Revised, October 17, 1997

Presumptive Eligibility for Children:
A Promising New Strategy for Enrolling Uninsured Children in Medicaid
by Donna Cohen Ross


An estimated 3.4 million of the 10.3 million uninsured children in the U.S. are eligible for Medicaid, but are not enrolled in the program. The Balanced Budget Act of 1997 contains a new Medicaid option that provides states with an effective new tool for enrolling these children in the Medicaid program.

The Balanced Budget Act contains a provision that gives states the option of allowing certain health care providers and other community-based organizations to "presumptively" enroll children in Medicaid who appear to be eligible based on their age and family income. Currently, presumptive eligibility determinations can be made only for pregnant women; as of February 1996, some 30 states had implemented this option. Extending presumptive eligibility to children gives states a new way to facilitate the enrollment of uninsured children in Medicaid. In addition to helping families obtain health insurance for their children, presumptive eligibility also can help assure that children get needed medical care as early as possible.


What is presumptive eligibility?

Under this state option, certain "qualified entities" can make a preliminary, or "presumptive", determination that a child is eligible for Medicaid based on the family's declaration that its income is below the state's Medicaid income eligibility guidelines. No verification of income is needed at the time the presumptive eligibility determination is made. By determining the child presumptively eligible, the qualified entity can provisionally enroll the eligible child in Medicaid. The child's parent or other adult caring for the child has until the end of the following month to submit a full Medicaid application on behalf of the child. While the child awaits the final eligibility determination, he or she is covered to receive all health services covered under the Medicaid state plan, including all Early and Periodic Screening Diagnosis and Treatment (EPSDT) services.


What types of providers could make presumptive eligibility determinations?

Qualified entities that provide "health care items and services" covered under the Medicaid state plan can make presumptive eligibility determinations. Such providers include, but are not limited to, pediatricians, health professionals who deliver care in community health centers, or staff of school-based programs that receive Medicaid reimbursements for health services provided to students. In addition, the legislation specifically allows others who frequently come in contact with uninsured children, and routinely collect income information from their families to determine eligibility for other federal benefit programs, to make Medicaid presumptive eligibility determinations. The "qualified entities", other than health care providers, designated in the legislation are WIC programs, Head Start programs, and state or local agencies or nonprofit groups that determine eligibility for subsidized child care under the Child Care and Development Block Grant.


How can presumptive eligibility benefit children?

Allowing states to establish presumptive eligibility procedures for children could prove to be a particularly effective outreach tool. A lack of information about Medicaid eligibility and an application process that is often difficult to navigate present significant barriers to participation for eligible children — especially if their parents are working in low-paying jobs. The providers and agencies that would meet the definition of a "qualified entity" have frequent contact with low-income working families and are trusted by those families for information and advice about children's health. These entities, particularly Head Start programs and agencies that determine eligibility for child care subsidies, often are set up to accommodate the schedules of working parents. Many child care agencies and Head Start programs already are engaged in efforts to inform working parents about the Medicaid program. These organizations are well-positioned to follow-up by assisting families in completing the formal Medicaid application process. Thus, presumptive eligibility could effectively link outreach activities to the eligibility process.

In addition, presumptive eligibility procedures can help get children into routine care early so that they can receive preventive services, which may be difficult to obtain without health insurance coverage. It also can facilitate prompt treatment for potentially serious health problems. Presumptive eligibility also may be the key to getting care for children whose parents cannot afford even modest fees uninsured patients are charged by many health care providers.


Presumptive eligibility is a promising outreach strategy

A GAO study ("Prenatal Care: Early Success in Enrolling Women Made Eligible by Medicaid Expansions", February 1991) examined ten states that implemented various options to expand Medicaid to pregnant women. One objective of the study was to determine the activities that are most common among the states that showed the most favorable enrollment trends. The study found states that simultaneously implemented presumptive eligibility and dropped the assets test used in determining Medicaid eligibility — another strategy for streamlining the Medicaid application process — experienced the most rapid growth in enrollment.

Currently, 34 states and the District of Columbia have eliminated the assets test in determining Medicaid eligibility for children. An additional four states no longer count assets for some groups of children. Thus, in a majority of states that have already taken at least this first step in simplifying the Medicaid application process, presumptive eligibility is likely to provide the "missing link" needed to improve Medicaid enrollment rates among children. The GAO report concluded that determining eligibility on the spot, "conveys a message of inclusion rather than exclusion early in the application process." Although applicants ultimately had to complete the formal application process, they did so with the understanding that it was highly probable that they would remain eligible for the program.

Massachusetts has been using a procedure analogous to presumptive eligibility for enrolling uninsured children in the Children's Medical Security Plan (CMSP), its state-funded child health insurance program. The Massachusetts procedure permits health providers, child care centers, WIC programs, school nurses, and other community-based programs to enroll children temporarily in CMSP, pending receipt of income verification needed to determine the family's share of cost for the program. CMSP's director credits the procedure with providing an array of access points to draw new applicants to the program. Presumptive eligibility enables community organizations to help families obtain health insurance for their children at the same time they are working with families to meet other needs, and it assures coverage before a child gets sick.


