/ en Sun, 20 Jul 2025 00:37:08 -0500 Mon, 07 Jul 25 09:37:33 -0500 /case-studies/2025-07-07-presumptive-eligibility-case-study-corewell-health <div class="container"><div class="row"><div class="col-md-8"><h2>Background</h2><p>Corewell Health, a 21-hospital nonprofit health system headquartered in Michigan, is strongly committed to communicating the availability of financial assistance to patients and the public, and to ensuring that consistent guidelines are applied to requests for financial assistance across its system. Compassion is a core value of Corewell Health. The health system is resolute in ensuring that all patients receive emergency or medically necessary care irrespective of their financial status. Determination of eligibility for financial assistance occurs after care is delivered and is based on the demonstrated financial need of individual patients as identified through traditional financial assistance applications, conversations with financial counselors and through new presumptive eligibility analytics tools. Corewell is partnering with financial services vendor FinThrive to help design and administer its presumptive eligibility tool, which pulls in publicly available financial data and other information to help identify eligible patients. Presumptive eligibility is not intended to take the place of traditional screening, but rather to augment the existing process.</p><div class="row"><div class="col-md-8"><h2>Financial Assistance Process, Including Presumptive Eligibility</h2><p>Corewell has long maintained a strong commitment to providing charity care and financial assistance to uninsured patients and patients of limited financial means. The Corewell Health team communicates widely with patients and the public about the availability of financial assistance from the beginning of a patient’s encounter with the health system, through signage in each hospital emergency department, registration areas and other public locations, and on the Corewell Health website. Corewell also includes a plain language summary of the <a href="https://assets.contentstack.io/v3/assets/blt3055f692fe7bf193/bltc1707ea925a2190c/faep-summary-english.pdf" target="_blank" title="Corewell Health: Financial Assistance Eligibility Policy Summary">Financial Assistance Eligibility Policy</a> in both the patient intake and discharge materials.</p></div><div class="col-md-4"><div><p>The presumptive eligibility process has opened up a new channel of financial relief for patients, generating positive feedback from patients and financial counselors. <strong>Since implementing presumptive eligibility for charity care, the system has seen an increase of 181% in total charity care.</strong></p></div></div></div><p>To maximize the effectiveness of the financial assistance program, Corewell provides multiple touchpoints for patients to share information in support of receiving financial assistance. After discharge, patients receive information about the financial assistance eligibility policy and are invited to connect with the health system’s team to learn more and apply for assistance.</p><p>After a patient receives care and before financial assistance is applied, patients and Corewell Health pursue third-party payment from insurers. Additionally, Corewell provides support for eligible patients to enroll in long-term coverage options, including Medicaid and coverage options in the Health Insurance Marketplace.</p><p>After insurance coverage or self-pay status has been determined, patients who self-report that they are financially unable to pay, or have otherwise been identified by Corewell Health as potentially unable to pay, are connected with financial counselors for evaluation. Patients may be asked to proceed with the traditional financial assistance application process to determine the appropriate level of financial assistance. For certain qualified patients with balances under $2,000, the application process may be streamlined. If Corewell receives even an incomplete financial assistance application, it will move away from collections efforts and instead continue to work with the patient to determine what financial assistance might be available.</p><p>Over a period of at least 120 days from the first post-discharge bill, or four billing statements, patients are repeatedly notified about financial assistance opportunities. After the fourth statement, Corewell conducts a presumptive eligibility screening, taking into account elements such as credit scores, income, household size and health payment scores.</p><p>Through the presumptive eligibility screening, Corewell Health generates a “likelihood to pay” score using a model developed by FinThrive that utilizes credit report information, self-reported data, marketing data sources and average incomes for others near the patient’s reported address. In certain cases, such as individuals deemed to be homeless, patients will presumptively qualify for 100% financial assistance for their cost-sharing in the form of a charity care adjustment. An uninsured or self-pay patient falling below 250% of the federal poverty guidelines would receive an automatic discount before a bill is sent.</p><h2>Benefits to Patients</h2><p>The effort to hardwire presumptive eligibility into the health system’s financial assistance processes was driven by a desire to streamline the process for patients and the growing Corewell Health system without supplanting entirely the real human conversations between patients and their providers about their coverage and ability to pay. In addition to increasing efficiency for patients, the presumptive eligibility process expands financial assistance access to patients who qualify but have not applied through the traditional process. This enables Corewell to support a broader population of patients through its charity care program.</p><p>Finally, presumptive eligibility brings added consistency to the financial assistance program across the Corewell Health system. Presumptive eligibility is applied to both professional and technical service line items, and the same policy is applied throughout the entire system, ensuring consistency across locations and with physicians.</p><h2>Lessons Learned</h2><p>As Corewell Health worked to build and implement the presumptive eligibility tool into their process, the team quickly learned the importance of investing time with vendors and understanding the algorithm. It took six to eight months to capture the correct data and adjust the tool and discount automation before it was fully operational, and the process is always being monitored.</p><p>Corewell recommends that hospitals developing a presumptive eligibility process ensure that finance, reimbursement and other departments involved have deliberate and intentional conversations about how the process is working and what the timing will be, and model the likely impact on reserves, bad debt and charity care.</p><p>The Corewell team stressed the need to work with their ecosystem of suppliers and vendors, including Epic, to leverage the tools across all locations. For example, Corewell works closely with Epic to automate the write-off logic and file data returned from FinThrive to ensure a consistent process for all patients who qualify. Strong vendor partners were particularly instrumental in the testing phase, identifying ranges and populating scores to drive the evolution of the automated presumptive eligibility process. Along with vendor partners, Corewell began with an interface to trigger the query during the registration process, and ultimately determined that moving registration and financial counseling teams under the same umbrella at Corewell was advantageous.</p><p>The team at Corewell notes that presumptive eligibility tools need to be monitored frequently to ensure they are capturing the appropriate data to identify eligible patients, as well as tracking other markers of charity care eligibility. To support this work, Corewell recommends that financial counselors and data analytics teams work collaboratively to test and retest algorithms and advises that the teams be trained to fully understand the system’s financial assistance policies and practices. It is equally important to fully train front-end and registration staff as the process of collecting and inputting information requires careful attention to detail. The Corewell team monitors data monthly to review traditional counseling versus automation and adjust as appropriate.</p><h2>Next Steps</h2><p>In the future, Corewell envisions presumptive eligibility playing an even greater role in providing financial assistance paths for uninsured patients, as well as potentially for certain categories of underinsured patients. Moving forward, financial counselors will remain a key element of the charity care and financial assistance process at Corewell Health, continuing to offer presentations, discussions and trainings about related policies and processes with all staff, and particularly clinical teams and discharge planners, to ensure all are aware of the support Corewell’s financial counselors can provide. The system is also engaged in active conversations with community partners to determine where financial counselors are most needed and will be identifying additional opportunities to leverage this effort for future health equity and social drivers of health work.</p></div><div class="col-md-4"><div class="sticky"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Corewell-Health.pdf"" target="_blank" title="Click here to download the Presumptive Eligibility Case Study: Corewell Health PDF.">Download the Case Study PDF</a></div><a href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Corewell-Health.pdf"" target="_blank" title="Click here to download the Presumptive Eligibility Case Study: Corewell Health PDF."><img src="/sites/default/files/inline-images/Page-1-Presumptive-Eligibility-Case-Study-Corewell-Health.png" data-entity-uuid="8fa2da21-c196-4678-a583-7e46106b14f1" data-entity-type="file" alt="Presumptive Eligibility Case Study: Corewell Health page 1." width="695" height="900"></a><hr><div><a class="btn btn-wide btn-primary" href="/advocacy/advocacy-issues/presumptive-eligibility" target="_blank" title="Click here to see advocacy resources on Presumptive Eligibility.">Advocacy Issue: Presumptive Eligibility</a></div><hr><div><a class="btn btn-wide btn-primary" href="/fact-sheets/2025-05-30-fact-sheet-presumptive-eligibility" target="_blank" title="Click here to read the Fact Sheet: Presumptive Eligibility.">Fact Sheet: Presumptive Eligibility</a></div><hr><div><a class="btn btn-wide btn-primary" href="/case-studies/2025-06-02-presumptive-eligibility-case-study-houston-methodist" target="_blank" title="Click here to read the Presumptive Eligibility Case Study: Houston Methodist.">Presumptive Eligibility Case Study: Houston Methodist</a></div></div></div></div></div> h2 { color: #9d2235; } h3 { color: #9d2235; } div.sticky { position: sticky; top: 0; } Mon, 07 Jul 2025 09:37:33 -0500 Presumptive Eligibility /case-studies/2025-06-02-presumptive-eligibility-case-study-houston-methodist <div class="container"><div class="row"><div class="col-md-8"><h2>Background</h2><p>Houston Methodist, an eight-hospital system headquartered in Houston, Texas, is leading the way by reenvisioning its financial assistance policies to meet the changing needs of its community. At Houston Methodist, multiple teams are involved in finding resources for all uninsured and underinsured patients receiving medically necessary health care. These teams undertake Texas Medicaid eligibility screening, financial counseling and guidance on estimated and known financial obligations, as well as screening for financial assistance. Houston Methodist maintains a standard financial assistance policy, which utilizes a traditional application and evaluation process, as well as undertakes presumptive eligibility screenings for charity care; each of these components of the charity care program is described in more detail below.</p><p>All uninsured inpatients are screened for Texas Medicaid eligibility based on their income and other criteria. Teams of financial counselors also assist patients who proactively seek financial advice before receiving scheduled services. The teams use these encounters to estimate financial obligations, including financial assistance eligibility, and discuss payment options.</p><p>For uninsured or underinsured patients who receive unplanned or unscheduled services, typically following direct admission or entry through the emergency department, presumptive eligibility for financial assistance screenings are performed within one day of discharge.</p><h2>Presumptive Financial Assistance Mechanics</h2><p>Houston Methodist is committed to providing financial assistance to patients in need. All uninsured and underinsured patients who have not otherwise made a financial arrangement are presumptively screened for financial assistance within one day of discharge. This presumptive screening process uses an independent third-party firm to provide electronic data on certain patient characteristics, such as the number of members in the household and household income. When received, the hospital’s patient accounting system converts the data into a percentage of the federal poverty level (FPL) and then automatically applies financial assistance discounts. Patients who receive a financial assistance discount of 100% off gross charges never receive a bill; patients with partial discounts will receive a bill for the discounted amount. Patients who receive a discounted bill, but need additional discounts, can complete the traditional application process discussed below.</p><div class="row"><div class="col-md-8"><p>To account for the possibility that the presumptive eligibility tool may miss eligible patients, Houston Methodist will run certain patient populations through the screening process several times at various timing intervals. Houston Methodist advises that hospitals developing these programs not let the potential “exceptions” to the automation be a deterrent to implementing the process. Approximately 76% of total financial assistance at Houston Methodist is now provided through the presumptive eligibility process.</p></div><div class="col-md-4"><div><p>Don’t let automation exceptions and outliers deter you. Keep the big picture in mind: helping the most patients, the best you can.