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 coverage.
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 measures (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.
