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Presumptive Eligibility

As part of the Affordable Care Act, hospitals have a new opportunity to better connect eligible patients to Medicaid using Presumptive Eligibility (PE).

Beginning in 2014, as part of the Affordable Care Act, hospitals have a new opportunity to better connect eligible patients to Medicaid. Using presumptive eligibility (PE), hospitals are able to enroll patients and their families who are likely to be eligible into Medicaid immediately, without waiting for an eligibility determination from the state. Patients will provide basic information about their incomes and household size, and if the patient appears to be eligible for Medicaid based on this information, a hospital can determine that individual or family to be “presumptively eligible” for Medicaid. The hospital will receive payment for services provided, just as though the patient were already enrolled in Medicaid. The PE coverage ends the last day of the following month in which the individual was determined PE.

Qualified Entities

Hospitals must  become “qualified entities” through a process that  requires hospital staff to complete a 15-minute online training. After completing the online training, hospitals sign an agreement with ODM and are deemed a qualified entity. Only one acknowledgement form is required for each hospital, but every employee performing PE needs to complete the training. Hospitals will then have the ability to complete the PE process for each individual through the MITS portal.

To be a qualified entity, a hospital must:
  • Participate in the Medicaid program
  • Notify the state of its election to make PE determinations, complete required training, and sign and return an acknowledgement form to
  • Agree to make PE determinations consistent with the policies and procedures of the state by signing the Acknowledgement of Terms and Conditions
  • Agree to provide the consumer with 36 hours’ worth of needed medications
Any employee who is properly training and certified can make PE determinations. This includes employees in hospital-owned physician practices or clinics, including those in offsite locations. Third party vendors or contractors may make PE determinations.

The training and acknowledgement form can be found at:

The Ohio Department of Medicaid will monitor PE enrollments monthly, quarterly and annually to determine if the following standards are being met by each PE
  • For all persons enrolled presumptively by a QE, at least 85% must have had an application for full Medicaid benefits submitted.
  • For all persons who had an application for full benefits filed, at least 85% of those must result in an awarding of Medicaid eligibility.
  • The state has the authority to take corrective action against providers, including termination from the PE program, if the provider does not follow state policies or does not meet established standards.

The security role that you are assigned in the PE and Deemed Portal determines the requests that a worker can view and update. Qualified Entity Workers (MITS Agent) can submit, search for and update their won PE requests. Qualified Entity Supervisors (MITS Administrator) can do everything the Workers can do in addition to searching and updating the requests of workers assigned to their provider.

Presumptively Eligible Individuals

To be presumptively eligible, the patient must not be currently receiving Medicaid benefits and have not had a PE span in the last 12 months (pregnant women and limited to one PE span per pregnancy).

Approved individuals are categorized into one of the following four PE types:
  • PE child
  • PE parent/caretaker
  • PE pregnant woman
  • PE adult

Presumptive Eligibility Process

The presumptive eligibility period will begin the day the application is approved and will end the last day of the following month. Therefore, an individual can have coverage for up to 60 days. However, if the individual submits a full Medicaid application during the PE period, the PE coverage will continue until a full eligibility determination is completed. If the applicant is approved for Medicaid, he or she will be moved from the PE program to the appropriate Medicaid program. PE requests must be submitted and accepted within 25 hours of initiations. Requests that exceed the 25 hour window will expire.

Presumptive Eligibility Process Prior to March 31, 2014

Prior to March 31, 2014, some hospital had been doing PE for pregnant women and children. Because the technology systems that would allow hospitals to do PE were not yet automated, the Ohio Department of Medicaid (ODM) designated 44 hospitals as qualified entities in late 2013. These hospitals were chosen by Medicaid based on Medicaid volume and interest. These hospitals were using MITS to enter PE determinations:
  • Mercy Franciscan Mt. Airy / West
  • Mercy Franciscan Hospital Western Hills
  • Mercy Hospital Anderson
  • Mercy Hospital Clermont
  • Mercy Hospital Fairfield
  • Jewish Hospital of Cincinnati
  • Ashtabula County Medical Center
  • Southeastern Ohio Regional Medical Center
  • Henry County Hospital
  • McCullough Hyde Memorial Hospital
  • Clinton Memorial Hospital
  • Med Central Health System
  • Fairfield Medical Center
  • Springfield Regional Medical Center
  • Community Health Partners / Mercy Regional Medical Center
  • Mercy Allen Hospital
  • Mercy Memorial Hospital
  • St. Rita’s Medical Center
  • Mercy Hospital Tiffin
  • Mercy Hospital Willard
  • Mercy Hospital of Defiance
  • Mercy Hospital St. Anne / Riverside
  • Mercy Hospital St. Charles
  • Mercy Hospital St.Vincent
  • Adams County Regional Medical Center
  • Riverside Methodist Hospital
  • Saint Elizabeth Health Center
  • St. Joseph Health Center
  • St. Elizabeth Boardman Health Center
  • Genesis Health Care System
  • Fayette County Memorial Hospital
  • Wooster Community Hospital
  • St. Vincent Charity Medical Center
  • Grandview Medical Center
  • Grant Medical Center
  • Miami Valley Hospital
  • The Ohio State UniversityWexner Medical Center
  • ProMedica St. Luke’s Hospital
  • ProMedica Toledo Children’s Hospital
  • Dayton Children’s Hospital
  • UC Health
  • University Hospitals Rainbow Babies & Children’s Hospital
  • UH Case Medical Center
  • Hopewell Health Centers (Chillicothe, New Lexington, Logan, McArthur, Pomeroy and The Plains)

Presumptive Eligibility FAQs

Click here for  frequently asked questions and additional resources about presumptive eligibility.
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