Patient access staff at Unity Point Health System — Rock Island (IL) occasionally see patients who reside in Iowa. There is a marked difference in how self-pays are handled in the two states. The reason is that Iowa offers a larger eligibility criteria for presumptive eligibility, which “has been a big revenue producer and a godsend for a lot of patients,” says Linaka Kain, manager of the Marketplace Exchange and disability examiner.

Under the Iowa presumptive eligibility program, eligible patients are given a Recipient Identification Number right away, so their care is not delayed. “If we have somebody scheduled for surgery a week from now, it usually takes about 48 hours to show up in the online verification system,” says Kain. “But by the time of surgery, they’ve got the coverage.”

Since Illinois has not yet passed pending legislation allowing full presumptive eligibility, the process of obtaining coverage for self-pay patients is more difficult. After patients apply for Medicaid, says Kain, “it can be anywhere from a 30- to 45-day turnaround, compared to presumptive eligibility where you have an answer within 24 hours.”

This delay presents a problem for critically ill intensive care unit patients awaiting transfer. “That is very difficult to do if they don’t have a presumptively approved ID number,” says Kain. “If somebody is presumptively eligible, we have a lot easier time transferring them to another facility.”

Approval in minutes

At University of California — Los Angeles Medical Center, presumptive eligibility “helps us to at least bridge the patient onto something else for 60 days,” says Cris De Castro, CCS, manager of financial counseling for patient access services.

Previously, anyone between ages 21 and 64 completed a regular Medicaid application. This application took from three to eight months to approve. “Now we can get them approval in five minutes if they meet the criteria,” says Castro. “That helps the hospital tremendously.”

Financial counselors emphasize the need for patients to submit the necessary paperwork, in order to not lose coverage. “We don’t want them to wait until the sixtieth day to submit all the documentation requirements, so there won’t be any gap in their coverage,” says Castro. “For the most part, we’ve been successful in that.”

Presumptive eligibility helps with discharge planning for admitted patients, because outpatient care and prescriptions are covered. “That benefits everybody all around,” says Castro.

Patients find it easier to obtain follow-up care in other settings, post-discharge. “If the patient has only a pending case number, a lot of places want to know that they have full scope coverage, so they know it’s not restricted,” explains Castro.

On the hospital side, says Castro, “we can bill Medi-Cal right away. Previously, we were billing patients, and if the patient couldn’t pay, then it went to bad debt.”