Presumptive eligibility is a Medicaid policy option that permits states to authorize specific types of "qualified entities," such as federally qualified health centers, hospitals, and schools, to screen eligibility based on gross income and temporarily enroll eligible children, pregnant women, or both in Medicaid or the Children’s Health Insurance Program (CHIP). Presumptive eligibility serves a dual purpose of providing immediate access to needed health care services while putting people on a path to ongoing coverage.
The Affordable Care Act (ACA) extends presumptive eligibility beyond children and pregnant women and expands the role of hospitals in determining eligibility presumptively. States that have adopted the policy for children or pregnant women now have flexibility to extend it to parents and adults. Moreover, the law gives hospitals the prerogative to make presumptive eligibility determinations for low-income people, regardless of whether the state has an established program. Given the current status of ACA implementation, presumptive eligibility may be an important tool to expedite access to coverage as states fine-tune their business processes and tweak new eligibility and enrollment systems.