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How Does Hospital Presumptive (HPE) Eligibility Impact a Hospital and Its Patients?

Hospital Presumptive Eligibility (HPE) is a Medicaid program that allows certain qualified entities, such as hospitals, to make presumptive eligibility determinations for individuals. HPE aims to provide temporary Medicaid coverage for individuals who appear to be eligible while their full Medicaid application is being processed.

Hospital Presumptive Eligibility

Is Your Facility Fully Optimizing HPE in Your State?


Immediate Access to Healthcare Services: One of the primary benefits of HPE is that it allows eligible individuals to receive immediate access to necessary healthcare services. Hospitals can provide essential care to patients in their communities who might not otherwise have coverage during the traditional Medicaid application processing period.


Financial Impact on Hospitals: By providing presumptive eligibility, hospitals can receive reimbursement for services rendered to individuals who are later determined to be eligible for Medicaid. This helps reduce the burden of uncompensated care that hospitals might otherwise face when treating uninsured patients.


Streamlined Medicaid Enrollment Process: HPE simplifies and expedites the Medicaid enrollment process. Hospitals can quickly assess and determine eligibility based on basic information provided by the individual. This streamlined process allows for faster reimbursement for services, benefiting both hospitals and patients.


Improved Continuity of Care: HPE ensures that eligible individuals can access necessary healthcare services without delays. This can contribute to improved continuity of care, as individuals can receive ongoing medical attention without interruptions while awaiting the final determination of their Medicaid eligibility.


Hospital Presumptive Eligibility (HPE) Hurdles


Administrative Challenges: While HPE provides benefits, it also has administrative challenges for hospitals. They need to implement processes and systems to determine presumptive eligibility accurately, document the information, and communicate effectively with Medicaid agencies to ensure proper reimbursement.


Varied State Implementation: HPE programs can vary by state. Each state has the flexibility to design its HPE program within federal guidelines. Therefore, hospitals may need to adapt to different eligibility criteria and program requirements depending on the state in which they operate. A study done in June 2023 showed substantial variability in HPE generosity amongst the 50 states. In 7 states, visibility of the program information was so limited patients faced challenges learning about HPE from official government websites. Understanding your state policies and being an advocate for your patient is key to a successful HPE program in your


Hospital Presumptive Eligibility can positively impact hospitals by providing a means for quicker access to healthcare services for eligible patients, reducing uncompensated care, and improving the overall efficiency of the Medicaid enrollment process. However, a complete understanding of your state’s policy, along with effective implementation and coordination are essential to realizing these benefits.


EligibilityOne Streamlines HPE Processes with On-Site Eligibility Advocates & Technology


EligibilityOne specializes in eligibility and enrollment for uninsured patients. Our screening technology was designed to identify existing coverage or alternate funding sources for patients’ including Medicaid. The assessment is generated based on the answers the patient gives, utilizing business rules and automated workflows. The tool includes integrated calculators for defining household income and supports patient advocacy through prompted financial counseling discussions. We also provide full transparency with our online, real-time reporting tool.


Let our team evaluate the opportunities an HPE program has in your state, contact us at


About EligibilityOne


EligibilityOne is a service solution specializing in third-party eligibility, designed to manage your self-pay population and reduce uncompensated care. We utilize real-time coverage discovery and verification, our comprehensive screening tool (AdvocatorAI), and expanded onsite coverage hours. We also offer complex claims support, disability specialists, credentialing solutions, and out-of-state Medicaid services through our experienced offsite business offices. Our complementary goals of promoting patient advocacy and improving your revenue cycle go hand-in-hand as we strive to create a healthier financial environment for your entire community.


Impacting Communities, One Patient at a Time.®





State-Level Variability in Hospital Presumptive Eligibility Programs. (2023, November). National Library of Medicine.,expand%20access%20to%20health%20care.

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