Putting Express Lane Eligibility into Practice · 2019-02-08 · A Briefing Book and Guide for Enrolling Uninsured Children Who Receive Other Public Benefits into Medicaid and CHIP

A Briefing Book and Guide forEnrolling Uninsured Children WhoReceive Other Public Benefits intoMedicaid and CHIP

Putting Express LaneEligibility Into Practice

N o v e m b e r 2 0 0 0

A Publication of The Children’s Partnership

and

The Kaiser Commission on Medicaid and the Uninsured

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Stan DornHealth Consumer Alliance,National Health Law Program

Trish RileyNational Academy for StateHealth Policy

Sara RosenbaumCenter for Health Policy Research,George Washington University

Donna Cohen RossCenter on Budget and PolicyPriorities

Robert RossSan Diego County, Health andHuman Services Agency

Glen RosselliState of California, Health andHuman Services Agency

Sarah ShuptrineThe Southern Institute on Childrenand Families

Denise TaylorChicago Public Schools System

Special thanks to Barbara Lyonsand Christina Chang with TheKaiser Commission on Medicaidand the Uninsured for their sup-port and continued guidance.

About The Children’s PartnershipThe Children’s Partnership (TCP) is a national, nonprofitorganization founded to put the unique needs of childrenfront and center in a changing economy, culture and policyworld. TCP works to ensure that all children have access to the resources they need and to involve more Americans in the cause for kids. The Children’s Partnership’s work is supported by private foundations, corporations, the entertainment community, interested individuals, and others with whom it partners on projects. TCP has offices in Santa Monica, CA and Washington, DC.

About The Kaiser Commission on Medicaid and the UninsuredThe Kaiser Commission on Medicaid and the Uninsuredserves as a policy institute and forum for analyzing healthcare coverage and access for the low-income population and assessing options for reform. The Commission, begun in1991, strives to bring increased public awareness andexpanded analytic effort to the policy debate over healthcoverage and access, with a special focus on Medicaid andthe uninsured. The Commission is a major initiative of theHenry J. Kaiser Family Foundation and is based at theFoundation’s Washington, DC office.

The Children’s Partnershipwww.childrenspartnership.org1351 3rd Street Promenade, Suite 206Santa Monica, CA 90401-1321310-260-1220310-260-1921 [email protected]

The Kaiser Commission on Medicaid and the Uninsuredwww.kff.org1450 G Street, NW, Suite 250Washington, DC 20005202-347-5270202-347-5274 fax

E x p r e s s L a n e E l i g i b i l i t y

Project Advisors

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T A B L E O F C O N T E N T S

Executive Summary page 1

Introduction page 3

Chapter 1 Uninsured Children Already Enrolled in Public Programs page 5

Chapter 2An Overview of Express Lane Eligibility page 8

Chapter 3Implementing Express Lane Eligibility under Current Law page 11

Chapter 4Implementation Issues to Address page 17

Chapter 5Legislative Precedents page 22

Chapter 6Recommendations for Getting Started and Conclusion page 25

Appendices:A. Endnotes page 27

B. USDA School Lunch Prototype Applications page 31

C. Washington State’s Free and Reduced-Price Meals Pilot Program Applications page 38

D. State Income Eligibility Guidelines for Children’s Medicaid and Separate Child Health Insurance Programs (Prepared by the Center on Budget and Policy Priorities) page 42

E. Washington State’s Medicaid & Food Stamp Program Eligibility Guidelines page 45

F. California’s Medi-Cal, Healthy Families & Food Stamp Program Eligibility Guidelines page 47

G. Federal Program Confidentiality Provisions page 49

H. Comparison of Federal Program Eligibility Guidelines page 50

I. Sample State Legislation page 55

Introduction

Chapter 1Uninsured ChildrenAlready Enrolled inPublic Programs

Chapter 2An Overview ofExpress LaneEligibility

Chapter 3ImplementingExpress LaneEligibility underCurrent Law

Chapter 4ImplementationIssues toAddress

Chapter 5LegislativePrecedents

Chapter 6Recommendationsfor Getting Startedand Conclusion

Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

A Briefing Book and Guide for Enrolling Uninsured Children Who Receive OtherPublic Benefits into Medicaid and the Children’s Health Insurance Program (CHIP)

November 2000

A Publication of The Children’s Partnership and The Kaiser Commission on Medicaid and the Uninsured

TCP DirectorsWendy LazarusLaurie Lipper

Project DirectorDawn HornerThe Children’s Partnership

Research and WritingDawn HornerBeth MorrowWendy LazarusThe Children’s Partnership

Andy Schneider, PrincipalMedicaid Policy LLC

This report was made possiblethrough support from The KaiserCommission on Medicaid and theUninsured and partial supportfor design and printing from theDavid and Lucile PackardFoundation.