</p><p><strong>– Kimberley Doucet</strong></p></div></div></div><h2>Traditional Financial Assistance Process</h2><p>Through its traditional financial assistance process, Houston Methodist invites patients to submit information to qualify for financial assistance. The formula for financial assistance eligibility includes the number of members in the household and household income relative to the FPL. The following financial assistance discounts are available:</p><ul><li>Less than 200% of the FPL: 100% discount off gross charges.</li><li>Between 201% and 500% of the FPL: 95% - 55% discount off average insurance payment, and the patient will never pay more than 5% of household income.</li><li>Greater than 500% of the FPL: discounts are available to ensure that the patient will never pay more than 10% of household income.</li></ul><p>Houston Methodist reviews each patient holistically for financial assistance rather than on an episode-by-episode basis. This means that once the patient has reached their one-time maximum payment (5% - 10% of household income), they will receive 100% discounted care for the remaining calendar year. This includes hospital and professional (i.e., Houston Methodist physician) account balances.</p><p>Houston Methodist continues to streamline its financial assistance application process. To apply for financial assistance, only two data elements are required for determining financial assistance eligibility: number of members in the household and household income. Asset testing and verification are no longer required. Houston Methodist provides everything a patient may need to know and access the financial assistance process on its website, including the financial assistance application, a copy of its financial assistance policy and a further plain language summary. These materials are translated into 18 different languages. Houston Methodist’s goal is to meet the needs of the patients seeking financial assistance based on their preferred delivery method. Patients can securely upload copies of required documents through Epic’s MyChart or provide a printed copy of their documents if they prefer. After Houston Methodist receives a completed application, a response is provided to the patient within an average of 7.5 days.</p><p>Approximately 24% of total financial assistance is provided through the traditional application process.</p><h2>Insured Patients</h2><p>Houston Methodist follows a traditional collections policy for insured patients responsible for a portion of the payment due to their deductible or other cost-sharing obligations. The patient is billed in various intervals for 120 days after the insurance balance is settled. All unpaid patient balances, excluding those on an established payment arrangement, are screened for presumptive eligibility for charity care at day 119. Houston Methodist endeavors to ensure that no financial assistance-eligible patient’s unpaid balance is classified as a bad debt.</p><h2>Other Considerations</h2><p>For those patients who are not eligible for any of the discounts described above, Houston Methodist has a self-pay discount policy that currently allows for a 50% discount off gross charges. All patients who receive a discounted bill are also eligible for an interest-free monthly payment plan for up to 36 months. At no time in the collection cycle does a patient get reported to a collections bureau, have wages garnished or a lien filed against them, or receive harassing and harsh communications. And Houston Methodist never sells its debt to an outside collections firm.</p><h2>Lessons Learned</h2><div class="row"><div class="col-md-8"><p>Timing is everything. Houston Methodist views the application of financial discounts in coordination with the first billing statement as crucial for successful patient engagement.</p><h3>Be fearless in being generous.</h3><p>Houston Methodist continues to reimagine its financial assistance program. Don’t be deterred by worries of over-inclusion. Develop a solid process within your organization’s financial means and proceed with a goal of helping as many patients in need as possible.</p></div><div class="col-md-4"><div><p>Be fearless in being generous. The process of presumptive eligibility is sound, so be bold when thinking about people and how you can help.</p><p><strong>– Lisa Schillaci</strong></p></div></div></div><h3>Hands off.</h3><p>Design the program with automation in mind to reduce manual labor and expedite the process. This is a win-win for both the staff and the patient. Seventy-six percent of Houston Methodist’s financial assistance is presumptive. And of that, 95% of the presumptive financial assistance is “hands-free.” Automation allows a quicker response to the patient. By automating the process, the number of days to respond to the patient was reduced from over 30 days to now an average of 7.5 days.</p><h3>Challenge traditional thinking.</h3><p>This process surfaced instances of patients in all financial classes who qualified for financial assistance, including patients with Medicare, commercial or military coverage. Houston Methodist challenged the notion that insured patients don’t experience bad debt.</p><h2>Next Steps</h2><h3>Annual Review</h3><p>Houston Methodist’s commitment to providing financial assistance to patients goes beyond just establishing these policies. The system is committed to performing annual reviews and continuing to develop all financial assistance and charity care policies and the presumptive eligibility screening tools used.</p><h3>Going Paperless</h3><p>Leadership is considering expanding the screening tools to reduce traditional paper applications further and broaden access to financial assistance, reducing the burden of administrative tasks for patients.</p><h3>Analysis</h3><p>Additionally, leaders are considering whether and how to use the presumptive eligibility screening tool and associated data to identify trends that could influence health equity work around social drivers of health. This type of analysis may be able to further identify populations of patients that are more frequently underinsured, advancing work around ensuring adequate coverage for the broader community.</p></div><div class="col-md-4"><div class="sticky"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Houston-Methodist.pdf" target="_blank" title="Click here to download the Presumptive Eligibility Case Study: Houston Methodist PDF.">Download the Case Study PDF</a></div><a href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Houston-Methodist.pdf"><img src="/sites/default/files/inline-images/Page-1-Presumptive-Eligibility-Case-Study-Houston-Methodist.png" data-entity-uuid="19acd3f1-365f-477b-b50f-88e3fe814dc5" data-entity-type="file" alt="Presumptive Eligibility Case Study: Houston Methodist page 1." width="695" height="900"></a><hr><div><a class="btn btn-wide btn-primary" href="/advocacy/advocacy-issues/presumptive-eligibility" target="_blank" title="Click here to see advocacy resources on Presumptive Eligibility.">Advocacy Issue: Presumptive Eligibility</a></div><hr><div><a class="btn btn-wide btn-primary" href="/fact-sheets/2025-05-30-fact-sheet-presumptive-eligibility" target="_blank" title="Click here to read the Fact Sheet: Presumptive Eligibility.">Fact Sheet: Presumptive Eligibility</a></div><hr><div><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Corewell-Health.pdf" target="_blank" title="Click here to read the Presumptive Eligibility Case Study: Corewell Health.">Presumptive Eligibility Case Study: Corewell Health</a></div></div></div></div></div> h2 { color: #9d2235; } h3 { color: #9d2235; } div.sticky { position: sticky; top: 0; } Mon, 02 Jun 2025 13:24:19 -0500 Presumptive Eligibility /fact-sheets/2025-05-30-fact-sheet-presumptive-eligibility <div class="container"><div class="row"><div class="col-md-8"><h2>The Issue</h2><p>A growing trend in hospital and health system financial assistance programs is the incorporation of presumptive eligibility screenings for charity care. Presumptive eligibility refers to an automated process of analyzing readily available financial and other data to approximate a patient’s financial need. Implementing these presumptive eligibility screenings provides numerous benefits to both patients and the hospitals that serve them. Technological improvements and an increase in third-party solutions have made presumptive eligibility programs more accurate and easier to implement. This fact sheet provides hospitals and health systems with an overview of key considerations for implementing presumptive eligibility for charity care. <strong>The AHA encourages all members to consider whether some form of presumptive eligibility for charity care makes sense for their organization.</strong></p><h2>Background</h2><div class="row"><div class="col-md-6"><p>The use of presumptive eligibility for charity care — either in addition to or instead of traditional financial assistance application processes — has become more widespread in recent years. Presumptive eligibility screenings use information like income, enrollment in means-tested government programs, credit reports or other data to “presume” that a patient qualifies for financial assistance and how much financial assistance should be provided. Hospitals then automatically apply a discount to the cost of care without first requiring patients to complete an application. Automatically identifying certain patients as presumptively qualifying for charity care reduces costs and other burdens for both patients and hospitals and health systems.</p></div><div class="col-md-6"><h3>   AHA Patient Billing Guidelines</h3><p>For decades, the AHA has actively engaged in identifying and promoting best practices in patient billing. The AHA’s latest voluntary patient billing guidance, released in 2020, includes recommendations for financial assistance programs and debt collection. Among other things, the 2020 guidelines outline best practices and standards for assisting patients who cannot pay for the care they receive and protecting patients from certain debt collection practices, such as garnishment of wages, liens, interest on debt, adverse credit reporting and lawsuits.</p></div></div><p>Hospitals and health systems are already providing generous amounts of charity care to patients. According to a review of the IRS Form 990 Schedule H data, over 70% of tax-exempt hospitals provide free care at an income limit of at least 200% of the federal poverty level (FPL), while 15% extend free care at a broader threshold of at least 300% of FPL. In addition, over 50% of hospitals provide discounted care at an income limit of at least 400% of FPL, and over 80% provide discounted care at an income limit of 300% of FPL. Many hospitals incorporate other measures, such as the amount of the patient’s bill, to determine appropriate discount or financial aid amounts. On top of these existing charity care efforts, presumptive eligibility programs can help reduce low-income patients’ financial liability.</p><p>At the same time, providers have reported that they are only collecting about half (47.6%) of what patients owe them, with over 50% of their bad debt stemming from patients with some form of health insurance coverage.<a href="#fn1"><sup>1</sup></a> Presumptive eligibility for charity care expands current financial assistance to capture patients whose unpaid invoices might otherwise become bad debt and generate additional financial hardship for both patients and hospitals.</p><p>In short, presumptive eligibility programs benefit patients and hospitals and health systems by reducing administrative burdens on each, making care more affordable and accessible, and anticipating efforts by state legislatures and others that have sought to regulate hospital billing and collections practices — including by mandating presumptive eligibility screenings in certain circumstances.</p><h2>Hospitals and Health Systems Leading the Way</h2><p>Many hospitals and health systems across the country are proactively conducting presumptive eligibility screenings for charity care. Below, we highlight some health systems and hospitals that are leading the way. We provide an overview of each of their programs and key lessons learned in the sections that follow, but more detailed information on these programs can be found in the AHA’s Presumptive Eligibility Toolkit.</p><h3>Corewell Health</h3><p>Corewell Health, a 21-hospital system in Grand Rapids, Mich., has built presumptive eligibility for charity care into its robust financial assistance process. Corewell financial counselors and data analytics teams partnered with FinThrive to build out the necessary systems and processes to screen patients toward the end of the billing cycle. Implementing presumptive eligibility has enabled Corewell to offer financial assistance more broadly, as well as enhanced efficiency and consistency in the process generally, generating positive feedback from patients and stakeholders alike.</p><h3>Houston Methodist</h3><p>Houston Methodist, an eight-hospital system in Houston, Texas, has implemented presumptive eligibility for charity care for every patient at multiple stages of the patient’s engagement with the system. Working with a third-party vendor, Houston Methodist built an automated screening tool in order to more effectively identify and offer charity care to patients who qualify. Houston Methodist continues to refine its presumptive eligibility tool and processes to identify opportunities to enhance and expand its program.</p><h2>Why Consider Presumptive Eligibility for Charity Care</h2><p>The benefits of adopting presumptive eligibility for charity care are far reaching, from helping patients avoid complex financial assistance application processes and the long-term impact of medical debt, to precluding the need for onerous legislatively imposed policies (as some states are beginning to do), and mitigating the potential risks associated with certain aggressive collections efforts.</p><h3>Presumptive Eligibility Offers Financial and Efficiency Benefits to Patients</h3><p>Presumptive eligibility for charity care offers important financial protections for patients. Although health insurance is intended to be the primary mechanism to cover health care costs, many Americans remain uninsured. Moreover, inadequate health insurance coverage and health plans that intentionally push excessive costs onto patients leave many Americans financially vulnerable when seeking medical care. This is especially true when patients are met with unexpected or especially complex care. As a result, many Americans, including those with health insurance coverage, struggle to pay for their care. Presumptive eligibility screenings can identify these patients more efficiently, helping to remove any financial barriers to getting the care they need.