For seniors looking to gain access to home- and community-based services (HCBS), wait times can be a major roadblock. Policy aimed at reducing those wait times could also have a positive effect on providers.
In a recent MACPAC meeting, Tamara Huson, a senior analyst and contracting officer at the organization, presented early findings on the use of presumptive eligibility and expedited eligibility, as a way to clear up those wait times.
“We’ve been working to understand states’ eligibility and enrollment processes, particularly ways in which states streamline the process to enable more timely receipt of services,” Huson said during the meeting, which took place last week.
Broadly, presumptive eligibility lets people who aren’t eligible for Medicaid to receive services under the program while they’re completing the application process. This period lasts up to 60 days.
“Providers, such as a home health care agency, furnishing HCBS during the period in which a beneficiary is deemed presumptively eligible are reimbursed by Medicaid,” Huson said.
On the flip side, expedited eligibility is when someone’s Medicaid application is processed faster to make a Medicaid eligibility determination. However, the applicant doesn’t receive services until determination is made.
Huson noted that this was the key distinction between presumptive and expedited eligibility.
In order to examine states’ use of presumptive eligibility and expedited eligibility, MACPAC interviewed six states, four national organizations, as well as some Centers for Medicare & Medicaid (CMS) officials.
Of the six states, five are using presumptive eligibility and one is using expedited eligibility, according to Huson.
“We also heard a number of common characteristics from state programs,” she said. “First is that states are generally using presumptive and expedited eligibility for older adults and individuals with disabilities, with a focus on helping individuals transition from hospitals back to the community. Four states that we spoke with currently include hospitalized individuals, and one state was exploring how to expand their population to hospitalized individuals.”
Additionally, three of the national experts MACPAC interviewed emphasized the importance of “disrupting” the hospital to nursing facility pipeline.
“They were hopeful that state efforts to use these flexibilities would be effective in ensuring that individuals are able to receive care in the setting of their choice,” Huson said.
Some of those interviewed did, however, bring up their financial concerns.
“A few interviewees expressed concern about a state’s financial risk for services provided to individuals found presumptively eligible for HCBS and then later found ineligible, despite CMS policy to the contrary,” Huson said.
Ultimately, those interviewed believe that timely access to care services is crucial.
“Interviewees agreed that timely access to services is critical, particularly when an individual may be in an emergency situation, citing particular concerns around individuals discharging from hospitals as to prevent institutionalization,” Huson said. “Experts also reiterated that these policy tools support consumer preferences to remain in the community.”
Companies featured in this article:
