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Fast-tracking Approval for Publicly Funded LTSS: Presumptive Eligibility

Nurse and older man in wheel chair

When a person with limited resources needs publicly funded long-term services and supports (LTSS) to assist with daily living activities in their home, obtaining it can be difficult and time-consuming. And it comes at a time when the stakes are high. Beginning services immediately, rather than waiting to determine financial eligibility, can make the difference between someone returning home from a hospital, staying at home, or entering an institution that he or she is unlikely to ever leave.

Presumptive Eligibility (PE) is a promising practice that fast-tracks the eligibility approval process. It allows case managers, nurses, or social workers to initiate services before Medicaid makes an official eligibility determination.

This paper examines Presumptive Eligibility programs in five states -- Michigan, Ohio, Rhode Island, Vermont, and Washington – comparing key features and making the following recommendations for effective programs that increase access to LTSS: 

  • State LTSS agencies that are part of an umbrella agency serving as the single state Medicaid agency may be assigned responsibility for determining both functional and financial eligibility. Medicaid financial eligibility is determined more quickly when both the case managers who complete the functional assessment and the financial eligibility workers are employed by the same agency and work near one another.
  • As in Michigan, Medicaid eligibility workers also can be out-stationed to the organization responsible for determining whether the applicant meets the nursing home level-of-care criteria. 
  • When eligibility staff and care coordinators are in separate agencies, more cooperation and coordination is needed. Eligibility workers assigned exclusively to LTSS applications can specialize in complex verifications and work more closely with care managers to process applications. Eligibility staff who also handle applications for women and children and the food stamp program are more likely to process applications as they arrive, may not understand the impact of delayed financial determinations on service choices, and face competing pressures that may interfere with the processing of LTSS applications.
  • While the risk of paying for ineligible applicants is low, if states are concerned about this, other funds may be available, including state general revenues or Social Services Block Grant funds. Alternatively, the Medicaid agency could forgo claiming the match from CMS to cover services approved for individuals found to be ineligible for Medicaid.
  • For states with both home- and community-based services waiver programs and state-funded home care programs, the process simply determines which program will cover the cost of services.
  • The PE process should have deadlines by which the applicant must submit a financial application for Medicaid.
  • Case managers need to track the status of the formal application to make sure it has been filed and acted on.
  • A clear explanation should be given to applicants that services may be terminated if the Medicaid application is not submitted or the person is found to be ineligible.

Suggested Citation:

Robert, Mollica. Expediting Medicaid Financial Eligibility Determinations to Promote Access to Long-Term Services and Supports. Washington, DC: AARP Public Policy Institute. November 2019.  https://doi.org/10.26419/ppi.00085.001

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