Hospital Presumptive Eligibility (HPE) is a program designed to remove financial barriers and ensure immediate access to medical services for individuals likely to qualify for Medicaid. This temporary mechanism allows uninsured people to receive necessary care without the delay of a standard application process. HPE provides coverage while the state determines an individual’s long-term eligibility for Medicaid or the Children’s Health Insurance Program (CHIP).
Defining Hospital Presumptive Eligibility
Hospital Presumptive Eligibility is an immediate, temporary determination that a patient is eligible for Medicaid coverage. A qualified hospital makes this determination directly, bypassing immediate review by a state agency. The process was expanded under the Affordable Care Act (ACA) to allow hospitals to enroll a broader range of individuals into temporary Medicaid.
The goal is to ensure patients who meet basic income and household criteria can receive care right away. Trained hospital staff use preliminary information to make an eligibility finding in real time. Although HPE is a federal option, its specific implementation, required forms, and eligible groups vary across states.
The Eligibility Criteria
A hospital makes the HPE determination using basic, self-declared information provided by the patient or their representative. The hospital cannot request extensive documentation or perform verification checks at this initial stage. The determination relies on the patient’s attestation regarding household size, state residency, and monthly income against the state’s established Medicaid income limits.
Qualifying categories generally mirror those expanded under the ACA, though they are subject to state adoption. Common groups eligible for a presumptive determination include:
- Pregnant women
- Infants and children
- Parents or caretaker relatives
- Non-elderly adults with income below a certain Federal Poverty Level (FPL) threshold
Former foster care youth are also often included and may have no income limit. This preliminary approval is an initial assessment based on a simplified application, not a final state decision for long-term coverage.
Scope of Temporary Coverage
The temporary coverage provided through HPE generally includes the full range of services offered under a state’s standard Medicaid program, such as doctor visits, hospital stays, prescriptions, and laboratory tests. Coverage begins immediately on the date the qualified hospital determines the individual is presumptively eligible.
The temporary benefit period has a strict end date. Coverage terminates on the last day of the month following the month in which the HPE determination was made. For example, if a patient is determined eligible in January, coverage ends on the last day of February.
The temporary coverage also ends immediately if the state Medicaid agency processes the formal application and determines the individual is ineligible for ongoing Medicaid. Individuals are limited to one HPE period within a rolling 12-month period, underscoring the program’s temporary nature. Pregnant women are an exception, as they may receive one HPE determination for each pregnancy.
Transitioning to Full Medicaid
Receiving Hospital Presumptive Eligibility does not guarantee approval for full, ongoing Medicaid benefits. To secure long-term coverage, the patient must complete a formal Medicaid application before the temporary HPE period expires. This application is often submitted through the hospital staff or directly to the state’s designated agency.
If the application is submitted on time, the temporary HPE coverage will continue past the original termination date until the state makes a final determination on eligibility. This extension ensures a seamless transition into long-term coverage without a gap in medical benefits. Failing to submit the application by the deadline means the temporary coverage will end.
If the individual does not apply for ongoing Medicaid before the temporary coverage expires, they will lose their benefits and must wait 12 months before they can be determined presumptively eligible again. Qualified hospitals are often required to help patients complete and submit the formal application. The intent of the program is to use the temporary coverage as a pathway to enrollment in long-term health insurance.