The Big Picture
Coverage is the first step to ensuring that people have the care and information they need during this public health crisis while also ensuring a payment source for testing and treatment. In all states, a significant number of people are eligible for Medicaid but not enrolled. Additionally, business closings and other economic disruptions rippling across the nation mean many more people are likely eligible and uninsured.
While states have several options to expand coverage, they also can take steps—with the help of hospitals, local government, and community partners—to cover newly eligible people. Presumptive eligibility (PE) can be an important and useful tool to quickly enroll eligible people into coverage, and in some cases to get them into a new coverage group. The new Medicaid Disaster State Plan Amendment (SPA) Template, released by the Centers for Medicare & Medicaid Services (CMS) on March 22, gives states the opportunity to efficiently request temporary changes to their current PE authorities to facilitate enrollment during the current public health emergency.
Federal Medicaid law has two PE authorities—one that relies on hospitals and one that relies on a broad array of entities (including state and local government offices, first responders, and others)—to temporarily enroll people into Medicaid, allowing them to immediately seek treatment and permitting payment to providers to flow. All states are required to have a hospital PE program, while the broader PE authority is a state option.1
Each of these authorities offers flexibilities that can be used to make PE an effective tool during the COVID-19 public health crisis.2 For example:
- Under hospital PE, states may allow hospitals to enroll all eligible people regardless of their “eligibility category,” and enrollment can be done off-site and by third parties as long as it is done under the supervision of the hospital.
- The broader PE option allows a state to identify, enlist, and train community entities that remain open to conduct PE determinations, and allows PE to be done by the state or local government itself.
This document outlines the PE authorities and the flexibilities available to states, starting with a description of the rules and options particularly relevant to the current situation.
PE Authorities and Flexibilities Available to States
Table 1: Key Requirements and Options for Medicaid Presumptive Eligibility
Table 2: Other Presumptive Eligibility Requirements and Options
1 For a list of states that currently take up the PE option, see Kaiser Family Foundation, Presumptive Eligibility in Medicaid and CHIP (Jan. 2019), https://www.kff.org/health-reform/state-indicator/presumptive-eligibility-in-medicaid-chip.
2 These flexibilities were highlighted in recent guidance for responding to COVID-19. See Centers for Medicare and Medicaid Services (CMS), COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies (Mar. 18, 2020), https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf. See also 42 CFR 435.1110(c).