will make presumptive eligibility determinations for individuals who are potentially eligible for Medi-Cal under the following five primary ACA groups:

  1. Children
  2. Parent-caretaker relatives
  3. Pregnant women
  4. Former foster care children
  5. Newly eligible adults with incomes up to 138 percent of the federal poverty level

The presumptive eligibility determination will be based on income, household size and state residency, and will be conducted in real time. The qualified hospital will accept self-attestation of information and will not be required to perform any verification checks of information provided. Full scope Medi-Cal benefits will be provided during a presumptive period of up to two months to individuals who are determined by a qualified hospital, on the basis of preliminary information, to be presumptively eligible for Medi-Cal benefits. The eligibility period will begin the first day of the month the presumptive eligibility application is submitted, and will end the last day of the following month. The program will have an effective date of Jan. 1, 2014.

The program is still in development. CHA will publish additional guidance for hospitals in CHA News as new information becomes available, including an implementation timeline, participation requirements, training requirements and additional resources. A DHCS resource document about the HPE program is attached.