Presumptive eligibility means that people are presumed eligible for Medicaid and can receive Medicaid services without going through the normal application process.
Under the HHS rule filed on July 5, hospitals will now be able to determine presumptive eligibility for Medicaid. States may establish state-specific standards for qualified hospitals for all potential Medicaid eligible populations, but no training for eligibility determination is required by the federal government.
Taxpayers are required to pay for the services provided even if the person is later proven not to have been eligible for Medicaid. States will not be permitted to recoup money from the hospital, and CMS will not recoup money from the state.
In 2004, the State of Colorado canceled a program under which medical clinics could determine presumptive eligibility for Medicaid prenatal care. A state audit showed that more than half of the 19,000 women who received care through the program in 2003 were ultimately determined to be ineligible. Almost a third of the women were illegal aliens. Almost a quarter were ineligible because they did not meet income restrictions. Before the audit, the clinics had assured the state Medicaid department that more than 90 percent of women that they said were presumptively eligible did in fact end up qualifying for Medicaid.