Presumptive Eligibility Criteria

Hospitals must develop by January 1, 2014 a presumptive eligibility policy outlining the criteria it will use to determine if eligibility for hospital financial assistance without further scrutiny by the hospital. Several categories of criteria are mandatory but a hospital may consider other categories, depending on the facility’s location.

Mandatory categories are intended to reflect the new free care mandate included in the 2012 amendment to the Hospital Uninsured Patient Discount Act legislation for uninsured patients at up to 200% of the federal poverty level (FPL) at urban hospitals and up to 125% FPL at rural and Critical Access Hospitals (CAHs).

The Illinois Office of Attorney General (OAG) has indicated that a hospital could have a separate presumptive eligibility section within its financial assistance policy that would meet the requirement for a presumptive eligibility policy.

The presumptive eligibility policy shall be applied to an uninsured patient as soon as possible after the patient receives hospital services and prior to issuing any bill for those hospital services. A presumptive eligibility policy is defined as the criteria used to deem a patient eligible for financial assistance. The criteria are defined as the categories identified as demonstrating financial need.

All Hospitals: Mandated Categories

• Homelessness;
• Deceased with no estate;
• Mental incapacitation with no one to act on patient’s behalf; and
• Medicaid eligibility, but not on date of service or for non-covered service.

Urban Hospitals: Additional Mandated Categories

Enrollment in the following programs with criteria at or below 200% FPL:

• Women, Infants and Children Nutrition Program (WIC);
• Supplemental Nutrition Assistance Program (SNAP);
• Illinois Free Lunch and Breakfast Program;
• Low Income Home Energy Assistance Program (LIHEAP);
• Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria; and
• Receipt of grant assistance for medical services.

All Hospitals: Optional Additional Criteria

• Recent personal bankruptcy;
• Incarceration in a penal institution;
• Affiliation with a religious order and vow of poverty;
• Enrollment in the following assistance programs for low-income individuals:
  • Temporary Assistance for Needy Families (TANF); and
  • Illinois Housing Development Authority’s Rental Housing Support Program.

  CAH and Rural Hospitals: Optional Additional Criteria

  • Enrollment in an organized community-based program providing access to medical care that assesses and documents limited low-income financial status as criteria.

  Reporting

  Hospitals must submit a report to the OAG annually regarding compliance with this rule either when submitting the Community Benefits Report (if subject to that requirement) or when submitting its Medicare Cost Report Worksheet C pursuant to that requirement under the Hospital Uninsured Patient Discount Act.

  OAG submitted a report form to the Joint Committee on Administrative Rules with the final rule. The report shall include:

  • Financial Assistance Application Form;
  • Presumptive Eligibility Policy, including each criteria used;
  • Financial Assistance Statistics on OAG form
    • Applications submitted (complete and incomplete);
    • Applications approved (including number approved using presumptive eligibility);
    • Applications denied;
    • Dollar amount of financial assistance at cost; and

    Hospitals are allowed to use electronic and information technology in both the financial assistance application form process and presumptive eligibility requirements. If a hospital does so, the annual report shall also include a description of the type and source used. The hospital shall also certify that the electronic system includes the requirements for the application and presumptive eligibility in the rule.

    • Hospitals must develop a presumptive eligibility policy outlining the criteria it will use to determine if a patient is eligible for financial assistance without further scrutiny by the hospital.
    • Mandated categories include may consider other categories, depending on the facility’s location.
    • Hospitals must submit a report to the OAG annually regarding compliance with this rule either when submitting the Community Benefits Report or the Medicare Cost Report Worksheet C.

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