</p><p>For a variety of reasons, however, these patients do not always seek financial assistance through the traditional application pathways. As much as hospitals have tried to simplify the application processes, we know that some patients who may otherwise be eligible for assistance do not complete the process.</p><p>In fact, a complex framework of federal and state law governing the application process has only worsened the situation.<a href="#fn2"><sup>2</sup></a> While these laws set an important standard to help many patients avoid unaffordable medical bills, they also can create barriers to financial assistance. For example, varying requirements around financial assistance policies and different ways of implementing these requirements can generate daunting financial aid applications that eligible patients may opt to forgo. A recent report addressing this challenge quoted a hospital leader who had tried to simplify the process but was advised that the law precluded that. “[W]e tried to move to a one-page Charity Care application, and we were told by our auditors we could not because these were required questions that we have to ask. So that’s what we do.”<a href="#fn3"><sup>3</sup></a> Presumptive eligibility, by providing an avenue for charity care for eligible individuals who may not have completed a financial assistance application, has an important role to play in addressing these challenges. By streamlining the assistance process, fewer patients will have to apply to get the assistance they are otherwise entitled to.</p><h3>Presumptive Eligibility Offers Financial and Efficiency Benefits to Hospitals and Health Systems, Too</h3><p>Hospitals and health systems face a range of challenges in billing and collections that can be solved, in part, by a presumptive eligibility process.</p><p>First, billing and collections can be a financially costly and administratively burdensome — if necessary — effort for hospitals and health systems. The cost-to-collect, which measures the ratio of net operating revenue to revenue cycle operations expenses, takes into account the cost of staff salaries and technology to do both initial billing as well as the time spent working and re-working claims.<a href="#fn4"><sup>4</sup></a> According to a study by AKASA surveying hospital CFOs and revenue cycle leaders across the country, the cost-to-collect averages 3.68% and ranges as high as 5% or greater for nearly 20% of surveyed hospitals and health systems.<a href="#fn5"><sup>5</sup></a> Reducing collections efforts unlikely to bear fruit can help mitigate these costs; even smaller percentage point changes in the cost-to-collect can translate into substantial savings for a hospital or health system.</p><p>Some states are turning their attention to hospital financial assistance and debt collection practices. And while it is important to remind regulators of how inadequate health care coverage and coverage decisions by insurers exposes patients to the risk of medical debt and financial ruin, it also behooves hospitals and health systems to consider presumptive eligibility programs to preempt burdensome laws and requirements.</p><p>A presumptive eligibility process can help hospitals and health systems ensure that they are only pursuing collections activities against patients who can pay but refuse to do so. This can help focus public attention on the critical lifesaving work at the core of a hospital’s mission.</p><h2>Lessons Learned</h2><p>The hospitals that have implemented presumptive eligibility for charity care shared a number of lessons to help members who may be considering launching similar efforts:</p><ol><li>Aligning presumptive eligibility processes with existing electronic health records and IT processes helps to efficiently operationalize presumptive eligibility.</li><li>Facilitating collaboration among different business units in support of presumptive eligibility provides ancillary benefits and process improvement opportunities in the revenue cycle space.</li><li>Coordinating a robust communications rollout helps to engage both internal and external stakeholders and ensure appropriate transparency.</li><li>Establishing protocols to monitor the impact of the presumptive eligibility program will enable ongoing modifications to ensure maximum effectiveness.</li><li>The benefits of applying presumptive eligibility for charity care to all patients prior to the collection process outweigh the costs of doing so later, after incurring costs to collect payment and the potential for reputational harm.</li><li>Presumptive eligibility determinations promote efficiency by avoiding the complex circumstance-heavy analysis of whether and how to pursue unpaid bills.</li></ol><h2>Conclusion</h2><p>Presumptive eligibility screenings are a tool that hospitals and health systems are increasingly embracing to make charity care more accessible for patients. Presumptive eligibility can help both hospitals and patients to streamline charity care processes, ensure key patient populations are accessing the appropriate level of charity care, and limit the costs and burdens associated with downstream collections efforts.</p><hr><h3>End Notes</h3><ol><li id="fn1"><a href="https://static1.squarespace.com/static/65d790c56a64c0761fd9171e/t/65e89b6675bb5378dd694cf2/1709742959117/KPI%2BBenchmark%2BReport%2BQ1%2B2024.pdf" target="_blank">static1.squarespace.com/static/65d790c56a64c0761fd9171e/t/65e89b6675bb5378dd694cf2/1709742959117/ KPI%2BBenchmark%2BReport%2BQ1%2B2024.pdf</a></li><li id="fn2">Federal law requires tax exempt hospitals to maintain a financial aid policy and imposes limits on when and how a hospital can pursue “extraordinary collections actions,” e.g., selling the medical debt or placing a lien on a patient’s home. And many states have opted to impose stricter requirements than the federal baseline. For example, 20 states mandate financial assistance policies that set minimum standards for when the policies apply, such as defining eligibility criteria.</li><li id="fn3"><a href="https://unduemedicaldebt.org/navigating-the-maze-of-health-care-finances-a-revenue-cycle-perspective/" target="_blank" title="Undue Medical Debt: Navigating the Maze of Health Care Finances: A Revenue Cycle Perspective">unduemedicaldebt.org/navigating-the-maze-of-health-care-finances-a-revenue-cycle-perspective/</a></li><li id="fn4"><a href="https://akasa.com/press/survey-cost-to-collect-lower-with-automation/" target="_blank" title="Akasa: Survey: Cost-to-Collect Nearly .25% Lower for Hospitals and Health Systems That Leverage Automation in the Revenue Cycle">akasa.com/press/survey-cost-to-collect-lower-with-automation/</a></li><li id="fn5"><a href="https://akasa.com/press/survey-cost-to-collect-lower-with-automation/" target="_blank" title="Akasa: Survey: Cost-to-Collect Nearly .25% Lower for Hospitals and Health Systems That Leverage Automation in the Revenue Cycle">akasa.com/press/survey-cost-to-collect-lower-with-automation/</a></li></ol></div><div class="col-md-4"><div class="sticky"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/Fact-Sheet-Presumptive-Eligibility.pdf" target="_blank" title="Click here to download the Fact Sheet: Presumptive Eligibility PDF.">Download the Fact Sheet PDF</a></div><a href="/system/files/media/file/2025/05/Fact-Sheet-Presumptive-Eligibility.pdf"><img src="/sites/default/files/inline-images/Page-1-Fact-Sheet-Presumptive-Eligibility.png" data-entity-uuid="ed08c8a3-71e7-4afc-82e7-d528eb955778" data-entity-type="file" alt="Fact Sheet: Presumptive Eligibility page 1." width="695" height="900"></a><hr><div><a class="btn btn-wide btn-primary" href="/advocacy/advocacy-issues/presumptive-eligibility" target="_blank" title="Click here to see advocacy resources on Presumptive Eligibility.">Advocacy Issue: Presumptive Eligibility</a></div><hr><div><a class="btn btn-wide btn-primary" href="/case-studies/2025-06-02-presumptive-eligibility-case-study-houston-methodist" target="_blank" title="Click here to read the Presumptive Eligibility Case Study: Houston Methodist.">Presumptive Eligibility Case Study: Houston Methodist</a></div><hr><div><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/Presumptive-Eligibility-Case-Study-Corewell-Health.pdf" target="_blank" title="Click here to Presumptive Eligibility Case Study: Corewell Health.">Presumptive Eligibility Case Study: Corewell Health</a></div></div></div></div></div> h2 { color: #9d2235; } h3 { color: #9d2235; } div.sticky { position: sticky; top: 0; } Fri, 30 May 2025 15:32:32 -0500 Presumptive Eligibility /advocacy/advocacy-issues/presumptive-eligibility <div class="container"><div class="row"><div class="col-md-8"><p>A growing trend in hospital and health system financial assistance programs is the incorporation of presumptive eligibility screenings for charity care. Presumptive eligibility refers to an automated process of analyzing readily available financial and other data to approximate a patient’s financial need. Implementing these presumptive eligibility screenings provides numerous benefits to both patients and the hospitals that serve them. Technological improvements and an increase in third-party solutions have made presumptive eligibility programs more accurate and easier to implement.</p><p>This fact sheet provides hospitals and health systems with an overview of key considerations for implementing presumptive eligibility for charity care. The AHA encourages all members to consider whether some form of presumptive eligibility for charity care makes sense for their organization.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Resources</h2><ul><li><a href="/fact-sheets/2025-05-30-fact-sheet-presumptive-eligibility" target="_blank" title="Fact Sheet: Presumptive Eligibility">Fact Sheet: Presumptive Eligibility</a></li><li><a href="/case-studies/2025-07-07-presumptive-eligibility-case-study-corewell-health" target="_blank" title="Click here to read the Presumptive Eligibility Case Study: Corewell Health.">Presumptive Eligibility Case Study: Corewell Health</a></li><li><a href="/case-studies/2025-06-02-presumptive-eligibility-case-study-houston-methodist" target="_blank" title="Click here to read the Presumptive Eligibility Case Study: Houston Methodist.">Presumptive Eligibility Case Study: Houston Methodist</a></li></ul></div></div></div><div class="col-md-4"><p><div class="views-element-container"> <section class="top-level-view js-view-dom-id-0529cb7bc6468d13f5f6fbeb43264f933ad12c2ac9a0a157f367f0c8d9d6fdf4 resource-block"> <h3>Latest Presumptive Eligibility Advocacy and News</h3> <div class="resource-wrapper"> <div class="resource-view"> <div class="article views-row"> <div class="views-field views-field-field-access-level"> <div class="field-content"> <div class="meta custom-lock-position"> <div class="views-field-access-level access-type-member-non-fed" data-toggle="tooltip" data-placement="bottom" title="Members only"><a href="/taxonomy/term/280" hreflang="en">Member Non-Fed</a></div> </div></div> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/case-studies/2025-07-07-presumptive-eligibility-case-study-corewell-health" hreflang="en">Presumptive Eligibility Case Study: Corewell Health</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-07-07T09:37:33-05:00">Jul 7, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-field-access-level"> <div class="field-content"> <div class="meta custom-lock-position"> <div class="views-field-access-level access-type-member-non-fed" data-toggle="tooltip" data-placement="bottom" title="Members only"><a href="/taxonomy/term/280" hreflang="en">Member Non-Fed</a></div> </div></div> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/case-studies/2025-06-02-presumptive-eligibility-case-study-houston-methodist" hreflang="en">Presumptive Eligibility Case Study: Houston Methodist</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-06-02T13:24:19-05:00">Jun 2, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-field-access-level"> <div class="field-content"> <div class="meta custom-lock-position"> <div class="views-field-access-level access-type-member-non-fed" data-toggle="tooltip" data-placement="bottom" title="Members only"><a href="/taxonomy/term/280" hreflang="en">Member Non-Fed</a></div> </div></div> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/fact-sheets/2025-05-30-fact-sheet-presumptive-eligibility" hreflang="en">Fact Sheet: Presumptive Eligibility</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-05-30T15:32:32-05:00">May 30, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-field-access-level"> <div class="field-content"> <div class="meta custom-lock-position"> <div class="views-field-access-level access-type-member-non-fed" data-toggle="tooltip" data-placement="bottom" title="Members only"><a href="/taxonomy/term/280" hreflang="en">Member Non-Fed</a></div> </div></div> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/advocacy/advocacy-issues/presumptive-eligibility" hreflang="en">Advocacy Issue: Presumptive Eligibility</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2025-05-30T10:10:38-05:00">May 30, 2025</time> </span> </div></div> <div class="article views-row"> <div class="views-field views-field-field-access-level"> <div class="field-content"> <div class="meta custom-lock-position"> <div class="views-field-access-level access-type-public" data-toggle="tooltip" data-placement="bottom" title="Members only"><a href="/taxonomy/term/278" hreflang="en">Public</a></div> </div></div> </div><div class="views-field views-field-title"> <span class="field-content"><a href="/testimony/2024-07-10-aha-senate-statement-what-can-congress-do-end-medical-debt-crisis-america" hreflang="en">AHA Senate Statement on What Can Congress Do to End the Medical Debt Crisis in America</a></span> </div><div class="views-field views-field-created"> <span class="field-content"><time datetime="2024-07-10T12:11:44-05:00">Jul 10, 2024</time> </span> </div></div> </div> </div> <div class="more-link"><a href="/topics/presumptive-eligibility">More on Presumptive Eligibility</a></div> </section> </div> </p></div></div></div> .meta.custom-lock-position { position: relative; top: 0px; right: inherit; display: block; float: right; } Fri, 30 May 2025 10:10:38 -0500 Presumptive Eligibility /testimony/2024-07-10-aha-senate-statement-what-can-congress-do-end-medical-debt-crisis-america <p class="text-align-center"><strong>Statement</strong><br><strong>of the</strong><br><strong>���������� Association</strong><br><strong>for the</strong><br><strong>Committee on Health, Education, Labor & Pensions</strong><br><strong>of the</strong><br><strong>United States Senate</strong><br><strong>“What Can Congress Do to End the Medical Debt Crisis in America?”