DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
   
 
CMCS Informational Bulletin 
 
DATE:  January 24, 2014 
 
FROM:  Cindy Mann 
Director 
 
SUBJECT:  Implementation of Hospital Presumptive Eligibility 
 
This informational bulletin announces the release of a number of resources designed to assist 
states in the implementation of hospital Presumptive Eligibility (PE) as authorized by the 
Affordable Care Act.  Beginning in January 2014 all states must implement hospital PE and 
ensure that hospitals that participate in the Medicaid program can begin making PE 
determinations to provide temporary Medicaid coverage to individuals who qualify including 
children, pregnant women, parents, individuals formerly in foster care, and if applicable in a 
state, adults covered under the new low-income adult eligibility group. The Affordable Care Act 
directs that hospital PE be available in every state.  
 
Today the Centers for Medicare & Medicaid Services (CMS) is releasing a set of frequently 
asked questions for states and stakeholders regarding hospital PE.  This document discusses 
questions on the application process, the eligible populations, information on the qualified 
entities that can make hospital PE determinations, qualification standards for participating 
hospitals, and the federal matching funds available.  
 
In addition, CMS is posting tools for states to use in developing policies and procedures related 
to hospital PE. In response to state requests, CMS has developed templates for training 
materials, and model agreement forms, and will provide a model PE application, samples of 
acceptable PE applications, and a model memorandum of understanding for states to use with 
participating hospitals in the near future.  These tools can be found on Medicaid.gov 
at: http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Learning-
Collaborative-State-Toolbox/State-Toolbox-Expanding-Coverage.html.  
 
The following are some important policy considerations for states as they implement hospital 
PE:  
 
  The PE period varies depending on whether an individual submits a full 
application.  The PE period begins on the day that the qualified hospital approves PE. If 
the individual submits a Medicaid application by the last day of the month after the 
month that PE is determined, the PE end date is the date full Medicaid eligibility is 
approved or denied. If a full Medicaid application is not filed, by the last day of the 
month following the month that PE is determined, the PE period ends on that date.  For 
example, if a hospital determines an individual to be presumptively eligible on February  Informational Bulletin  Page 2 
 
20th, the PE period will end on March 31st if the individual does not file a full application 
by that date. 
 
  A full Medicaid application is not a condition of eligibility for PE. The purpose of PE 
is to provide a streamlined option for people to get access to immediate coverage. Under 
the statute and applicable regulations, a full eligibility determination is not needed and 
may not be required for PE to be approved.  However, filing a full application may be 
encouraged, and states may require that hospitals assist individuals who are 
presumptively eligible in completing a full application during the PE period. States may 
also establish performance standards for hospitals that measure the extent to which 
individuals covered during a PE period submit a full application.  
 
Because a full application cannot be required for PE, if states use the single streamlined 
application for hospital presumptive eligibility determinations, they must clearly denote 
the required questions in order for PE to be determined.  PE may not be denied or 
delayed if the applicant does not complete questions that are optional for PE. If the state 
uses a separate application designed specifically for PE, the questions must be limited to 
those needed by the qualified hospital to make a PE determination. 
 
  States may not require verification of information provided as a condition of PE.  
States must rely on attestation of information for a PE determination.  Once a PE period 
has been established, states may proceed with verification during the full application 
process. 
 
Hospital presumptive eligibility offers a streamlined, expedited path to coverage for individuals 
in all states.  In states where Medicaid system development and testing remains underway and 
the system is not yet ready to make real-time eligibility determinations, timely implementation is 
particularly important.