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Journal Issue: Health Insurance for Children Volume 13 Number 1 Spring 2003

Presumptive Eligibility
Rachel Klein

Introduction

When Congress established the State Children's Health Insurance Program (SCHIP) in 1997, it also enacted presumptive eligibility, a new state option for expediting children's enrollment in Medicaid.1 Presumptive eligibility helps states cover children more quickly by allowing them to provide immediate, but temporary, enrollment in Medicaid or SCHIP to children who appear to meet program eligibility standards. During a period of presumptive eligibility, children have access to the full range of Medicaid- or SCHIP-covered services (for whichever program they are presumed to be eligible), allowing them to receive needed health care immediately rather than waiting for completion of a full eligibility determination. This approach facilitates access to care for uninsured children and contributes to state efforts to increase participation in Medicaid and SCHIP.

This article provides an overview of presumptive eligibility as a strategy for increasing participation in Medicaid and SCHIP. In addition to describing the process of determining presumptive eligibility and its benefits for children, the article also examines some concerns that have slowed the widespread adoption of presumptive eligibility to date. Finally, the article discusses possible solutions that will enable presumptive eligibility to meet its potential to quickly cover eligible children and increase the continuity of their care.