</strong><br><br><strong>July 11, 2024</strong><br> </p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) writes to share the hospital field’s comments on medical debt. While we appreciate Congress’s interest in addressing medical debt, we encourage policymakers to do more to prevent patients from incurring this type of debt, rather than focusing on credit reporting and alleviating acquired debt.</p><h2>OVERVIEW OF MEDICAL DEBT</h2><p>More Americans than ever are dealing with medical debt, a consequence of patients not paying some or all their health care bills, despite benefiting from the highest levels of insurance coverage in history. Unlike other types of debt, medical debt can be unexpected, due to an accident or illness. These debts can impact patients’ abilities to pay for necessities, including food, clothing and household items, and can result in patients using savings or loans to address their medical debt. Recent polling by the KFF found that “41% of adults have health care debt according to a broader definition, which includes health care debt on credit cards or owed to family members.”<sup>1 </sup>The survey also showed that:</p><ul><li>U.S. residents owe at least $220 billion in medical debt.</li><li>Approximately 14 million people (6% of adults) in the U.S. owe over $1,000 in medical debt.</li><li>About three million people (1% of adults) owe medical debt of more than $10,000.</li></ul><p>Hospitals and health systems are very concerned about patients’ medical debt. While health insurance is intended to be the primary mechanism to protect patients from unexpected and unaffordable health care costs, for too many that coverage is either unavailable or insufficient. Trends in health insurance coverage that are driving an increase in medical debt include inadequate enrollment in comprehensive health care coverage, growth in high-deductible and skinny health plans that intentionally push more costs onto patients and misleading health plan practices that confuse patients’ understanding of their coverage. These gaps in coverage leave individuals financially vulnerable when seeking medical care. The primary causes of medical debt include the following.</p><ul><li><strong>There are still too many uninsured Americans</strong>. Affordable, comprehensive health care coverage is the most important protection against medical debt. While the U.S. health care system has achieved higher coverage rates over the past decade, gaps remain.</li><li><strong>High deductibles subject many Americans to cost-sharing they cannot afford</strong>. High-deductible plans are designed to increase patients’ financial exposure through high cost-sharing in exchange for lower monthly premiums. Yet many individuals enrolled in high-deductible plans find they cannot manage their portion of health plan expenses. A Federal Reserve report found that 37% of adults could not afford a $400 emergency, an amount $1,000 less than the average general annual deductible for single, employer-sponsored coverage<sup>.2</sup></li><li><strong>Certain health plans provide inadequate benefits that frequently lead to surprise gaps in coverage</strong>. Short-term, limited-duration health plans and health-sharing ministries cover fewer benefits and include few to no consumer protections, such as required coverage of pre-existing conditions and limits on out-of-pocket costs. Patients with these types of plans often find themselves responsible for their entire medical bill without help from their health plan, including critical services such as emergency medical and oncology care. These denials can lead to an accumulation of significant medical debt.<sup>3</sup></li><li><strong>Complex health plan benefit design and misleading marketing can expose patients to unexpected costs</strong>. Many health plans have complex benefit designs that are not transparent to patients, such as what is covered pre-deductible, the interaction between point-of-service copays, coinsurance and deductibles, and poor communication and education about what the plan covers. For example, a recent National Association of Insurance Commissioners report found significant gaps and inconsistencies in how insurers share information about pre-deductible, no-cost-sharing preventive services with their members, resulting in a “meaningful barrier to effective understanding and use of preventive service benefits.”<sup>4</sup></li></ul><h2>HOSPITALS AND HEALTH SYSTEMS ADDRESSING DEBT</h2><p>Hospitals are the only part of the health care sector that provide services to patients regardless of their ability to pay. They underscore that commitment by offering financial and other assistance, including helping patients qualify for federal and state health care programs, such as Medicaid. In doing so, patients can receive regular preventive care, not just episodic care for serious injuries or illnesses. In addition, hospitals absorb billions of dollars of losses for patients who cannot pay their bills, mainly due to inadequate commercial insurance coverage; in 2020, the latest figure available, hospitals provided more than $42 billion in uncompensated care.<sup>5</sup></p><p>This is why hospitals are staunch supporters of ensuring everyone is enrolled in some form of comprehensive coverage. However, we appreciate that closing the remaining coverage gaps may be a longer-term solution and that more immediate steps can be taken. To that end, the AHA has routinely developed patient billing guidelines to help prevent patients from incurring medical debt. The AHA’s Board of Trustees adopted the most recent <a href="/standardsguidelines/2020-10-15-patient-billing-guidelines" target="_blank">set of guidelines</a> in 2020, which reaffirm the hospital field’s commitment to:</p><ul><li>Treating all people equitably, with dignity, respect and compassion.</li><li>Serving the emergency health care needs of all, regardless of a patient’s ability to pay.</li><li>Assisting patients who cannot pay for part or all the care they receive.</li></ul><p>Tax-exempt hospitals are also subject to a federal statute that requires written financial assistance and debt collection policies. These hospitals must wait at least 120 days after sending the initial bill to initiate extraordinary collections actions, notify the patient at least 30 days before taking the collections action and allow patients to submit financial aid applications for up to 240 days following the initial bill.</p><p>Several of the AHA’s guidelines directly address medical debt, including encouraging hospitals to forego adverse credit reporting of outstanding patient bills. So far, nearly 2,800 hospitals and health systems have affirmed their commitment to the guidelines, and the AHA revisits them regularly for updates.</p><p>Some hospitals are taking additional steps to help all eligible patients afford their medical bills, including using programs originally intended for the uninsured. These “presumptive eligibility” endeavors include proactively screening patients for financial assistance eligibility, regardless of insurance coverage or whether a patient has completed a financial aid application. The goal is to limit the need for hospitals to seek repayment by reducing patients’ financial liability to a more affordable amount.</p><h2>FEDERAL OVERSIGHT OF MEDICAL DEBT</h2><p>Policymakers at the federal level have acted to address the burden of medical debt through statutory changes, such as collection practices of tax-exempt hospitals, as well as those made through the Fair Debt Collection Practices Act, as overseen by the Consumer Financial Protection Bureau (CFPB), which impact how medical debt is displayed on credit reports. Recently, CFPB issued medical debt payment products and medical debt collection practices requests for information and a proposed rule to ban credit reporting agencies from incorporating medical debt when calculating credit scores.</p><p>While hospitals and health systems are assisting patients with their bills, policymakers must do more to prevent them from incurring these debts. Rather than focusing on debt relief grants or putting additional administrative burdens on providers, Congress must ensure patients can access comprehensive, affordable health insurance products.</p><p>Some of these suggested changes include:</p><ul><li> Restricting the sale of high-deductible health plans to only those individuals with the demonstrated means to afford the associated cost-sharing.</li><li>Prohibiting the sale of health-sharing ministry products and short-term limited-duration plans that go longer than 90 days.</li><li>Lowering the maximum out-of-pocket cost-sharing limits.</li><li>Eliminating the use of deductibles and co-insurance, and instead relying solely on flat co-payments which are easier for patients to anticipate and for providers to administer.</li><li>Removing providers from the collection of cost-sharing by requiring health plans to collect directly from their enrollees the cost-sharing payments they impose. This approach would eliminate most patient bills from providers altogether.</li></ul><p>Congress could also do more to improve health literacy by funding health navigators, community health workers and financial advisors to assist patients in selecting appropriate health insurance products.</p><h2>CONCLUSION</h2><p>Thank you for your consideration of the AHA’s comments on issues related to medical debt. We look forward to continuing to work with you to address these important topics on behalf of our patients and communities.</p><p>__________</p><p><small class="sm"><sup>1</sup> </small><a class="ck-anchor" href="https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/" id="https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/"><small class="sm">https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/</small></a><small class="sm"> </small><br><small class="sm"><sup>2</sup> </small><a class="ck-anchor" href="https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm" id="https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm"><small class="sm">https://www.federalreserve.gov/publications/2023-economic-well-being-of-us-households-in-2022-expenses.htm</small></a><br><small class="sm"><sup>3 </sup></small><a class="ck-anchor" href="https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/" id="https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/"><small class="sm">https://kffhealthnews.org/news/sham-sharing-ministries-test-faith-of-patients-and-insurance-regulators/</small></a><small class="sm"> </small><br><small class="sm"><sup>4</sup> </small><a class="ck-anchor" href="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/" id="https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/"><small class="sm">https://healthyfuturega.org/ghf_resource/preventive-services-coverage-and-cost-sharing-protections-are-inconsistently-and-inequitably-implemented/</small></a><small class="sm"> </small><br><small class="sm"><sup>5</sup> </small><a class="ck-anchor" href="/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf" id="/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf"><small class="sm">/system/files/media/file/2020/01/2020-Uncompensated-Care-Fact-Sheet.pdf</small></a><small class="sm"> </small><br> </p> Wed, 10 Jul 2024 12:11:44 -0500 Presumptive Eligibility /news/headline/2022-09-28-study-finds-many-hospitals-expanded-charity-care-during-covid-19-pandemic <p>In a <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796731">study</a> of 151 tax-exempt hospitals reported yesterday in JAMA Network Open, 84% updated their charity care policies between 2019 and 2021. Among the 77 hospitals that made substantive changes, most made their policies more generous, such as expanding charity care and expand eligibility criteria. Income cutoffs for free and discounted care were the criteria most frequently changed. Sixteen policies expanded presumptive eligibility, which uses certain patient characteristics such as homelessness or lack of employment to shorten the application process. Researchers also noted that hospitals made generous revisions to asset tests, residency requirements and the duration of charity care eligibility. Many of these changes are targeted toward the needs of underinsured individuals.</p> Wed, 28 Sep 2022 16:06:00 -0500 Presumptive Eligibility /lettercomment/2022-04-15-letter-cms-response-rfi-access-coverage-and-care-medicaid-chip <div class="container"><div class="row"><div class="col-md-8"><p>April 15, 2022</p><p>Daniel Tsai Deputy Administrator and Director<br>Center for Medicaid & CHIP Services<br>Centers for Medicare & Medicaid Services<br>7500 Security Boulevard<br>Baltimore, Maryland 21244</p><p><em><strong>RE: Request for Information: Access to Coverage and Care in Medicaid & CHIP</strong></em></p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2022/04/2022-04-15-Letter-to-CMS-Medicaid-Access-RFI.pdf" target="_blank" title="Click here to download the Letter to CMS in Response to RFI: Access to Coverage and Care in Medicaid & CHIP PDF.">Download the PDF</a></div></div></div></div><div class="container"><div class="row"><div class="col-md-8"><p>Dear Mr. Tsai:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, two million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to provide comments in response to the Centers for Medicare & Medicaid (CMS) request for information (RFI) regarding access to coverage and care in the Medicaid and Children’s Health Insurance Program (CHIP) programs.</p><p><strong>The AHA applauds CMS’s undertaking to conduct a comprehensive review of access and care challenges faced by Medicaid and CHIP beneficiaries and the agency’s commitment to develop policies to address them. The AHA believes that the critical components for a comprehensive access and coverage strategy for Medicaid and CHIP should include:</strong></p><ul><li><strong>Robust outreach and enrollment efforts to secure and maintain coverage for eligible individuals and families, as well as ensure beneficiary knowledge of how to use this coverage,</strong></li><li><strong>Standards to ensure timely and equitable access to quality care, and</strong></li><li><strong>Provider payments that are sufficient to enable beneficiaries' access to quality care.</strong></li></ul><p>CMS plays a crucial role in enforcing the mandate established by Congress that reimbursement rates for health care providers are sufficient to ensure Medicaid beneficiaries enjoy the same access to health care services as the general population.<a href="#fn1"><sup>1</sup></a> In the wake of the U.S. Supreme Court’s 2015 decision in <em>Armstrong v. Exceptional Child Center, Inc.