Beginning January 1, 2014, the Affordable Care Act (ACA) gives qualified hospitals the opportunity to determine presumptive eligibility (PE) for certain Medicaid-eligible populations. This will enable hospitals to temporarily enroll individuals in Medicaid, ensuring compensation for hospital-based services, while providing patients access to medical care and a pathway to longer-term Medicaid coverage. As many states prepare to expand Medicaid coverage under the ACA in 2014, this new hospital-based capability will help expedite access to coverage.

States have an important role in the implementation and oversight of hospital PE. The Centers for Medicare & Medicaid Services’ (CMS) final rule on hospital PE (CMS-2334-F) provides states with flexibility in how to design their hospital PE programs. In particular, the final rule provides opportunities for states to train and certify hospital PE providers, track provider performance, and oversee program quality.

This brief, authored by the Center for Health Care Strategies for the Robert Wood Johnson Foundation’s State Health Reform Assistance Network, provides guidance to aid state Medicaid programs in developing policies for hospital PE implementation and details existing practices from select state PE programs. The information was obtained from the final CMS rule, related CMS guidance, expert sources, and interviews with states currently operating PE programs. The brief organizes information on hospital PE under four topics: (1) qualified provider requirements; (2) training and certification; (3) performance standards; and (4) plan enrollment and payment.


This brief is a product of the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation that is providing technical support to states to maximize coverage gains as they implement key provisions of the Affordable Care Act. The program is managed by the Woodrow Wilson School of Public and International Affairs at Princeton University.