CHA News Article

CMS Announces Hospitals May Implement PE With Help From Contractors

The Centers for Medicare & Medicaid Services (CMS) has released an FAQ document related to the Hospital Presumptive Eligibility (PE) program under the Affordable Care Act. In the document, CMS indicates that when hospitals determine PE, they are subject to the same general rules as are other qualified entities that may determine PE, including the requirement that they cannot “delegate the authority to determine presumptive eligibility to another entity” (see 42 CFR 435.1102(b)(2)(vi)). However, hospitals may implement PE with the support of third-party contractors. For example, hospitals can rely on third-party contractors to help staff their in-hospital PE operations and welcome desks, or to meet with consumers to help them complete PE applications, as long as the hospital takes responsibility for the resulting PE determinations.

In addition, the regulations at 42 CFR 435.1102(b)(2)(vi) do not limit the ability of third-party contractors to assist individuals in completing and submitting the full application. Hospitals that conduct off-site, targeted outreach may also employ third-party contractors to reach out to individuals who may be Medicaid eligible and assist them with a presumptive application and the single streamlined application, at the individual’s request. Hospitals must oversee such off-site outreach to ensure hospital accountability for the PE determinations, including hospital review and approval of the PE recommendations made by non-hospital employees. States should not unduly limit a hospital’s ability to rely on third-party contractors as long as the hospital is not delegating its authority to determine presumptive eligibility to a third party and is meeting appropriate state-established performance standards.

For more information about California’s Hospital PE program, including how to participate, visit