</em><a href="#fn2"><sup>2</sup></a>, which ended providers’ and beneficiaries’ right to challenge state Medicaid payment rates in federal court, CMS has become the final arbiter in determining if provider payments are adequate to ensure access under federal statute.<a href="#fn3"><sup>3</sup></a> The safeguards embedded in the current regulatory requirements, established in 2015, are all that remain to hold federal and state governments accountable to ensure access for historically marginalized and special needs populations covered by Medicaid. State governments’ chronic underfunding of the program, and the added pressure for states, hospitals and others providers in managing the ongoing COVID-19 pandemic, present significant challenges for CMS in developing comprehensive solutions to ensure access and coverage. <strong>The AHA recommends that the agency convene stakeholder roundtables or workgroups to explore regulatory and legislative solutions to these access and coverage challenges and ensure that both beneficiaries and their hospital and health system providers are represented.</strong></p><p>AHA’s specific comments to the request for information follow and focus on the agency’s five objectives: enrollment, coverage, access standards, data for monitoring and provider payment and administrative burden.</p><h2>Objective 1: Reaching and Enrolling those Eligible for Medicaid and CHIP</h2><p>Patient and community access to health care coverage has long been a top priority for hospitals and health systems. As part of their mission and service to their communities, they work to connect their patients and community members to both public and private health care coverage options through enrollment fairs, public service announcements, social media campaigns, Marketplace assisters and other community-based outreach strategies. <strong>The AHA encourages CMS to look to the hospital community as trusted voices as they build new community-based Medicaid and CHIP outreach and enrollment initiatives.</strong></p><p>The Affordable Care Act (ACA) provided additional muscle to hospitals’ voluntary enrollment efforts by requiring states to allow for hospital presumptive eligibility (PE), which allows hospitals to provide temporary Medicaid coverage to individuals who are likely to qualify for Medicaid. The ACA provision allows hospitals to make PE determinations in every state for all individuals eligible for Medicaid based on modified adjusted gross income and at the state's discretion for other populations groups, including those covered by Section 1115 demonstration waivers. In addition, it allows hospital PE determinations to be extended to the patients’ families and eligible individuals from the broader community.<a href="#fn4"><sup>4</sup></a> The expansion of Medicaid PE policy, which is strongly supported by the AHA, has become an essential tool for states to ensure those eligible for the program can begin the enrollment process when seeking care for themselves or their family members.</p><p>The COVID-19 pandemic only underscored hospitals' critical role in connecting their patients to coverage. For example, CMS extended considerable flexibility to states that allowed them to process hospital PE applications using phone and on-line portals, extend hospital PE to disabled and institutionalized individuals and relax certain hospital PE performance standards and metrics during the public health emergency (PHE).<a href="#fn5"><sup>5</sup></a> <strong>While CMS has encouraged states to consider adopting some of these policies once the PHE ends and states resume their redetermination processes, the AHA recommends that CMS standardize and make permanent these policies.</strong> In particular, CMS should normalize the performance standards across states to ensure individual state policies do not become a barrier to a hospital's participation in PE programs.</p><p>In addition to hospital PE determinations, the Medicaid retroactive eligibility provision has also allowed hospitals to provide potential beneficiaries timely access to necessary health care services. This provision provides coverage for health care expenses three months prior to the beneficiaries’ application date, provided the beneficiary is eligible during that period. Some states have moved to restrict the retroactive provision through Section 1115 demonstration Medicaid waivers. However, Medicaid retroactive eligibility has provided access to critical services for many individuals, particularly during downturns in the economy and is an important vehicle for ensuring that those who are eligible for enrollment have coverage.<a href="#fn6"><sup>6</sup></a> <strong>The AHA recommends that CMS preserve the Medicaid retroactive eligibility provision to protect access to needed services and treatment for Medicaid beneficiaries.</strong></p><h2>Objective 2: Maintaining Coverage</h2><p>Issues related to the continuity of coverage for Medicaid and CHIP populations have long been a concern for policymakers and stakeholders. Income fluctuations can result in beneficiaries dis-enrolling and re-enrolling in the programs multiple times over the course of a year, known as churn. Congress has attempted to address concerns about continuous eligibility and minimize churn for specific population groups such as children. Since 1997, states have had the option to extend continuous eligibility to children to provide a more stable source of coverage. As of January 2022, nearly half of the states have extended continuous eligibility for children in Medicaid or CHIP.<a href="#fn7"><sup>7</sup></a> In response to the COVID-19 pandemic, Congress also required that states provide continuous coverage to Medicaid beneficiaries through the entirety of the PHE in order to be eligible for enhanced federal matching funds.</p><p>The continuous coverage requirements also ensured continuous postpartum coverage since the start of the PHE. Relatedly, and also during the pandemic, Congress recently established a new state option to extend Medicaid postpartum coverage for five years beginning in April 2022 through a state plan amendment to help address disparities and inequities in maternal health. Prior to the new state option, states could establish postpartum coverage through a Section 1115 demonstration waiver. Over half of the states are in various stages of action through the new state plan amendment option or through 1115 waivers to establish postpartum coverage.<a href="#fn8"><sup>8</sup></a> These efforts to ensure continuous coverage for Medicaid and CHIP enrollees, as well as for postpartum women, are important advances in expanding access to health care insurance coverage.</p><p>The AHA has supported and will continue to support legislative initiatives to provide continuous coverage for Medicaid beneficiaries. However, as the Medicaid and CHIP Payment and Access Commission (MACPAC) work in this area has highlighted, there are state policies and practices that could help address continuous coverage challenges and mitigate churn. MACPAC, in their examination, found that overall, 8% of Medicaid and CHIP beneficiaries in 2018 enrolled and re-enrolled within 12 months. The highest rates of churn were found in children enrolled in separate CHIP programs (16%) and adults enrolled in Medicaid through the modified adjusted gross income eligibility group (9%).<a href="#fn9"><sup>9</sup></a> MACPAC highlighted two particular state practices that affected churn rates in Medicaid beneficiaries: (1) mid-year data checks for changes in circumstances; and (2) use of automated renewal processes.<a href="#fn10"><sup>10</sup></a> The Commission found that states with mid-year data checks had a more significant share of beneficiaries with fewer than 12 months of continuous coverage and a higher churn rate of beneficiaries dis-enrolling and re-enrolling within 12 months. On the other hand, states with an increased use of automated renewals, which included the use of available electronic data sources and pre-populating renewal forms, showed a decrease in the average share of beneficiaries dis-enrolling and re-enrolling within 12 months.</p><p>As CMS and states begin the eligibility redetermination process once the COVID-19 PHE ends, state eligibility practices will be important in mitigating potential coverage losses. Toward that end, the AHA has provided tools and resources for our hospital members and state hospital associations to use as they work with their state Medicaid agencies to examine state policies to mitigate coverage losses when the continuous eligibility requirements end and eligibility redetermination resumes.<a href="#fn11"><sup>11</sup></a> Recommendations include:</p><ul><li>Confirm eligibility using an ex parte process that looks at available data sources;</li><li>Adopt an automated renewal process that pre-populates eligibility forms;</li><li>Use self-attestation of income allowed during the PHE;</li><li>Use data from other federal means test programs to streamline redeterminations and new enrollments;</li><li>Partner with stakeholders to reach Medicaid beneficiaries; and</li><li>Use hospital PE programs to assist with eligibility determinations.</li></ul><p><strong>The AHA recommends that CMS consider standardizing eligibility practices across states to promote continuous eligibility and minimize enrollment churn.</strong></p><h2>Objective 3: Establishing Standards for Equitable and Timely Access to Providers and Services</h2><p>As CMS contemplates establishing standards for equitable and timely access to providers and services, examining where current policies and practices are subverting that objective is essential. We would recommend that the agency, in particular, examine the following areas: Medicaid managed care, behavioral health, and maternal. pediatric, and adolescent access.</p><h3>Medicaid Managed Care</h3><p>Medicaid beneficiaries enrolled in some form of Medicaid managed care account for nearly 70% of total Medicaid enrollment.<a href="#fn12"><sup>12</sup></a> Medicaid managed care is heavily reliant on commercial health plans to administer benefits to enrollees. However, certain practices by commercial health plans are eroding Medicaid beneficiary access to care and services.</p><p>AHA’s survey from 2019 found that commercially-administered Medicaid managed care plans had the highest prior authorization denial rate, and the highest rates of claims denial based on inaccurate enrollment files when compared to Medicare Advantage and other commercial health plan products outside of Medicaid and Medicare.<a href="#fn13"><sup>13</sup></a> Providers at times must begin treatment or move a patient to a more appropriate site of care before obtaining a response to a prior authorization request to prevent harm and adequately care for patients. Some Medicaid managed health plans deny care that they acknowledge to be medically necessary because the provider in their clinical judgement could not wait any longer to begin care before prior authorization process was completed. According to an AHA 2019 survey, hospitals and health systems reported steep increases in short-stay denials, even when clinical indicators and the severity of illness meet the standards for inpatient admission. In these instances, the commercial Medicaid managed care plans downcode the inpatient claims to observation status and, in some instances, use the downcoding to deny the claim altogether by arguing that the provider did not seek prior authorization for observation status.</p><p>In addition, it is not uncommon for Medicaid managed care plans to deny claims based on coverage errors or inaccurate enrollment information. These problems occur most frequently in the first quarter of the year when insurers do not update membership files on a timely basis. Enrollees, who are eligible for services, are experiencing inappropriate denials that limit access to needed care.</p><p><strong>To curb these practices, the AHA recommends a number of solutions to standardize the prior authorization process and increase the oversight of Medicaid managed care plans including:</strong></p><ul><li><strong>Standardizing the format for prior authorization requirements;</strong></li><li><strong>Requiring plans have 24/7 capability to respond to requests for authorization;</strong></li><li><strong>Standardizing the timeline for responses such as 72 hours for scheduled, non-urgent services and 24 hours for urgent services; and</strong></li><li><strong>Standardizing the appeals process.</strong></li></ul><p><strong>In addition, the AHA recommends additional health plan oversight and performance measures, including: setting appropriate thresholds for prior authorization and payment denials; applying financial penalties for inappropriate denials; testing to demonstrate the adequacy of provider networks; and publishing performance data on prior authorization or other payment denials.</strong><a href="#fn14"><sup>14</sup></a></p><p>It is also important to note that many states opted to waive Medicaid managed care prior authorization requirements to expedite patient access to services during the COVID-19 pandemic. This has been an important indicator of improved access to timely health care services during the PHE.</p><p>In addition, the AHA urges CMS to establish additional policies and oversight requirements regarding Medicaid managed care networks, including the updating and managing of provider directories. Current managed care regulations replaced time and distance standards for meeting provider network adequacy requirements with state-established quantitative network adequacy standards. <strong>The AHA recommends that CMS return to time and distance standards as a measure of adequate provider networks and align such standards with those required for qualified health plans offered in the marketplaces.</strong> Such quantifiable standards are particularly important in assessing the robustness of provider networks for adult and pediatric specialists or behavioral health providers to ensure vulnerable enrollees with complex medical conditions that need specialty care or behavioral health needs are met. We are deeply concerned that the lack of consistency in network adequacy standards that vary by state will fall short of ensuring equal access to health care services for all Medicaid beneficiaries.</p><p><strong>The AHA further recommends that CMS look at how frequently managed care plan networks rely on out-of-network authorizations for care as a measure of network adequacy, particularly for adults and pediatric patients with complex medical health needs and behavioral health patients.