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Patients presumed Medicaid-eligible get immediate aid under Obamacare

TNS Regional News • May 12, 2014 at 2:07 PM

The stroke that temporarily robbed Andrew Starkey of the use of his left side hit at a vulnerable time for the Marietta man’s family.

Only a week into his new job as a heavy-equipment operator, he had not yet worked enough hours to qualify for the company’s health plan. His wife, Robin, had no coverage available through her part-time job as an aide in a doctor’s office.

But Starkey, 51, received good news during his six-day stay this month in OhioHealth Riverside Methodist Hospital, where he underwent an angioplasty and will have surgery on a blockage and blood clot in his carotid artery. He is eligible for the Affordable Care Act’s new “presumptive eligibility” initiative. Those who qualify get Medicaid benefits immediately instead of waiting weeks.

Starkey, for example, had his prescription filled at no cost to him after leaving Riverside.

“I couldn’t believe it. I figured what cash we did have was going to be gone,” he said. “Words can’t explain the relief.”

As of last Monday, 3,924 Ohioans had been approved presumptively for coverage, said Sam Rossi, spokesman for the Ohio Department of Medicaid.

Some Ohio hospitals have been able to presume pregnant women and children are eligible for Medicaid since January, and that option was expanded at the end of March to all people eligible under Ohio’s recent Medicaid expansion. The choice to give patients immediate access to Medicaid rests with individual hospitals, not states.

State Medicaid officials have no estimate of how many people might qualify for presumptive eligibility in the future or how much money has been paid out to hospitals and community health centers.

Ohio is the only state so far that also has allowed community health centers to presume certain patients are eligible for Medicaid, said Julie DiRossi-King of the Ohio Association of Community Health Centers. “It’s extremely, extremely valuable,” she said.

The immediate access to Medicaid gives enrollees access to prescriptions that might otherwise go unfilled, as well as timely follow-up care from specialists. That might prevent a patient’s condition from getting worse or possibly rule out a return trip to the hospital.

Many people are eligible for Medicaid but don’t enroll until they’re in a crisis, said Joel Potts, spokesman for the Ohio Job and Family Services Directors’ Association, which represents county agencies that sign people up for Medicaid. Presumed eligibility gives those people a new way to access that help quickly when they’re in a jam, he said.

Under federal rules, Rossi said, Ohio Medicaid cannot recoup money from hospitals in cases in which patients who were given immediate Medicaid access were ultimately found ineligible for the program.

However, Ohio hospitals are expected to make sure that 85 percent of the patients who they presume are eligible for Medicaid complete a full application and submit it by no later than the end of the month after they receive the status. (Someone found eligible on April 15, for example, would need to submit a completed application by the end of May.)

Of those who complete applications, the expectation is that 85 percent will be found eligible for Medicaid, Rossi said.

If patients presumed eligible don’t complete applications, their coverage will lapse. Patients can be presumed eligible only once per year.

“You can’t go to the hospital seven times during the course of the year and get presumptive eligibility each time,” Rossi said.

It’s too soon to say how much Medicaid money has been paid out to hospitals for patients who should not have qualified for presumptive enrollment, he said.

Ohio State University’s Wexner Medical Center expects compensation of about $400,000 from Ohio Medicaid for patients it presumed were eligible, said Debra Lowe, the administrative director of revenue cycle. Without presumptive eligibility, Wexner Medical Center might have received as little as half of that sum, she said.

Of the 54 applications that Ohio State patients have submitted so far, only three have been denied, Lowe said.

Nationwide Children’s Hospital said it has presumed 355 patients as eligible for Medicaid so far; the families of most of them are still completing applications or awaiting a decision from Medicaid on longer-term coverage. There were 14 approvals and no denials as of Wednesday.

OhioHealth said it has presumed 478 patients eligible for Medicaid, with long-term eligibility decisions pending for 462 of them. The rest have been approved.

To help ensure a high approval rate, the health system is being “very conservative” in presuming patients are eligible, said Margaret Schuler, executive director of revenue cycle.

Mount Carmel Health System is taking steps to participate, a spokeswoman said.

Starkey said he’s never relied on government assistance and had to swallow his pride after his stroke.

“I will be functional, and I will be productive to where I can support myself and my family,” he said. “I won’t settle for anything less.”


By Ben Sutherly - The Columbus Dispatch, Ohio (MCT)

©2014 The Columbus Dispatch (Columbus, Ohio)

Visit The Columbus Dispatch (Columbus, Ohio) at www.dispatch.com

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