Establishing Performance Standards for Hospital-Based Presumptive Eligibility

Considerations for State Medicaid Agencies

While presumptive eligibility (PE) is not a new concept in Medicaid, the ACA for the first time gives hospitals—rather than states—the authority to decide whether to participate in PE. While states are obligated to allow hospitals that participate in Medicaid to conduct PE determinations, they have the authority to oversee the quality of hospitals’ PE determinations, which may include requiring hospitals to meet performance standards on an ongoing basis.

This issue brief describes the flexibility available to states to establish performance standards and discusses approaches states may want to consider as they develop standards. It is based on Manatt Health Solutions’ review of federal law and regulations, as well as interviews with several state officials and other experts from states that currently operate hospital-based presumptive eligibility programs.

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The State Health Reform Assistance Network (State Network) is a Robert Wood Johnson Foundation program dedicated to providing technical assistance to states in order to maximize coverage expansions under the Affordable Care Act (ACA).

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