NCMS Seeks to Clarify What Medicaid Presumptive Eligibility Means in North Carolina

Recently there has been some confusion about changes in Medicaid’s “presumptive eligibility” rules under the Affordable Care Act, which will give hospitals more leeway to assume people seeking care fit into various Medicaid-eligible categories.

The North Carolina Medical Society (NCMS) would like to clarify what presumptive eligibility means for North Carolina, which has not yet elected to expand Medicaid eligibility.  In general, presumptive eligibility is an initial Medicaid determination made by a qualified provider based on preliminary information provided by the applicant. Before the ACA, Medicaid statutes allowed for presumptive eligibility for children and pregnant women. Because more populations are eligible due to Medicaid expansion under the ACA, presumptive eligibility is now available for these newly eligible patients. However, providers are still required to make determinations consistent with the state’s Medicaid eligibility criteria.

Since North Carolina did not expand Medicaid, the state’s Department of Health and Human Services has stated that the only new categories for presumptive eligibility are: coverage for parent or caregiver or individual age 19/20; children under age 19; former foster care children to age 26; family planning; and breast and cervical cancer. Presumptive eligibility will not expand Medicaid to other populations because qualified providers are required to make determinations in accordance with North Carolina’s Medicaid eligibility criteria.

North Carolina already allows qualified providers to presume Medicaid eligibility for low-income pregnant women. Presumptive eligibility allows these women to receive ambulatory prenatal care, which includes prescription drugs, doctor visits and medical services related to the pregnancy. Their presumptive eligibility period ends either when a Medicaid eligibility determination is made or at the end of month following the month determined presumptively eligible, whichever comes first.


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