Presumptive Eligibility Connects Kids (and Others) to Coverage – Say Ahhh! A Children’s Health Policy Blog

Over most of the two decades I’ve been working on
children’s coverage, it was generally believed that sustaining an uninsurance
rate among children of less than 5% was unlikely. Several states came close,
hovering just above or below 5%, but still, the notion lingered. That is, until
Massachusetts solidly broke the 5% barrier and can now boast that 99% of
Massachusetts children have insurance. While this sets a new standard for
coverage, states have a number of helpful policy tools at their disposal –
including presumptive eligibility, a policy that will have greater impact as
states implement the Affordable Care Act.

Presumptive eligibility is an effective approach to
reaching uninsured children and pregnant women who are eligible for Medicaid
and CHIP and providing them with access to urgently needed health care
services. This policy option is best used in conjunction with targeted efforts
at the community level to find and enroll the hardest-to-reach, uninsured
children. It effectively combines proven strategies of conducting outreach
through community partners and simplifying the enrollment process through
direct, one-on-one assistance.

The policy was first established in Medicaid as a state
option to accelerate access to ambulatory prenatal care services for pregnant
women, but it now can be used more broadly for children and other adults. In
light of its success for pregnant women, Congress extended the option to
children in Medicaid when CHIP was enacted in 1997. In 2010, the Affordable Care
Act (ACA) added a new population to presumptive eligibility, giving states the
flexibility to extend it to include parents and other adults eligible for
Medicaid. This is an important step that can help states move to more
coordinated family-based coverage.

The policy gives states the option to train specific
“qualified entities,” such as health care providers, schools, government
agencies and community-based organizations, to screen for eligibility and
temporarily enroll children and pregnant women in Medicaid or CHIP. Individuals
determined presumptively eligible can secure covered health care services
without delay while they complete the regular application process for ongoing

In implementing presumptive eligibility, there is much we
can learn from the 16 states that have adopted the policy for children. We’ve
tried to capture the highlights of these experiences, as well as lay out the
considerations states face as they develop their presumptive eligibility
processes and systems in this new brief.

Presumptive eligibility can ease the administrative
burden on state eligibility agencies by working through providers or community
agencies to help families complete the regular application process, including
submitting all documents needed to verify eligibility. It also is one of eight
(of which states have to adopt five) a state must have in place to
qualify for a performance bonus if the state also meets specific Medicaid
enrollment targets

Notably, the ACA will give hospitals that provide
Medicaid services the prerogative to make presumptive eligibility decisions
regardless of whether the state otherwise has adopted the option. This
authority goes into effect in 2014 along with the new national income
eligibility floor for Medicaid of 133 percent of the federal poverty level
(FPL). Given this new reality, states may want to consider implementing
presumptive eligibility now to get their systems and processes in place in
advance of 2014.

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