Presumptive Eligibility in Hospitals



The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed actions pursuant to the requirements of Title 42 CFR § 435.1110 regarding eligibility changes implemented in accordance with The Patient Protection and Affordable Care Act of 2010 (ACA) under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).

Effective for services provided on or after January 1, 2014, SCDHHS proposes to amend the South Carolina Title XIX eligibility methodology to include Presumptive Eligibility in Hospitals as required by the Affordable Care Act. Through the Presumptive Eligibility Program, hospitals that participate in the Medicaid program and have not been disqualified can make presumptive Medicaid eligibility determinations for individuals who attest to a simplified set of eligibility requirements for the following SCDHHS categories:  Pregnant Women, Family Planning, Former Foster Care Children to Age 26, Breast and Cervical Cancer Treatment, Infants and Children under Age 19, Parents and Caretaker Relatives. SCDHHS will communicate the program requirements and provide training to these hospitals. Individuals who are determined presumptively eligible will be enrolled in a fee-for-service payment category based on the hospital’s assessment of categorical eligibility, household income, state residency and citizenship, status as a national or satisfactory immigration status as attested by the applicant. The agency will provide all services covered under the plan, including EPSDT, during this Presumptive Eligibility Period. Exceptions to this include individuals found presumptively eligible for family planning will receive services limited to family planning, and individuals enrolled in the presumptively eligible category for pregnant women will only receive ambulatory prenatal care. Presumptive Eligibility Periods are limited to no more than one period within two calendar years. The Presumptive Eligibility Period begins on the date the determination is made.  The Presumptive Eligibility Period ends with the earlier of: 

  • The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or
  • The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date.

SCDHHS will require hospitals to meet performance standards that relate to the proportion of individuals determined presumptively eligible who submit a full application before the end of the Presumptive Eligibility Period and the proportion of individuals who are determined eligible for Medicaid based on the submission of an application before the end of the Presumptive Eligibility Period.

This program is designed to reach SC residents who are eligible but unenrolled which includes an estimated 162,000* individuals that are expected to enroll in Medicaid as an effect of the implementation of the Affordable Care Act.  If each of these individuals is enrolled through this program and receives full Medicaid eligibility, Medicaid expenditures have the potential to increase by approximately $996.9 million state dollars during state fiscal years 2014 through 2020*. Additional costs may be incurred in the event that individuals who are not truly eligible are granted presumptive eligibility by hospitals in error.

Hospitals that want to participate in the Presumptive Eligibility Program for January 1, 2014 must contact SCDHHS no later than November 1, 2013 to allow for training. Participating hospitals must agree to make determinations according to state policy.  Email, and a program representative will contact you.

Copies of this notice are available at each County Department of Health and Human Services Office and at for public review.  Additional information concerning the proposed action is available upon request at the address cited below.

Written comments may be sent to the division of Eligibility, Enrollment, and Member Services, South Carolina Department of Health and Human Services, Post Office Box 8206, Columbia, South Carolina 29202-8206.  Comments may also be submitted to . Written and e-mailed comments must be received by November 16, 2013.

Any written comments submitted may be reviewed by the public at the SCDHHS, Eligibility, Enrollment, and Member Services, 1801 Main Street, Columbia, South Carolina, Monday through Friday between the hours of 9:00 A.M. and 5:00 P.M.

*Milliman ACA Impact Analysis dated January 11, 2013. This is an average estimate based on the assumption that 67% of those eligible but unenrolled join the Medicaid program as an effect of ACA implementation.

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