IAAAA Policy
on
Presumptive Eligibility

Position  

To support the effort by the Indiana Division on Aging to move from institutional care to community-based care, the Indiana Association of Area Agencies on Aging (IAAAA) recommends that “Presumptive Eligibility” be used by Indiana Area Agencies on Aging (AAAs) when assessing potential clients for the Medicaid Waiver program.

Background

The term “Presumptive Eligibility” means that an elderly applicant is temporarily accepted for Medicaid and can receive services through the Waiver program following an initial screening by the appropriate AAA.  If the applicant meets the basic functional and financial eligibility criteria, the applicant can immediately begin receiving in-home services, case management and other benefits through Medicaid Waiver. AAAs would determine eligibility  through statements from the applicant and an assessment.

The applicant must still be approved by the state agency responsible for Medicaid, but the application process would not delay the applicant receiving services.  This change would increase the number of diversions and the federal dollars coming into Indiana.  The formal Medicaid application process can begin immediately following the Presumptive Eligibility action, but waiting on Medicaid approval would not delay the diversion process.  If the applicant is not approved at this point, past expenditures may be paid through CHOICE funds or, in the case of false statements, from the applicant.  Eligibility at this stage may require more documentation than during the Presumptive Eligibility stage.

Governor Daniels approved Presumptive Eligibility for pregnant women in low-income families in 2008.  The policy granted immediate, temporary health coverage through Medicaid to women meeting the basic eligibility guidelines. The goal was to quickly start prenatal care and reduce infant mortality by funding services during the waiting period for final approval.

Advantages

In this situation, applicants are frail elderly adults who face the risk of nursing home placement because they are not able to provide self-care.  Applicants are also at or below the 300% poverty level as determined by the federal government.  They are at risk of losing their homes in the community and face increased impairment with longer recovery times. 

Presumptive eligibility has been used for a number of years in other states, such as Ohio, Pennsylvania, Washington, and Iowa. 

The advantages are:

• More Federal money is pulled into the state through Medicaid.
  
• The case is expedited with the client receiving services more quickly.
  
• There is less risk of nursing home placement due to faster provision of in-home services.
  
• Applications are done more thoroughly with low error rates (less than 2% in other states).

• Less CHOICE funds would be used for Medicaid Waiver Administration.
  
• The Kaiser Commission recommended this process in September, 2005.

These results have been summarized in the 2004 report “Expediting Medicaid Financial Eligibility” by the National Academy for State Health Policy.  This report was funded by the Centers for Medicare and Medicaid Services (CMS).

Issues

There is the possibility that an applicant could be determined to be eligible by the initial assessment and later found to ineligible by the state because of client misrepresentation or other errors in the initial assessment.  Funds expended during the time between the initial assessment and the state’s approval process would need to be paid through CHOICE/Medicaid Waiver Admininstration funds.  While this is a concern, historically there is a very low error rate for the initial screening and there would not be a large amount of CHOICE funds required.

Current Action Needed

I4A believes that Presumptive Eligibility should become accepted procedure within the Medicaid Waiver application process immediately.  This process has been supported for pregnant low-income women by Governor Daniels and has been used successfully in several states in the past five years.  I4A asks the state Division on Aging to request approval from the federal government for this process; the state would be able to approve funding from the date-of-application.

Last Updated April 2010