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Starting January 1, 2014, hospitals participating in Medicaid will be permitted to presume that some uninsured patients are eligible for Medicaid and bill the state for their care, according to a final rule about Medicaid eligibility released by the federal Department of Health and Human Services (HHS). The new rule is part of the implementation of a provision of the Patient Protection and Affordable Care Act of 2010 (PPACA). Hospitals will be permitted to make presumptive eligibility determinations for uninsured individuals based on income for all state Medicaid program eligibility categories. This is a federal rule, states are not required to have this provision in their state Medicaid plan. The provision applies only to hospitals.

States may also permit hospitals to make presumptive eligibility determinations for uninsured populations for which income is not the only factor of Medicaid eligibility. These uninsured patients include children, pregnant women, parents and caretaker relatives, former foster children, women with breast or cervical cancer, and individuals seeking coverage for family planning services. States cannot hold hospitals liable for the costs of care for patients incorrectly assumed to be eligible for Medicaid. However, states can disqualify a hospital with inaccurate presumptive eligibility rates.

The final rule implementing the PPACA provision granting hospitals the ability to determine eligibility was included in "Medicaid and Children's Health Insurance Programs (CHIP): Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment." The final rule was published in the Federal Register on July 15, 2013. Additional provisions of the final rule addressed coordination of benefits, notices, design of Medicaid alternative benefit plans, Medicaid cost sharing, open enrollment, and verification of employer-sponsored coverage. Additional details from the final rule included the following:

• Coordination of appeals of eligibility determinations to simplify the process for consumers and states. The final rule provides options for a coordinated appeals process between the Marketplace, Medicaid and CHIP. The rule establishes that state Medicaid agencies may delegate the authority to conduct Medicaid fair hearings to the Marketplace, provided that certain standards that protect Medicaid applicants and beneficiaries are met.
• Consumer notices from Medicaid, CHIP, and the health insurance marketplaces to applicants, enrollees and beneficiaries must include clear and accurate information about eligibility for all insurance affordability programs (including Medicaid, CHIP, and premium tax credits and cost-sharing reductions to help pay for health insurance coverage through the Marketplace). Electronic notices will be available from the Marketplace starting on October 1, 2013, and from state Medicaid and CHIP agencies no later than January 1, 2015.
• State Medicaid alternative benefit packages (now known as Alternative Benefit Plans) must assure that the 10 categories of essential health benefits (EHBs) specified in the Patient Protection and Affordable Care Act are provided in the alternate plans. The final rule also provides guidance on the design and use of these benefit plans and their coverage of EHBs for the new adult group beginning January 1, 2014.
• States can establish higher cost sharing for prescription drugs and for non-emergency use of the emergency department. The final rule also creates one streamlined set of rules for all Medicaid premiums and cost sharing while clarifying that the limit on out of pocket costs will continue to ensure that coverage remains affordable for the lowest income Americans.
• State Medicaid and CHIP agencies must accept the single streamlined application during the initial open enrollment period, which starts October 1, 2013. During the three-month open enrollment period, state Medicaid and CHIP agencies will determine for coverage that will begin in 2014 and accept electronic account transfers from the Marketplace.

Additionally, the final rule includes details on the procedures for the Marketplace to verify access to employer-sponsored coverage. Individuals who are enrolled in employer-sponsored coverage or eligible for employer-sponsored coverage that meets affordability and minimum value standards are ineligible to receive advance payments of the premium tax credit or cost-sharing reductions through the Marketplace.

For more information, contact: Emma Sandoe, Media Contact For Medicaid/Dual Eligibles, Office of External Affairs, Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244; 202-690-6145; Fax: 202-690-7159; E-mail: emma.sandoe@cms.hhs.gov; Website:  www.cms.hhs.gov.