601.01 Introduction

Effective for healthcare services provided on or after January 1, 2014, hospitals will have the option to perform Presumptive Eligibility (PE) determinations for select Medicaid eligibility group coverage as granted by the Affordable Care Act. Through this program, a qualified hospital may conduct an eligibility determination of a potentially Medicaid-eligible applicant based on his/her self-attestation of income and circumstances. A qualified hospital is one that meets the criteria stated in the SC Medicaid Provider Manual. No verifications are required from the applicant to complete a PE determination. PE may only be applied towards the following SCDHHS categories:

Pregnant Women,

Family Planning (FP),

Former Foster Care (FFC),

Breast and Cervical Cancer Program (BCCP),

Infants and Children under Age 19, and

Parents/Caretaker Relatives (PCR).

Individuals who are determined presumptively eligible will be enrolled in a fee-for-service payment category based on:

the hospital’s assessment of categorical eligibility,

household income,

South Carolina state residency, and

United States citizenship status, either as a national or satisfactory immigration status as attested by the applicant.

The agency will provide all services covered under the plan during this Presumptive Eligibility Period. An exception to this rule includes pregnant women, who will only receive ambulatory prenatal care.

To participate in the PE program, hospitals must participate in Medicaid, assist individuals in completing PE applications, and must not be disqualified as a qualified hospital. In addition, PE determinations must be performed by a hospital employee, and authority may not be delegated to any non-employee, including employees of affiliated entities. The PE program should be used by hospital workers as a payment option for individuals who attest to being eligible for Medicaid but are unenrolled and unable to complete the full Medicaid application at the time of care; if a patient has any other alternative insurance coverage, the hospital worker should seek to use the alternative coverage rather than the PE coverage. SCDHHS will communicate the program requirements, provide training to participating hospitals, monitor compliance with program requirements, and provide corrective actions as necessary for non-compliance.