CMS: Hospitals can use vendors to enroll patients into Medicaid

The Centers for Medicare & Medicaid Services has issued guidelines clarifying that hospitals can use outside vendors to determine whether pregnant women or children are eligible under presumptive eligibility guidelines to enroll in the Medicaid program, AHA News Now reported.

The decision lifts a burden off hospitals, which want to enroll as many patients as possible into Medicaid so they are assured of a revenue stream for treating them. Many retain contractors focused on that task to assist in that process.

Presumptive eligibility allows hospitals, federally-qualified health clinics and even schools to quickly enroll patients into Medicaid if it appears they are eligible based on cursory questions about their income. Patients must officially enroll in the program shortly thereafter if they want to remain covered. Such programs are currently active in 33 states. Presumptive eligibility can expand Medicaid enrollment by as much as 6.4 percent, according to academic studies.

The income requirements for pregnant women, for example, are also less restrictive than for other enrollees in Medicaid. Indiana's requirements allow a single woman who is pregnant to earn up to $32,261 and still be eligible, while a family of four earning less than $48,984 is also eligible.

Once patients are enrolled in Medicaid via presumptive eligibility, they have until the end of the next month after they were temporarily enrolled to confirm permanent eligibility.

"Hospitals can rely on third-party contractors to help staff their in-hospital PE [presumptive eligibility] operations, by staffing welcome desks, meeting with consumers, and helping them fill out PE applications as long as the hospital takes responsibility for the PE determinations that result," the CMS declared. The agency also noted that states administering the program "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."

To learn more:
- read the AHA News Now article
- check out the CMS guidelines (.pdf)
- here are the Indiana guidelines