</strong> Up-to-date provider directories are also an essential tool for assessing provider networks. As a condition of their contract with the state, managed care plans should be required to frequently update their provider directories, proactively reach out to providers to confirm the accuracy of information and publicly share whether that provider is accepting new patients. Further, CMS should continue to push for standardization of provider directories using the most up-to-date interoperability standards.</p><h3>Behavioral Health</h3><p>Medicaid is the single largest payer for behavioral health services in the nation. As such, it is particularly important that CMS focus on the behavioral health needs of Medicaid beneficiaries when establishing access standards that promote the integration of behavioral health and physical health. When looking at Medicaid managed care, CMS should be focused on behavioral health measures for network adequacy, including time and distance standards, prior authorization practices that may impede timely access, denial rates and managed care plans’ reliance on out of network providers. <strong>In addition to evaluating behavioral health access in the managed care setting, the AHA recommends that CMS look at behavioral health access barriers for Medicaid beneficiaries in the context of the current Institutions for Mental Disease (IMD) exclusion.</strong> While AHA advocates for the legislative repeal of the IMD exclusion, it also supports CMS’s regulatory steps to make IMD services available in the Medicaid managed care setting, as well as implementing the state option to use IMDs for Substance Use Disorder treatment. CMS could further explore renewing the use of the Section 1115 demonstration waiver authority to promote access to IMD providers for Medicaid beneficiaries.</p><h3>Maternal, Pediatric and Adolescent Services</h3><p>The Medicaid program has a special obligation to ensure access to maternal, pediatric and adolescent services for the Medicaid and CHIP population. While expansion of coverage, continuous coverage, and access for these populations may require federal legislation, CMS can take actions to improve access and set standards.</p><p>For example, while states can use telehealth to improve access to care, the AHA encourages CMS to further explore how Medicaid telehealth coverage could specifically be used to improve maternal health through prenatal and postnatal care, recognizing this may require additional regulatory flexibility or waivers. This is particularly important for those rural and urban areas with no or limited access to obstetric providers. A small number of state Medicaid programs include obstetrical care in their telemedicine reimbursement and reimburse for telemedicine services delivered to the patient in their home but limit reimbursement of services, such as lactation assistance and in-home monitoring, during and after pregnancy.<a href="#fn15"><sup>15</sup></a> A study in the CDC’s Morbidity and Mortality Weekly Report examined work done by 13 state Maternal Mortality Review Committees to identify contributing factors and strategies to prevent future pregnancy-related deaths, which included addressing personnel issues at hospitals by providing telemedicine for facilities with no obstetric provider on-site.<a href="#fn16"><sup>16</sup></a> In addition, telehealth services would give clinicians an opportunity to monitor and treat postpartum mothers for postpartum depression, the most common complication after pregnancy according to the American Psychological Association.</p><p>The COVID-19 pandemic has pushed pediatric and adolescent mental health to crisis levels. According to the CDC, from March to October 2020, hospitals saw a 24% increase in the proportion of mental health emergency department visits in kids ages 5 to 11 and a 31% increase for kids and teens ages 12 to 17 compared to 2019. In a follow-up study, the CDC found that beginning in May 2020, emergency department visits for suicide attempts began to increase among adolescents’ ages 12 to 17, with visits 39% higher than during the same period in 2019.<a href="#fn17"><sup>17</sup></a></p><p>As behavioral health needs are increasing across the nation, we are seeing an alarming trend of decreasing behavioral health services in many communities, leading to severe challenges in providing inpatient psychiatric care to children and adolescents. Bed shortages lead to “boarding” in acute-care hospital emergency departments (EDs) and in non-psychiatric units as patients await available inpatient psychiatric beds. Although little data is available regarding boarding times for children and adolescents, our hospital members report untenable crowding in their EDs, with some describing a crisis in their communities.<a href="#fn18"><sup>18</sup></a></p><p>To amplify the call to address these urgent issues, the AHA has joined the Sound the Alarm for Kids initiative, which comprises more than 50 organizations united to raise awareness and urge immediate action to support the mental health of children, adolescents and their families. While Congressional action will be required to address some of these challenges, the Medicaid and CHIP programs can play a role in improving access. CMS could encourage states, through guidance and best practices, on the effective uses of telehealth mental health services for pediatric and adolescent populations. In addition, CMS could promote the integration of physical health and behavioral health for these populations by establishing access standards that would apply in the fee-for-service (FFS) as well as the managed care settings.</p><h2>Objective 4: Data Sources to Monitor Access</h2><p>Data will be critical for CMS and states to appropriately monitor access to coverage and services for the Medicaid and CHIP populations. The challenge for CMS is to balance existing data and reporting requirements with implementing new requirements. AHA encourages CMS to prioritize data the agency already has through T-MSIS or other sources such as current provider payment and Medicaid Disproportionate Share Hospital (DSH) and non-DSH supplemental payment reporting to be used more efficiently and reduce administrative burden.</p><p>In terms of additional reporting, we suggested in response to Objective 3 that CMS should require reporting and metrics on managed care plan prior authorization usage, claims denials and provider network adequacy. In other areas for reporting, CMS could consider more robust managed care plan reporting on beneficiaries’ use of the appeals and grievances process. Appeals and grievances are critical access indicators but often are not aggregated in ways that are specific enough for state or CMS action. Low appeal and grievance numbers suggest that beneficiaries are either not aware of the extent of their coverage or their rights to raise concerns and objections to manage care plan actions. Lastly, CMS should put forward requirements that states report metrics that measure dis-enrollment and re-enrollment rates, such as churn rates, of Medicaid beneficiaries to identify possible barriers to maintaining Medicaid and CHIP coverage.</p><h2>Objective 5: Ensuring Payment Rates Are Sufficient to Enlist and Retain Providers to Guarantee Access and Address Administrative Burden</h2><p>With the <em>Armstrong</em><a href="#fn19"><sup>19</sup></a> case ending providers’ and beneficiaries’ rights to challenge state Medicaid payment rates in federal court, the current regulatory access safeguards are all that remain to hold federal and state governments accountable to ensure access for vulnerable populations covered by Medicaid. At the core of the Medicaid “equal access” standard is the sufficiency of provider payments to ensure access to services. Yet, the data reflects that total Medicaid payment falls far below hospitals’ cost of caring for Medicaid patients.<a href="#fn20"><sup>20</sup></a> According to data from the AHA’s annual survey, hospitals received payment of only 88 cents for every dollar spent by hospitals caring for Medicaid patients in 2020. This underpayment resulted in a Medicaid shortfall of $24.8 billion in 2020.<a href="#fn21"><sup>21</sup></a> In addition, MACPAC’s analysis of Medicaid payments to hospitals shows that FFS rates are often far below Medicare payments for comparable services. For example, MACPAC reported that FFS Medicaid base payment rates were on average 78% of Medicare rates for the 18 Medicare Severity Diagnosis Related Groups studied using 2011 data.<a href="#fn22"><sup>22</sup></a> And, states continue to look to cutting provider payments to address budget constraints. The Kaiser Commission on Medicaid and the Uninsured in its FY 2022 survey of state Medicaid programs notes that even amid the COVID-19 pandemic, 22 states adopted measures to restrict inpatient hospital payments by cutting or freezing payments.<a href="#fn23"><sup>23</sup></a></p><p>Medicaid’s historically low provider reimbursement rates have led to the growth of other enhanced payments to help providers such as DSH and non-DSH supplemental payments. According to MACPAC, supplemental payments account for a quarter of hospital payments, including hospital payments made by managed care organizations.<a href="#fn24"><sup>24</sup></a> MACPAC further noted that hospital spending accounted for 34% of total Medicaid spending and Medicaid payments to hospitals accounted for 17% of all payments to hospitals in 2019.</p><p>While managed care rates are typically negotiated with health plans, the overall inadequacy of Medicaid payment rates has broadly substantiated the need for supplemental payments permitted by CMS’s 2016 Medicaid managed care rule as directed payments. These additional payments have been critical in paying for services provided to Medicaid enrollees and offsetting Medicaid base rates that are often below hospital cost. Directed payments have helped to fill these payment gaps as more states have transitioned populations into managed care, resulting in an inability to continue making FFS supplemental payments to providers. In this way, directed payments are a necessary continuation of Medicaid providers' funding that ensures patient access to critical health care services and helps stabilize those hospitals who serve historically marginalized communities.</p><p>Medicaid beneficiaries look to hospitals and health systems to address a wide variety of complex health and social needs. A prevalent view of the “equal access” standard is that provider payment rates should be set at a level that balances efficiency and economy, while creating incentive for providers to participate. Financially distressed hospitals and health systems often are faced with reducing specialty care that can result in access challenges for Medicaid beneficiaries. While provider participation is critical, rates should also be set such that beneficiaries can continue to expect access to needed specialty care provided by hospitals. <strong>CMS should consider the implication of low payment rates on hospitals’ ability to provide a broad variety of care, including access to specialists.</strong></p><p>As CMS considers its access strategy and the role adequate provider payments play in ensuring access for Medicaid beneficiaries, the AHA recommends that CMS consider the totality of provider payments, including base rates and supplemental payments, and the role hospitals play in helping states finance their Medicaid programs. <strong>AHA recommends CMS take steps to ensure that the totality of payment — whether reimbursed directly by the state or through a Medicaid managed care plan or some combination — are adequate to cover the costs of caring for beneficiaries and thereby support their access to health care services.</strong></p><p>Lastly, CMS examination of provider payments and access should include how payment rates impact physicians and behavioral health providers’ participation in the Medicaid and CHIP programs as well. A recent Urban Institute study found that Medicaid physician reimbursement is significantly lower than commercial payer and even Medicare payments for the same services despite growing enrollment in the public health care program.<a href="#fn25"><sup>25</sup></a> Administrative burden for providers is another area for examination. Prior authorization denials not only contributed to negative clinical impact but to physician burnout issues as well.<a href="#fn26"><sup>26</sup></a></p><p>The AHA appreciates this opportunity to support CMS’s endeavor to develop a comprehensive access and coverage strategy for the Medicaid and CHIP programs. We encourage CMS to consider roundtable sessions or workgroups of hospitals and other providers as the agency continues its work.</p><p>Please contact me if you have questions, or feel free to have a member of your team contact Molly Collins, director of policy, at (202) 626-2326 or <a href="mailto:mcollins@aha.org">mcollins@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p><hr><ol><li id="fn1"><a href="/system/files/content/15/150501-aha-amici-brief.pdf">Microsoft Word - Armstrong - Amicus Pre-Filing Draft -- FINAL clean (aha.org)</a></li><li id="fn2">[2] <a href="https://www.supremecourt.gov/opinions/14pdf/14-15_d1oe.pdf" target="_blank">https://www.supremecourt.gov/opinions/14pdf/14-15_d1oe.pdf</a></li><li id="fn3">Medicaid “Equal Access Standard” Soc. Sec. Act Se. 1902 (a) (30)(A)</li><li id="fn4"><a href="https://www.cdc.gov/phlp/docs/hospitalpe-brief.pdf" target="_blank">https://www.cdc.gov/phlp/docs/hospitalpe-brief.pdf</a></li><li id="fn5"><a href="https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf" target="_blank">COVID-19 FAQs for State Medicaid and CHIP Agencies</a></li><li id="fn6">Health Affairs <a href="https://www.healthaffairs.org/do/10.1377/forefront.20200506.111318/full/" target="_blank">https://www.healthaffairs.org/do/10.1377/forefront.20200506.111318/full/</a></li><li id="fn7">Kaiser Family Foundation, State Adoption of 12 Month Continuous Eligibility for Children, <a href="https://www.kff.org/statedata/" target="_blank">https://www.kff.org/statedata/</a>, Jan. 2022.</li><li id="fn8"><a href="https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/" target="_blank">https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/</a></li><li id="fn9"><a href="https://www.macpac.gov/wp-content/uploads/2021/10/An-Updated-Look-at-Rates-of-Churn-and-Continuous-Coverage-in-Medicaid-and-CHIP.pdf" target="_blank">An Updated Look at Rates of Churn and Continuous Coverage in Medicaid and CHIP (macpac.gov)</a></li><li id="fn10">Ibid.