How will states pay for presumptive eligibility?

A Medicaid provider who delivers health services to a presumptively eligible child will receive payment for care delivered during the presumptive period, regardless of whether or not the child ultimately is determined eligible for Medicaid. Under some circumstances Medicaid will pay these costs; under other circumstances the costs incurred during the presumptive period will be offset against the state's child health block grant allocation.


How Presumptive Eligibility Could Have Made A Difference: Three Examples


Children's Services in Boulder, Colorado administers the Child Care Assistance Program, which provides federal child care subsidies to eligible families. Heidi Rewinkle, the program supervisor, estimates that about 30 percent of the families who come to the program seeking child care assistance have children who are eligible for Medicaid, but who are not enrolled in the program.

Several months ago, a mother came to the agency to find out if she qualified to receive a child care subsidy for her four-year-old child. She and her child were living in a shelter for the homeless at the time, and she had just landed a full-time job at a wage of just over $6.00 per hour. The job did not provide health insurance benefits. The Children's Services staff learned that the child was not enrolled in Medicaid and that the mother was concerned the child might have a slight ear infection. If the child had needed emergency medical attention, Children's Services staff could have referred the child to a health clinic for immediate care, but in situations like the one described above, families have to wait until they receive a Medicaid card in order to get routine health care for their children. The Children's Services staff referred the mother to the Medicaid office and encouraged her to apply for the program so that she would have a source of ongoing health care for her child. It usually takes several weeks for the Medicaid card to be issued.

How could presumptive eligibility have helped this child?

The Children's Services staff was able to assess that the child was likely to be eligible for Medicaid, since the family income was less than 133 percent of the poverty line, the Medicaid income limit in Colorado for a child under age six. If presumptive eligibility had been an option, the staff could have enrolled the child in Medicaid on the spot. The child's ears could have been checked immediately, rather than waiting for the Medicaid card and taking the risk that the possible infection would go untreated.


North Carolina

According to Robert Jones, WIC Program director for the Reynold's Health Center in Winston-Salem, North Carolina, WIC staff frequently observe that the waiting period for Medicaid eligibility determination prevents children from receiving medical care. He also reports that, "children who haven't yet been approved for Medicaid have to pay a fee to see the clinic doctor. Many families cancel their appointments because they are unable to pay the fee. Sick children aren't seeing the doctor."

On Thursday, June 26, a mother brought her 11-month-old child into the WIC office. At the WIC evaluation, during which every child is measured and weighed, the child was found to be seriously underweight. WIC staff recommended that the mother take the baby to see the health center doctor for further evaluation. The mother agreed that her daughter needed to see a doctor, but said that — although she had applied for Medicaid a month and a half earlier — she had not yet received her Medicaid card and could not afford the ten dollar payment required of non-Medicaid patients. She also indicated that a lack of transportation would make it difficult for her to return to the clinic.

How could a presumptive eligibility procedure have helped this child?

In this case, the child was clearly eligible for Medicaid since the mother's income was less than $300 a month, much lower than the Medicaid income limit of 185 percent of the poverty line for infants in North Carolina. If WIC staff had been able to make a presumptive eligibility determination, this child could have been taken directly upstairs to see the health center doctor. Presumptive eligibility would have prevented financial barriers and transportation problems from standing in the way of the child receiving immediate care.



Janet Schultz, a pediatric nurse practitioner, is the health coordinator for the Prekindergarten Head Start Program of the Philadelphia School District, which serves more than 3,000 preschoolers. Virtually all Head Start children are in families with incomes below the federal poverty line, indicating they are well below the income cut-off for Medicaid. To be enrolled in Head Start, children must have a full child health assessment and must be up-to-date on their immunizations, but Ms. Schultz is unable to make appointments for children at area clinics unless the family has some form of health insurance. If a child applying for Head Start does not have health insurance coverage, Ms. Schultz informs the family about the child's eligibility for Medicaid and tells them where they can go to apply. Once a Medicaid application is complete, it typically takes several weeks before the family receives a Medicaid card.

Recently, a father came to Ms. Schultz's office. The father worked in a grocery store and indicated he earned less than $1,330 each month for his family of four, including his wife and two children, ages 4 and 6. The father explained that it was not possible for the children to go the doctor regularly since the family did not have health insurance, and he expressed concern that the children were "behind in their shots". Without proof of immunization, the younger child could not be enrolled in Head Start.

How could a presumptive eligibility procedure have helped these children?

If Ms. Schultz had been able to make the presumptive eligibility determination for the children, they could have received their immunizations right away and could have undergone a well-child check-up to identify any medical conditions that might need treatment. She also could have assured the four-year-old a slot in Head Start.