Final Rules for SCHIP and Medicaid Presumptive Eligibility


Publication Date: August 30, 2001



DATE: August 30, 2001


SUBJECT: Legislation on Presumptive Eligibility for Medicaid and Final Rules for State Child Health Insurance Program (SCHIP) and Medicaid Presumptive Eligibility

LEGISLATION:The Consolidated Appropriations Act of 2000 (PL 106-554) was enacted December 21, 2000. One of the several Congressional bills incorporated into PL 106-554 prior to enactment was HR 5661 (Medicare, Medicaid, and SCHIP Benefit Improvement and Protection Act of 2000). Section 708 of HR 5661 (Additional Entities Qualified to Determine Medicaid Presumptive Eligibility for Low-Income Children) amended section 1920A(b)(3)(A)(i) of the Social Security Act (the Act). A copy of section 708 of HR 5661 is attached.

BACKGROUND: Section 4901 of the Balanced Budget Act of 1997 (PL 105-33) established the State Child Health Insurance Program (SCHIP) under new Title XXI of the Act. Section 2101 of the Act authorized funds to States to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children (less than 200 percent of the Federal poverty level) in an effective and efficient manner that is coordinated with other sources of health benefit coverage for children. States have the option to provide the health benefit coverage by providing Medicaid benefits to eligible low-income children, by providing coverage under a separate program developed by the State, or by a combination of both.

Section 4912 of PL 105-33 amended Title XIX of the Act (Medicaid) by adding a new section 1920A to allow States the option to allow specified qualified entities to make presumptive eligibility determinations. The presumptive eligibility period for a child found to be eligible, based upon preliminary information that the family meets the financial eligibility standards, begins on the date of the presumptive eligibility determination and ends at the end of the next month.

The qualified entities in the original legislation included Medicaid providers, as well as those entities authorized to determine eligibility of a child for the Head Start Program, the Child Care and Development Block Grant (CCDBG) Program, or the USDA Supplemental Food Program for Women, Infants, and Children (WIC) Program.

Section 708 of HR 5661 adds to the list of qualified entities to include: (1) Medicaid and SCHIP eligibility agents; (2) Elementary and Secondary Education Act schools; (3) Bureau of Indian Affairs or tribal schools; (4) State or tribal child support enforcement agencies; (5) organizations proving services to the homeless under the Stewart B. McKinney Act; (6) State or tribal Medicaid, SCHIP, and TANF agencies; (7) HUD public and assisted housing programs; or (8) any other entity the State designates, with the approval of the Secretary.

The enactment of section 708 is in accord with Recommendation 17 of the Medical Child Support Working Group's Report to the Secretaries of Labor and HHS, which the Secretaries forwarded to the Congress August 15, 2000. Recommendation 17 stated that Congress should amend section 1920A of the Social security Act to include IV-D agencies among the "qualified entities" that may enroll children in Medicaid for a presumptive eligibility period, based upon preliminary information that indicates that the child is income-eligible for Medicaid.

The State Medicaid agency determines whether the potential qualified entity has the capability to make presumptive eligibility determinations. The State Medicaid agency must provide appropriate presumptive eligibility training and forms to the qualified entities. The Secretary of Health and Human Services may issue regulations further limiting those entities that may become qualified entities. The State IV-D agency should contact the State Medicaid agency to discuss the presumptive eligibility provisions in the State Medicaid program.

The Centers for Medicare and Medicaid Services (CMS) has responded in a series of questions and answers to questions from States implementing SCHIP. In response to question 85 in the fifth set of questions and answers ("Can a State do presumptive eligibility (PE) under its State Title XXI program?"), CMS responded that "although there is no express provision for PE under Title XXI, a State may craft an equivalent procedure in a non-Medicaid CHIP program as a health initiative." Question and answer 85 are attached. The State IV-D agency should contact the SCHIP agency to discuss further the presumptive eligibility provisions in the SCHIP program.

OCSE is working with CMS, which oversees the Medicaid and SCHIP programs, regarding the potential policy and practical implications of section 708 on IV-D agencies. Questions should be forwarded to ACF Regional offices or the OCSE Central Office, attention Andrew J. Hagan.

SCHIP FINAL RULES: The FEDERAL REGISTER published the final rule for SCHIP on January 11, 2001 (66 FR 2490). The effective date was June 10, 2001. The final rule is almost 200 pages. You may access the final rule by going to the CMS website Visit disclaimer page , then the SCHIP site to find the final rule, a summary of the provisions in the final rule, and other SCHIP material, including the questions and answers referenced above. The final rule does include related Medicaid changes, including the expanded list of qualified entities to make presumptive eligibility determinations, at 435.1101 and 436.1101.

A copy of the text of section 708 is enclosed. Copies of PL 106-554, as well as HR 5661 are available from the U.S. Government Publishing Office on the Internet ( Visit disclaimer page ).

ATTACHMENTS: Section 708 of HR 5661; Question and response 85 from the fifth set of responses by CMS to questions addressing SCHIP implementation.

INQUIRIES: ACF Regional Administrators


Frank Fuentes
Acting Commissioner
Office of Child Support Enforcement


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