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The HPE Determination Process: A Hypothetical Example
To illustrate how the HPE determination process might work in practice, following is a fictional account of an
uninsured patient during a hospital visit:
Oscar is a 42‐year‐old landscaper. Single and without children, he earns about $15,000 per year, and has
never had health insurance. He strained his back helping a friend move a broken refrigerator. After three
days of intense pain, Oscar decided to go to the emergency department (ED) at a local hospital.
In the ED, a hospital employee, Mary, gives Oscar a brochure explaining how the Affordable Care Act has
allowed their state to expand Medicaid for single adults ages 18 to 64 with annual incomes under
$16,105.iv Mary tells Oscar that she may be able to enroll him in Medicaid temporarily and help him apply
for permanent coverage. She asks Oscar for basic information, including his legal name, address, date of
birth, social security number, and his weekly take‐home pay. She then logs into an online hospital PE
applicationv provided by the state Medicaid agency and enters Oscar’s information, except his social
security number, which Oscar doesn’t remember.vi Mary quickly verifies that Oscar is not enrolled in
Medicaid, and determines that he is presumptively eligible for Medicaid.
Mary prints a temporary Medicaid eligibility card for Oscar. She also prints a checklist of information he’ll
need to provide to complete the full online Medicaid application, and schedules a follow‐up call with him
to finish the application. With temporary card in hand, Oscar goes back to the ED admit desk and gives his
new health insurance information. After seeing a doctor, Oscar takes his prescription for muscle relaxants
to a local pharmacy, where he uses his temporary Medicaid card to pay for the prescription. A few days
later, Oscar gets a call from Mary, and with her help, finishes his full Medicaid application online.
This story demonstrates how the HPE process can help an uninsured individual pay for immediate care at a
hospital and help connect the individual to long-term, stable health insurance coverage.
https://www.statereforum.org/system/files/hpe_fact_sheet_021114.pdf
To illustrate how the HPE determination process might work in practice, following is a fictional account of an
uninsured patient during a hospital visit:
Oscar is a 42‐year‐old landscaper. Single and without children, he earns about $15,000 per year, and has
never had health insurance. He strained his back helping a friend move a broken refrigerator. After three
days of intense pain, Oscar decided to go to the emergency department (ED) at a local hospital.
In the ED, a hospital employee, Mary, gives Oscar a brochure explaining how the Affordable Care Act has
allowed their state to expand Medicaid for single adults ages 18 to 64 with annual incomes under
$16,105.iv Mary tells Oscar that she may be able to enroll him in Medicaid temporarily and help him apply
for permanent coverage. She asks Oscar for basic information, including his legal name, address, date of
birth, social security number, and his weekly take‐home pay. She then logs into an online hospital PE
applicationv provided by the state Medicaid agency and enters Oscar’s information, except his social
security number, which Oscar doesn’t remember.vi Mary quickly verifies that Oscar is not enrolled in
Medicaid, and determines that he is presumptively eligible for Medicaid.
Mary prints a temporary Medicaid eligibility card for Oscar. She also prints a checklist of information he’ll
need to provide to complete the full online Medicaid application, and schedules a follow‐up call with him
to finish the application. With temporary card in hand, Oscar goes back to the ED admit desk and gives his
new health insurance information. After seeing a doctor, Oscar takes his prescription for muscle relaxants
to a local pharmacy, where he uses his temporary Medicaid card to pay for the prescription. A few days
later, Oscar gets a call from Mary, and with her help, finishes his full Medicaid application online.
This story demonstrates how the HPE process can help an uninsured individual pay for immediate care at a
hospital and help connect the individual to long-term, stable health insurance coverage.
https://www.statereforum.org/system/files/hpe_fact_sheet_021114.pdf