</li><li id="fn11">AHA. <a href="/system/files/media/file/2022/03/AHA%20PHE%20Unwinding%20Medicaid%20June%2C%202021.pdf">AHA PHE Unwinding Medicaid June, 2021.pdf</a></li><li id="fn12"><a href="https://www.kff.org/data-collection/medicaid-managed-care-market-tracker/" target="_blank">https://www.kff.org/data-collection/medicaid-managed-care-market-tracker/</a></li><li id="fn13"><a href="/system/files/media/file/2020/12/addressing-commercial-health-plan-abuses-ensure-fair-coverage-patients-providers.pdf">addressing-commercial-health-plan-abuses-ensure-fair-coverage-patients-providers.pdf (aha.org)</a></li><li id="fn14">Ibid</li><li id="fn15"><a href="https://www.kff.org/womens-health-policy/issue-brief/telemedicine-and-pregnancy-care/" target="_blank">Telemedicine and Pregnancy Care | KFF</a></li><li id="fn16"><a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm?s_cid=mm6818e1_w&T3_down" target="_blank">Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017 | MMWR (cdc.gov)</a></li><li id="fn17"><a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7108e2.htm" target="_blank">https://www.cdc.gov/mmwr/volumes/71/wr/mm7108e2.htm</a></li><li id="fn18"><a href="/system/files/media/file/2022/02/aha-senate-statement-protecting-youth-mental-health-part-ii-identifying-and-addressing-barriers-to-care-2-15-22.pdf" target="_blank">aha-senate-statement-protecting-youth-mental-health-part-ii-identifying-and-addressing-barriers-to-care-2-15-22.pdf</a></li><li id="fn19"><a href="https://www.supremecourt.gov/opinions/14pdf/14-15_d1oe.pdf" target="_blank">https://www.supremecourt.gov/opinions/14pdf/14-15_d1oe.pdf</a></li><li id="fn20">Total Medicaid payments include both Fee-For-Service and managed care payments, as well Disproportionate Share Hospital (DSH) payments, non-DSH supplemental payments, directed payments, and other adjustments, as reported by member hospitals.</li><li id="fn21">AHA. <a href="/system/files/media/file/2022/02/medicare-medicaid-underpayment-fact-sheet-current.pdf" target="_blank">/system/files/media/file/2022/02/medicare-medicaid-underpayment-fact-sheet-current.pdf</a>.</li><li id="fn22">MACAPC. <a href="https://www.macpac.gov/publication/medicaid-hospital-payment-a-comparison-across-states-and-to-medicare/" target="_blank">https://whttps://www.kff.org/report-section/states-respond-to-covid-19-challenges-but-also-take-advantage-of-new-opportunities-to-address-long-standing-issues-provider-rates-and-taxes/ww.macpac.gov/publication/medicaid-hospital-payment-a-comparison-across-states-and-to-medicare/</a>.</li><li id="fn23">Kaiser. <a href="https://www.kff.org/report-section/states-respond-to-covid-19-challenges-but-also-take-advantage-of-new-opportunities-to-address-long-standing-issues-provider-rates-and-taxes/" target="_blank">https://www.kff.org/report-section/states-respond-to-covid-19-challenges-but-also-take-advantage-of-new-opportunities-to-address-long-standing-issues-provider-rates-and-taxes/</a></li><li id="fn24"><a href="https://www.macpac.gov/wp-content/uploads/2020/03/Medicaid-Base-and-Supplemental-Payments-to-Hospitals.pdf" target="_blank">https://www.macpac.gov/wp-content/uploads/2020/03/Medicaid-Base-and-Supplemental-Payments-to-Hospitals.pdf</a></li><li id="fn25">Health Affairs <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00611" target="_blank">https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00611</a></li><li id="fn26">American Medical Association, <a href="https://www.healthit.gov/sites/default/files/facas/2019-03-20_Patient_Clinician_Perspective_AMA_Heather_McComas_508.pdf" target="_blank">“2018 AMA Prior Authorization (PA) Physician Survey”</a></li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2022/04/2022-04-15-Letter-to-CMS-Medicaid-Access-RFI.pdf" target="_blank" title="Click here to download the Letter to CMS in Response to RFI: Access to Coverage and Care in Medicaid & CHIP PDF."><img src="/sites/default/files/inline-images/Page-1-2022-04-15-Letter-to-CMS-Medicaid-Access-RFI.png" data-entity-uuid="80a38795-ce17-4506-be9a-9e89461e2d17" data-entity-type="file" alt="AHA Letter to CMS: Re: Request for Information: Access to Coverage and Care in Medicaid & CHIP page 1." width="1700" height="2200"></a></p></div></div></div> Fri, 15 Apr 2022 14:00:45 -0500 Presumptive Eligibility /testimony/2021-05-19-aha-statement-senate-covid-19-health-care-flexibilities-perspectives <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to submit this statement for the record. Since the first COVID-19 cases were diagnosed and the pandemic changed the ways in which patients were able to access traditional health care settings, providers were required to navigate significant challenges to ensure their services were still able to reach millions of patients. In response, Congress and the Administration granted various flexibilities intended to improve access and facilitate the delivery of safe, quality care.</p><p>As health care providers reflect on lessons learned and plan a post-pandemic course for the future, it is evident that several of the flexibilities have enhanced the patient experience and led to better outcomes. The AHA believes that, if extended, these flexibilities can continue to drive significant improvements in patient care long after the public health emergency (PHE) ends. Given the beneficial impact of those specific flexibilities, the AHA urges Congress and the Administration to make them permanent. In addition, a second group of flexibilities will remain critically important for some time following the PHE and will require a carefully crafted phase-out plan to ensure enough time is provided for a necessary transition. Without action from Congress and the Administration prior to the termination of the PHE, we are concerned that much of the progress made because of the implementation of many of these flexibilities may be unnecessarily halted or even lost. America’s hospitals, health systems and post-acute care providers have taken significant steps to improve the way care can be delivered due to the pandemic, and failing to seize the opportunity presented by the progress made would be a step back for the nation’s health care infrastructure. Following are the AHA’s recommendations for each category of flexibilities.</p><h2>Flexibilities That Should Be Made Permanent</h2><h3>Telehealth Provisions</h3><p>The increased use of telehealth since the start of the PHE is producing high-quality outcomes for patients, enhancing patient experience, and protecting access for individuals susceptible to infection. With the appropriate statutory and regulatory framework, this beneficial shift in care delivery could continue to improve patient experiences and outcomes and deliver health system efficiencies beyond the pandemic. The AHA urges Congress and the Administration to consider making these flexibilities permanent.</p><p>Telehealth policies should work together to maintain access for patients by connecting them to vital health care services and their personal providers through videoconferencing, remote monitoring, electronic consults and wireless communications. We support the following: elimination of the 1834(m) geographic and originating site restriction; coverage and reimbursement for audio-only services; an expanded list of providers and facilities eligible to deliver and bill for telehealth services, including rural health clinics and federally qualified health centers; a national approach to licensure so that providers can safely provide virtual care across state lines; and, adequate reimbursement for the substantial costs of establishing and maintaining a telehealth infrastructure, among others.</p><h3>Payment Flexibility</h3><p>In addition to the payment flexibilities needed to continue effectively offering telehealth services beyond the PHE, further payment flexibility is necessary to ensure access to care for patients. Specifically, Congress and the Administration should consider permanently increasing flexibility for site-neutral payment exceptions for providers seeking to relocate hospital outpatient departments and other off-campus provider-based departments. These steps would permit hospitals and health systems to better and more effectively serve their communities.</p><h3>Hospital-at-Home Programs</h3><p>The pandemic forced providers to rethink ways to deliver care safely to all patients, while simultaneously responding to surges in COVID-19 cases. To help providers make necessary adaptations, the Centers for Medicare & Medicaid Services (CMS) created new opportunities for providers to implement hospital-at-home programs.</p><p>These flexibilities permit approved providers to offer safe hospital care to eligible patients in their homes, and the results have proved pivotal in caring for COVID-19 and non-COVID-19 patients during the pandemic. While the initial aim of this flexibility was to increase health care capacity while keeping patients safe at home during the PHE, promising outcomes are demonstrating the need for hospital-at-home to be made permanent.</p><p>Hospitals and health systems are increasingly interested in standing up hospital-at-home programs, yet many hesitate to do so without assurances that their programs, which are very popular among patients and their families, could continue to exist beyond the PHE. Extending the hospital-at-home flexibilities permanently can engage providers who may be hesitant to implement these programs now and will help transform the way more providers deliver care, while enhancing the patient experience. Given the benefits provided by this program, AHA anticipates considerable additional provider interest and growth of hospital-at-home programs should the flexibilities be made permanent.</p><h3>Workforce Assistance</h3><p>The COVID-19 pandemic has exacerbated the strain on an already overworked and understaffed health care workforce. To help mitigate that strain, we support allowing health care professionals to practice at the top of their licenses and permanently permitting out-of-state providers to perform certain services when they are licensed in another state. We also support extensions of the five-year cap-building period for new Graduate Medical Education (GME) programs to account for COVID-19-related challenges and support long-term sustainability of physician training. Permanently extending these workforce flexibilities would help alleviate workforce shortages as the PHE ends.</p><h3>Review of Certain Conditions of Participation</h3><p>The PHE has shed light on several shortcomings and outdated practices across the national health care infrastructure; however, it also creates the unique opportunity to reevaluate and improve upon processes based on the lessons we have learned thus far. Conditions of participation (CoPs) are a logical starting point for review and reevaluation, as they serve as the foundation for ensuring high quality care and safety for patients and set the baseline for hospital participation in the Medicare and Medicaid programs. Compliance with the CoPs and the potential for termination from the Medicare and Medicaid programs for non-compliance serve as valuable tools ensuring hospitals are meeting critical safety and quality requirements. However, the past year’s experiences demonstrated the need to modernize certain CoPs. For example, reexamining and updating infection control and life safety code requirements would allow hospitals and health systems to continue to employ innovative approaches, such as allowing for separate facility entrances for potentially infectious patients and minimizing personal protective equipment (PPE) use and infection risk by placing IV tubes outside patient rooms. The AHA has urged CMS to collaborate with providers to determine how specific CoPs can be revamped to improve quality and safety.</p><h3>Rural Capacity</h3><p>CMS should continue to support increased bed capacity in rural areas when an emergency requires such action. Rural hospitals should be held harmless for increasing bed capacity during any future emergency, and those providers should be permitted to maintain pre-emergency bed counts for applicable payment programs, designations and other operational flexibilities.</p><h2>Flexibilities Requiring a Transition Period</h2><h3>Emergency Use Authorization (EUA) Transition</h3><p>The COVID-19 pandemic placed significant strain on an already fragile medical supply chain and highlighted several substantial flaws in the acquisition process. Many of those impacts still exist today to varying degrees. In response to supply chain disruptions, the Food and Drug Administration (FDA) issued an unprecedented number of EUAs to help mitigate constant disruption and continuous impact. The EUAs covered a broad range of devices, from respirators and COVID-19 tests to ventilators and decontamination systems. These EUAs saved lives by opening up new supply lines to ensure providers have the items they need to safely and effectively care for patients throughout the pandemic. However, the EUAs are not a silver bullet, and additional disruptions will occur post-pandemic. Congress should reassess how the supply chain operates and consider modifications to mitigate further disruptions. To ensure supply chain stability, the FDA should offer full approval to those devices deemed necessary, and provide sufficient transition periods to move away from devices that do not receive full approval.</p><h3>Personal Protective Equipment</h3><p>The COVID-19 pandemic illuminated several supply chain shortcomings, not least of which was adequate access to PPE necessary to keep both front-line health care workers and patients safe. In response to the massive PPE shortages, the FDA issued EUAs for a number of items, such as respirators and facemasks. To address the short-and-long-term challenges associated with PPE, the FDA should take steps to ensure a reasonable wind-down of PPE EUA flexibilities to allow the supply chain to recalibrate and providers to use supply on-hand. In addition, the FDA should examine the long-term fragility of the PPE supply chain and consider offering certain non-traditional medical PPE manufacturers the opportunity to receive full medical supply authorization from the FDA. Finally, as this wind-down occurs, the FDA and other federal agencies, including the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) should work together to ensure a coordinated approach to the transition.