Medicaid Presumptive Eligibility – Good Policy for West Virginia

A bill was introduced in the West Virginia legislature which would eliminate Medicaid presumptive eligibility for adults at hospitals.  SB 354, introduced by Senator Chandler Swope (R - Mercer, 06), is just a plain bad bill that would take away a very good policy for low-income West Virginians.  


The state option to use presumptive eligibility for adults at hospitals was included in the Affordable Care Act (ACA), sometimes called ObamaCare.  It is amazing how many important policies that help low-income people get the health care they need were included in the ACA back in 2014.  This is a great example of such a policy.

So what is this all about?

Presumptive eligibility allows people to get access to Medicaid health services without having to wait for their application to be fully processed. Before the ACA, states already had the option to allow health care providers to use presumptive eligibility for children or pregnant women.  States like West Virginia that already did so were given the flexibility to extend presumptive eligibility to adults.  And the ACA gave hospitals the right to make presumptive eligibility determinations even if a state had not adopted the policy. 

How does presumptive eligibility work? 

When a person comes into the hospital – perhaps for emergency care – the hospital can screen that patient’s household income and temporarily enroll them in Medicaid. The whole process is governed by a set of federal and state rules, and the state must make sure they are followed.  It is not an automatic stamp of Medicaid eligibility. 

The hospital has to notify the patient of the temporary eligibility determination or denial, give the patient the regular Medicaid application, and tell the patient when the temporary coverage will end if the regular application is not filed.  The hospital has to let the state know of the presumptive eligibility determination within 5 days.

Presumptive eligibility ends the day the patient is enrolled in regular Medicaid or on the last day of the month following the month in which the presumptive determination was made, whichever comes first. After a temporary presumptive eligibility determination, the hospital assists the patient with completing the regular application.  Regular applications require that an applicant provide documentation to prove their income meets Medicaid income eligibility levels. 

Why is presumptive eligibility important?

When a low-income person arrives at the hospital – perhaps with a serious medical emergency – they don’t usually have any kind of documentation of their income with them.  And state electronic income verification systems don’t always work in real time.  Yet the patient’s need for care is immediate.   Even today with strong outreach and education by our state, there are still eligible low-income West Virginians who don’t know about Medicaid until they get sick and a health provider tells them about the program.  

The consequences of not providing needed care are serious.  A patient’s health condition may grow more serious and expensive to treat at a later date.  A delay in needed care can even cause permanent harm or death.  Hospitals must treat anyone who comes into the emergency room under federal law, but the hospital is only required to “stabilize” the patient, not necessarily providing all needed tests, treatment, and health services.  It is in the patient’s best interest, the hospital’s best interest, and the state’s best interest to quickly enroll a hospital patient who appears to be eligible but can’t present the proper documentation right away.

All Medicaid health care services provided during the presumptive eligibility limited temporary Medicaid period receive Medicaid federal matching funds, even if the person is later determined ineligible. West Virginia cannot hold the hospital liable if the person presumptively enrolled is later denied Medicaid eligibility. The hospital can count on being paid for the needed urgent care.  In turn, West Virginia will receive Medicaid federal matching funds for all Medicaid-covered health care services, even if the person is later determined ineligible.  It is better for the state to receive federal matching funds for the care than to use all state dollars to reimburse hospitals. 

The bottom line is that Medicaid presumptive eligibility is a good policy for patients, hospitals, and West Virginia.  Without this policy, patients may have to wait to get urgent care, hospitals that put the patient’s care first will be hurt financially, and West Virginia will lose federal Medicaid dollars.


Kat Stoll


- Principal of Kat Consulting - Morgan County, WV - Policy Director,West Virginians for Affordable Health Care - Former Deputy Executive Director, Families USA