Presumptive Eligibility: Critical Tool for Protecting Young People during the Pandemic

By Kayla Tawa and Nia West-Bey 

The COVID-19 pandemic continues to exacerbate existing and systemic flaws within our health care system, including the high uninsured rate of youth and young adults. Under the current system, urgent care clinics can legally deny treatment to those without insurance, encouraging them to seek care in a hospital setting. Among those aged 18-35, 21 percent lacked insurance in 2018. Within the 19-25 age range, 14.3 percent lacked insurance. This system poses a challenge both to overburdened hospitals unable to treat an influx of patients and to individuals without insurance who risk greater exposure when forced to seek necessary care in a hospital setting. We must do more to protect vulnerable youth and young adults including those without insurance. Aggressively implementing and expanding presumptive eligibility for Medicaid represents a promising strategy. 

Presumptive eligibility allows individuals to temporarily enroll in Medicaid coverage based on the presumption that they are eligible for coverage. Only qualified entities can screen for presumptive eligibility, which only requires self-attestation, meaning the qualified entity doesn’t need to verify the information provided. People who qualify receive covered health services without delay and are encouraged to apply for permanent Medicaid coverage. Presumptive eligibility coverage usually lasts a maximum of 60 days. 

Thirty-one states currently have presumptive eligibility, but limit it to certain priority populations, usually pregnant women and children (up to 18). In all but six states, childless adults do not qualify. The Affordable Care Act (ACA), however, created hospital presumptive eligibility nationwide. Under this policy, all individuals can be screened, but hospitals are the only qualified entity. Therefore, in most states young people who are uninsured can only seek immediate care and coverage in a hospital setting. 

States should aggressively implement presumptive eligibility to maintain critical health infrastructure for young people who lost employer coverage and provide coverage for youth and young adults who never had insurance. People with low incomes, including young people and people of color, have the highest uninsured rates. In 2018, 14.3 percent of 18-25-year-olds were uninsured, with significant disparities by race and ethnicity:

  • Nearly 1 in 3 Native Hawaiian and Pacific Islander young people (29.4 percent uninsured) 
  • More than 1 in 5 Hispanic young people (21.6 percent uninsured)
  • Nearly 1 in 5 Black young people (18 percent uninsured)  
  • 1 in 6 Native young people (16 percent uninsured) 
  • Nearly 1 in 9 Asian American young people (11.4 percent uninsured)
  • 1 in 10 white young people (10.3 percent)

All of these rates are higher than the national average of 7.9 percent.

To combat the COVID-19 pandemic, states should use presumptive eligibility to better serve young people without insurance. In states where it exists, presumptive eligibility should be expanded to youth and young adults. Nationwide, restrictions on hospital presumptive eligibility should be loosened so individuals can seek care without risking hospital exposure to COVID-19. Temporary coverage is crucial for individuals who experience COVID-19 symptoms, as completing a full Medicaid application while sick is unsafe, burdensome, and unlikely. States can use waivers and Disaster Relief State Plan Amendments (SPAs) to make these changes

To improve presumptive eligibility and make it more effective for youth and young adults, states should:

  • Expand qualified entities that can screen for eligibility: Qualified entities should include urgent-care facilities, child care facilities, youth serving agencies, testing sites, and virtual options to avoid exposing others to COVID-19. 
  • Cover the continuum of care: In some states under the current system, individuals covered through hospital presumptive eligibility can only receive care in a hospital setting. People should be able to seek care at any site that accepts Medicaid, including through telehealth and primary care doctors. Both testing and treatment should be covered. While, the Families First Coronavirus Response Act gave states the option to expand Medicaid coverage to uninsured individuals, including immigrants, for diagnosis and testing, that coverage doesn’t extend to treatment.
  • Tie eligibility to episodes of COVID-19 exposure: Just as pregnant women are allowed one period of presumptive eligibility per pregnancy, individuals exposed to COVID-19 should be allowed one period of eligibility per COVID-19 exposure. Multiple periods are especially critical for essential workers without insurance who risk multiple exposures throughout the pandemic. 
  • Not include a citizenship question when screening for COVID-19 presumptive eligibility: Immigrants should be eligible for presumptive eligibility during the pandemic, regardless of their documentation status, and the five-year waiting period should be waived. 

We must do more to protect uninsured young people from both the economic and health crises spurred by the COVID-19 pandemic. Aggressively implementing presumptive eligibility for young people represents a promising strategy. However, we must also invest in sustainable changes to our health care system so young people have access to adequate, affordable, and comprehensive coverage. Making critical investments in the health and wellbeing of our young people ensures that we are better able to combat future public health crises when they arise.