Should Hospitals Get To Decide Who Is Eligible for Medicaid?
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.
“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”
Colorado’s experience is chilling
States will have to enforce better rules.
“States may establish state-specific standards for qualified hospitals for all potential Medicaid eligible populations”
Yes but, as with the medicaid expansion, there will be many different implementations. The interim period where everything adjusts will be very messy.
If everything works out optimally, that messy adjustment period should result in best practices that improve everyone’s life.
Oftentimes that federal benefit programs are abused and, yes, states ought to do more to enforce standards.
Interesting. I wonder how much more effective this will make transparency in eligibility. Clearly, it’s been quite easy to scam the system.
Yes. This is why it seems now they are trying to get a more micro-level enforcement system through qualified hospitals.
This is quite an indictment. But it is another piece of evidence that the argument for cost shifting (by providers to private payers to subsidize Medicaid’s underpayment), is inaccurate.
Pre-natal care is not emergency care, which hospitals must provide under EMTALA. Rather, these medical clinics sought out and enrolled Medicaid patients, suggesting that Medicaid reimbursement is profitable.
Wouldn’t hospitals have an incentive to allow people who wouldn’t be considered eligible by the common man, so they can make more money, and the Medicaid program will still be abused. The only thing that has changed is the culprit…
Maybe the key to improving hospitals’ accuracy is putting them on the hook for the cost should their eligibility assessment prove to be wrong (not the patient; nor the taxpayer). Under those conditions I bet the percentage of people incorrectly identified as Medicaid eligible would be much closer to being accurate.
How interested will a state government be in checking on presumptive eligibility determinations if it owns the hospital and every uninsured person is a direct loss?
And keep in mind that states have already been taxing the heck out of the private sector in order to inflate Medicaid pricing and get more federal matching funds.
The payees (the hospitals) will determine for whom the payor (Medicaid) must pay?
Seems to me a conflict of interests.
Good God! So basically there will be no stewardship over the people’s (taxpayers) money whatsoever. Just give it away to whoever you feel like, no questions asked, no accountability expected. If it costs a lot, oh well — we’ll just add it to the deficit. Belize is looking better all the time.