</p><h3>Health Information and Data Sharing</h3><p>Robust health information and data exchange capabilities among providers and with patients and government agencies are foundational to improving care delivery, supporting better health outcomes and facilitating emergency response. Data exchange capabilities support decision-making at the point of care and the data generated can provide insights into health disparities and inequities at the patient and population health levels. Yet, to realize these benefits, robust, secure infrastructure must be in place for all entities, utilizing a common set of data definitions and standards. Requirements around data collection and sharing also must be well defined and well understood by health care providers and have a clear value proposition. Building this information technology infrastructure requires significant resources, both capital and workforce, and extensive efforts to redesign procedures and workflows and train clinicians and staff across the organization. Until all of these core building blocks are in place across the health information exchange continuum, implementation of new requirements on health care providers, such as the Office of National Coordination for Health Information Technology’s information blocking rules and CMS’ admit, discharge and transfer notification CoP, should be delayed.</p><h3>Quality Measurement Reporting</h3><p>During the pandemic, CMS provided hospitals relief from quality reporting requirements, including making quality reporting optional in Q1 and Q2 of 2020, and allowing hospitals to apply for reporting waivers using the pandemic as justification. We note, however, that hospital performance on the measurement programs, like readmissions, hospital-acquired conditions and value-based purchasing, will be affected over multiple fiscal years to come, and it is vital that performance be assessed reliably and fairly. For that reason, CMS should use its statutory flexibilities to not apply payment adjustments in program years where it determines that, as a result of measure reporting exceptions, it has insufficient data to calculate national performance in a reliable manner.</p><h3>Federal Medical Assistance Percentages (FMAP) Increase</h3><p>The temporary FMAP increase in the COVID-19 relief laws has provided critical financial support for states to ensure their Medicaid programs can provide coverage for millions of their citizens during the COVID-19 pandemic. The temporary FMAP increase of 6.2 percentage points is set to expire at the end of the quarter in which the PHE ends. To benefit from the temporary FMAP increase, states must meet certain maintenance of effort requirements, including continuous enrollment for those enrolled in the program as of March 18, 2020. State governments, advocates and stakeholders recommend that additional federal funding will be needed for up to a year after the PHE ends. Extending FMAP will provide a smooth process to reevaluate Medicaid COVID-19-related coverage extensions.</p><p>Congress addressed a similar situation during the Great Recession of 2008-2009. Then, the FMAP was increased by 6.2 percentage points for 27 months (through the end of 2010) and then extended and tapered down from 6.2 % to 3.2% and finally to 1.2% for another six months ending in June 2011. Congress should consider a comparable approach for states at the end of the PHE. Congress also should consider an enhanced FMAP for states with high unemployment rates. During the Great Recession, states with increases in unemployment rates of 3.5% received an enhanced FMAP above the 6.2%.</p><h3>Medicaid Coverage, Enrollment and Outreach</h3><p>The PHE enabled states to leverage Medicaid’s emergency authorities to make temporary changes to their programs that increased access to coverage and care. Most policies adopted by states helped individuals qualify for and enroll in Medicaid coverage. The two major pathways for states to change Medicaid eligibility, coverage and enrollment during the PHE were: Medicaid disaster relief state plan amendments that allow states to modify their state Medicaid plans quickly to change eligibility, benefits, cost sharing and payments; and disaster relief verification plan addenda that allowed state agencies to verify eligibility and use electronic data sources without prior approval from CMS.</p><p>The coverage needs facing states – and the policy changes needed to respond adequately – will continue to exist beyond the PHE. To provide continued flexibility, CMS should relax hospital-based presumptive eligibility standards, maximize flexibility for income verification and the use of self-attestation, and continue allowing qualified entities like hospitals to make presumptive eligibility determinations for all Medicaid eligibility groups.</p><h3>Post-acute Care</h3><p>Post-acute care (PAC) providers continue to play a key role in the national COVID-19 response. In communities that faced or are facing surges of the virus, they have treated many of the sickest COVID-19 patients following hospital discharge, as well as provided important relief to hospitals and other settings overwhelmed by patients with and recovering from the virus. Concurrently, the prospective payment systems (PPS) of three of the four PAC settings – the long-term care hospital, inpatient rehabilitation hospital, and skilled nursing facility PPSs – have been in the midst of major payment transformations during the PHE. The collective magnitude of the PHE and these PPS redesigns is extensive, and time is needed for policyholders and stakeholders to disentangle and understand the longer-term ramifications of each. Thus far, their combined impact includes, as examples, material reductions in case volume and overall payments, the rise of average levels of patient acuity, facility closures, personnel shifts and revised clinical pathways. For example, AHA analysis shows that, in comparison to prior patterns, case volume for these settings dropped by 6% to 30% while the average case-mix index rose from between 2.5% and 6.9% over the prior year.<a href="#fni"><sup>i</sup></a> In recognition of this complex dynamic, the recent FY 2022 PAC proposed rule calls upon stakeholders to provide guidance on how to account for both of these overlapping and powerful drivers of change. At this time, it remains unclear which of these and other operational impacts will persist after the PHE, but given their scope and duration, it seems possible that the PAC field will not return to its pre-PHE profile. Given this level of change and uncertainty, key PAC flexibilities should remain in effect during a transition period that follows the official end of the PHE. In particular, such extended flexibilities should include PHE-levels of payment and coverage for highest acuity COVID-19 patients who remain in the PAC setting following the PHE, including those “long-haul COVID-19 patients” for whom the virus has concluded but related symptoms remain.</p><p>The AHA is gratified that the Committee is examining the many flexibilities granted during the COVID-19 pandemic. We stand ready to work with the Committee as you consider learnings from these flexibilities and how to ensure that the nation’s health care system can continue to evolve for the benefit of patients and the health of their communities.</p><hr><ol type="i"><li id="fni">These data compare a 12-month period during the PHE, January 27, 2020 through January 26, 2021, to a pre-PHE 12-month period, January 26, 2019 through January 26, 2020. Data source: Medicare fee-for-service claims, Centers for Medicare & Medicaid Services, Chronic Conditions Data Warehouse, <a href="https://www2.ccwdata.org/web/guest/home">https://www2.ccwdata.org/web/guest/home</a>.</li></ol> Wed, 19 May 2021 14:48:26 -0500 Presumptive Eligibility /special-bulletin/2020-06-04-cms-issued-new-guidance-states-medicaid-optional-uninsured-covid-19 <p>The Centers for Medicare & Medicaid Services (CMS) released <a href="https://www.medicaid.gov/state-resource-center/downloads/potential-state-flexibilities-guidance.pdf">guidance</a> on June 2 for states implementing the Medicaid Optional Uninsured COVID-19 Testing (XXIII) Group, established by the Families First Coronavirus Response Act. States can use this new optional Medicaid eligibility group to access federal funds to cover the full cost of COVID-19 testing-related services for uninsured individuals. This guidance reviews flexibilities available to states to aide in the implementation of this option. See CMS’s previous <a href="https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs.pdf">guidance</a> for more detailed information on eligibility requirements, benefits and federal matching rates for coverage under the optional COVID-19 testing group. The following is a summary of key provisions of CMS’s latest guidance.</p><p><strong>Enrollment.</strong> States can develop a simplified application for the new COVID-19 testing eligibility group to minimize burden on the applicant. States also are encouraged to assess whether individuals found ineligible for the state’s Medicaid program can be covered through the COVID-19 testing eligibility group. States can adopt a variety of strategies to obtain an applicant’s signature, including electronic means, as well as designating a provider as an authorized representative. States must verify citizenship and immigration status, using available federal systems. If such verification systems are not immediately available, states may conduct verification post-enrollment. In addition, states must accept attestations of citizenship and immigration status at the time of application and not let verification impede enrollment while the verification process continues.</p><p><strong>Hospital-based Presumptive Eligibility (HPE)</strong>. States can request to include the COVID-19 eligibility testing group as a group covered under HPE through their disaster state plan amendment. The guidance further suggests that hospitals participating in HPE could allow individuals to apply for the COVID-19 testing group through a phone call at the testing site since an applicant’s signature is not required when applying through HPE.</p><p><strong>Reporting and Provider Claims</strong>. States are not required to incorporate individuals determined eligible for the COVID-19 testing group into Medicaid’s eligibility system, known as the Medicaid Management Information System (MMIS), for purposes of claiming federal matching dollars. In order for states to receive the increased federal funding for this eligibility group, states must meet a continuous coverage requirement. As such, states must ensure that the individuals do not need to apply again for coverage of any subsequent testing. With regard to provider claims, states are not required to utilize the MMIS. However, states must maintain a provider claims process reflective of the CMS-64 form used for federal matching purposes. For example, the guidance suggests that providers could utilize non-standard claims forms or could submit rosters of patients who received testing which could then be manually entered or batch processed for payment.</p><p><strong>Coordination between Medicaid Uninsured Option for COVID-testing and HRSA COVID-19 Claims Reimbursement Program for Uninsured</strong>. States choosing the Medicaid COVID-19 testing option must coordinate benefits with the Health Resources & Services Administration (HRSA) COVID-19 claims reimbursement program. In this case, Medicaid is the primary payer for eligible beneficiaries receiving COVID-19 testing services. HRSA, via its claims contractor, UnitedHealthcare (UHC), will perform third-party clearances with states’ MMIS to ensure proper coordination of benefits for Medicaid beneficiaries. UHC will perform third-party clearances at the initial receipt of a claim from providers and conduct periodic retrospective reviews. If the state does not use the MMIS for the Medicaid optional COVID-19 testing group, the state will need to provide separate enrollment information for this group to HRSA for coordination of benefits to ensure that the HRSA-administered funds are not used for individuals enrolled in Medicaid.</p><p><strong>Further Questions:</strong> If you have questions, please contact the AHA at 800-424-4301.</p> Thu, 04 Jun 2020 12:23:32 -0500 Presumptive Eligibility /news/headline/2020-05-08-cms-issues-new-covid-19-faqs-medicaid-and-chip <p><span><span>The Centers for Medicare & Medicaid Services recently issued new </span></span><a href="https://nam03.safelinks.protection.outlook.com/?url=http:%2F%2Fsend.aha.org%2Flink.cfm%3Fr%3Do5Ps-NGTETCBkKNSISF-fw~~%26pe%3DqttQiw7K-eHZtk0nRarUidsfe8083n3fWdvIquS5F-aiPK1yZ30qkzwdHTkUubXbnsT2yX6LJyvnMKS5NBXp9w~~%26t%3DQMNYFTxaceGjk8YrCuOH1w~~&data=02%7C01%7Ctjordan%40aha.org%7Ce96e1cef216a41266d5d08d7f390eaa5%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C637245676047488347&sdata=kCbQTBq8RXN6pqP%2FGUqt%2BgaN87oKGiDZxZVxiva62GU%3D&reserved=0" target="_blank" data-fontcolor="1" originalsrc="http://send.aha.org/link.cfm?r=o5Ps-NGTETCBkKNSISF-fw~~&pe=qttQiw7K-eHZtk0nRarUidsfe8083n3fWdvIquS5F-aiPK1yZ30qkzwdHTkUubXbnsT2yX6LJyvnMKS5NBXp9w~~&t=QMNYFTxaceGjk8YrCuOH1w~~" shash="RbQZ7y24G09M5Zqd123kzucO4JjoigPiJ3QIRCQmxvbRGvxmfGQQNcEXnDF/MmjFlYQnTD03AwuRwoKYn8OMlGFhULJ0yjXkg1v6cumYgsLSEQjY8FVx2AE3+vYKplgySgRGCyleeJjOhe8mtr3IQ+kBm63jZKKuS2rT59FdWOs="><span><span><u>Frequently Asked Questions</u></span></span></a><span><span> to aid the Medicaid program and Children's Health Insurance Program in their response to the COVID-19 pandemic. The new FAQs cover a variety of Medicaid and CHIP topics, including provider payment, eligibility and enrollment flexibilities, many of which were advocated by the AHA. Of particular interest to hospitals are a series of FAQs that address Upper Payment Limit requirements and methodologies, provider payment increases related to COVID-19, and added flexibility for hospital presumptive eligibility. <strong>Read more details in the </strong></span></span><a href="https://nam03.safelinks.protection.outlook.com/?url=http:%2F%2Fsend.aha.org%2Flink.cfm%3Fr%3Do5Ps-NGTETCBkKNSISF-fw~~%26pe%3DkjKV-SVEytJ977EE84pPPRJlFb94OCxCIcdCpzbVEnzS5ByjhxLKikdWJwvhshlb8YKU014510bsa1u0XlEddg~~%26t%3DQMNYFTxaceGjk8YrCuOH1w~~&data=02%7C01%7Ctjordan%40aha.org%7Ce96e1cef216a41266d5d08d7f390eaa5%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C637245676047488347&sdata=jSYZ66Q9ujbKs6Xn0gtQfd%2B2iI5UlptbhJbj8IpxxVg%3D&reserved=0" target="_blank" data-fontcolor="1" originalsrc="http://send.aha.org/link.cfm?r=o5Ps-NGTETCBkKNSISF-fw~~&pe=kjKV-SVEytJ977EE84pPPRJlFb94OCxCIcdCpzbVEnzS5ByjhxLKikdWJwvhshlb8YKU014510bsa1u0XlEddg~~&t=QMNYFTxaceGjk8YrCuOH1w~~" shash="DS5luwtwmDl4FZ7kcXeApNlCLtNGrjFEhW5ocOHDmlVmpfJjeR3YtDT/qPAkCito4bPFnOJVg4vCnUISRHyeV98L9SbjnGGlM6zzy6TQkYiziMrdN9AYYAB6DToMs22M/fBecHEx8yRejHgYMjXopnGDY73sf9Rb3DKFhgAXlcs="><span><span><strong><u>AHA Special Bulletin</u></strong></span></span></a><span><span><strong>.</strong></span></span></p> Fri, 08 May 2020 15:17:48 -0500 Presumptive Eligibility