Presumptive eligibility

Future of Children

Volumn 13, Issue 1, 2003, Pages 230-236

  Klein, Rachel ^a  

^a Families USA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BUDGET; CHILD; CHILD HEALTH CARE; FINANCIAL MANAGEMENT; HEALTH CARE ACCESS; HEALTH CARE COST; HEALTH CARE POLICY; HEALTH INSURANCE; HUMAN; LOWEST INCOME GROUP; MEDICAID; REIMBURSEMENT; REVIEW; ARTICLE; ECONOMICS; ORGANIZATION AND MANAGEMENT; PUBLIC RELATIONS; UNITED STATES;

CHILD; CHILD HEALTH SERVICES; COMMUNITY-INSTITUTIONAL RELATIONS; ELIGIBILITY DETERMINATION; HEALTH POLICY; HUMANS; INSURANCE, HEALTH; MEDICAID; UNITED STATES;

EID: 0242304462     PISSN: 10548289     EISSN: 15501558     Source Type: Journal    
DOI: 10.2307/1602653     Document Type: Review

References (26)

1. Social Security Act, 42 U.S.C. 1396r-1a § 1920A (1997).
2. See note 1, Social Security Act. A period of presumptive eligibility lasts from the date the child is presumed eligible to the end of the following month (thus, up to 60 days). However, if the family submits an application for ongoing Medicaid or SCHIP coverage, or if the presumptive eligibility application is the same as the regular Medicaid or SCHIP application, the temporary coverage continues until a full eligibility determination is made.
3. The federal government shares the cost of Medicaid and SCHIP with the states. The federal government pays 50% to 75% of Medicaid costs. To give states incentive to expand coverage to children under SCHIP, the SCHIP statute authorizes the federal government to pay a higher percentage of SCHIP costs. In Fiscal Year 2002, the federal government paid 65% to 83% of SCHIP costs. Social Security Act, 42 USC § 1397ee (1997).
4. States that adopt presumptive eligibility in a Medicaid expansion will receive the regular federal match for children determined to be eligible for regular Medicaid and the enhanced SCHIP match for children made eligible through the expansion.
5. Benefits Improvement and Protection Act of 2000, Public Law 106-554. 2nd session, December 15, 2000.
6. Families USA. Promising ideas in children's health insurance: Presumptive eligibility. Washington, DC: Families USA, April 2000.
7. Lake, Snell, Perry, and Associates. Medicaid and children: Overcoming barriers to enrollment: Findings from a national survey. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2000.
8. Once Medicaid eligibility is determined, eligibility begins on the date of application. Medicaid rules allow families to receive coverage for up to three months prior to the date of application if they were eligible during that time and incurred medical expenses for qualifying services. This rule enables providers who have delivered services but not been paid to bill Medicaid, and it enables families to be reimbursed (at the Medicaid rate) for out-of-pocket payment for covered services.
9. Cohen Ross, D., and Cox, L. Making it simple: Medicaid for children and CHIP income eligibility guidelines and enrollment procedures. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2000.
10. Telephone survey of state SCHIP administrators, conducted by Families USA staff, June-August, 2000.
11. Institute for Child Health Policy. Florida KidCare evaluation, year 2, Fiscal Year 2000: vol. 1: Narrative. 2001. Available online at http://www.ichp.edu/FloridaKidCare/2000Reports/FlaKCEvalv1_FY2000.pdf.
12. Edmunds, M., and Coye, M.J., eds. America's children: Health insurance and access to care. Washington, DC: National Academy Press, 1998.
13. See note 6, Families USA.
14. See note 7, Lake, Snell, Perry, and Associates.
15. Kenney, G., and Haley, J. Why aren't more uninsured children enrolled in Medicaid or SCHIP? Washington, DC: Urban Institute, May 2001.
16. Pernice, C., Riley, T., Perry, M., and Kannel, S. Why eligible children lose or leave SCHIP: Findings from a comprehensive study of retention and disenrollment. Portland, ME: National Academy of State Health Policy, February 2002.
17. See note 7, Lake, Snell, Perry, and Associates.
18. Personal communications with state presumptive eligibility staff: Sue Fiero, Medicaid program specialist, Nebraska Department of Health and Human Services, May 2002; Kate Frye, Policy and Program Planning, New Hampshire Health Care Services Division, Department of Health and Human Services, May 2002; Fran Smith, director of Medicaid in the Schools, School Health Unit, New Mexico Department of Education, December 2000.
19. See note 17, Personal communications with state presumptive eligibility staff.
20. Personal communication with Pat Lopez, Lancaster County Kids Connection, May 2002.
21. The average cost per child per month for children enrolled in Kids Connection is $172.31. Personal communication with Rob Stevenson, program analyst, Nebraska Department of Health and Human Services Office of Finance and Support, June 5, 2002.
22. See note 17, Personal communications with state presumptive eligibility staff.
23. Retroactive eligibility allows individuals to receive coverage for services they received prior to enrollment in Medicaid, and it allows providers to be paid for those services, but only if the individual is determined to have been eligible during that time. In contrast, presumptive eligibility allows a child to receive services, and the provider to be paid for those services, even if the child is ultimately found ineligible for Medicaid or SCHIP.
24. Cohen Ross, D., and Cox, L. Enrolling children and families in health coverage: The promise of doing more. Washington, DC: Kaiser Commission on Medicaid and the Uninsured, June 2002.
25. See note 17, Personal communications with state presumptive eligibility staff
26. See note 10, Telephone survey of state SCHIP administrators.