©2000 The Children’s Partnership/The Kaiser Commission on Medicaid and the Uninsured. Permission tocopy, disseminate or otherwise use this work is normally granted as long as ownership is properly attributed toThe Children’s Partnership and The Kaiser Commission on Medicaid and the Uninsured.

Putting Express Lane Eligibility Into Practice

A serious challenge confronting leaderstoday is how to reach and enroll theroughly 8 million uninsured childrenwho are eligible for but not enrolled inMedicaid and the Children’s HealthInsurance Program (CHIP). This publi-cation describes one method for expedit-ing health insurance enrollment forthese uninsured children: Express LaneEligibility.

Express Lane Eligibility works by estab-lishing connections with programs thathave similar income eligibility rules toMedicaid and CHIP -- such as FoodStamps, the Special SupplementalNutrition Program for Women, Infantsand Children (WIC), and the NationalSchool Lunch Program (NSLP) -- to findand more quickly enroll uninsured chil-dren in the health insurance programs.

Over 70 percent of uninsured children withfamily incomes below 200 percent of the feder-al poverty level (FPL) participate in NSLP,WIC, Food Stamps or UnemploymentCompensation.

This briefing book and guide providestechnical information regarding what astate or locality needs to know to under-take Express Lane Eligibility. Its purposeis to serve as a resource for policymakerslooking for high-leverage ways to reachuninsured children -- state legislatorsand agency staff, as well as county andcity officials and program administrators.

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Introduction







Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

Implementing Express Lane Eligibility

Express Lane Eligibility is not "one size fits all."The ultimate design will depend on a number offactors: the state’s current Medicaid and CHIP eli-gibility guidelines; the income-comparable pro-grams that are chosen; and the administrative sys-tems already in place. However, there are threebasic models from which a state could start.

Ta r g e t e d O u t r e a c h

At a minimum, Express Lane Eligibility can beused to target outreach to uninsured children inpublic programs with income eligibility guidelinessimilar to those for Medicaid and CHIP.

Example: Targeted Outreach has been used most effective-ly with the NSLP where states have utilized the programas a referral tool for children’s health insurance.Activities have included providing health insurance pro-gram information with school lunch applications orallowing applicants to use the school lunch applicationto authorize the sharing of their names and addresseswith Medicaid and CHIP so they can receive healthinsurance information.

S t r e a m l i n e d A p p l i c a t i o n

At the next Express Lane Eligibility level, informa-tion already collected on a child by an income-comparable public program can be shared withthe Medicaid or CHIP program to streamline afamily’s health insurance application process.

Example: In 1999 Washington State began a pilot pro-gram operated in 15 school districts that allows familiesto consent to their school lunch application being sent tothe Medicaid agency. Upon receiving the application, theMedicaid agency mails the family a simple follow-upform to gather additional information needed to make afinal Medicaid eligibility determination.

A u t o m a t i c E l i g i b i l i t y

The most complete level of Express LaneEligibility would use the fact that a child isenrolled in an income-comparable program as thebasis for determining the child to be income-eligi-ble for Medicaid or CHIP.

E X E C U T I V E S U M M A R Y

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Example: A state with Medicaid income eligibility thresh-olds for children that are significantly higher than theminimums required under federal Medicaid law andthose with CHIP-Medicaid expansions would have thehighest potential for implementing Automatic Eligibility.With a higher eligibility threshold, the state’s Medicaideligibility rules would probably be liberal enough so thatno child could qualify for the income-comparable publicprogram, such as Food Stamps, and be ineligible forMedicaid. In a state where this is the case, the fact that achild is in Food Stamps could make him or her automati-cally income-eligible for Medicaid, negating the need forthe family to complete a regular application.

Implementation Issues to Address

States and localities should anticipate and be readyto address several implementation issues that arisearound Express Lane Eligibility including:

• Meeting the confidentiality rules of each pro-gram, including the establishment of any neces-sary interagency agreements.

• Addressing the immigration restrictions ofMedicaid and CHIP, and establishing clear guide-lines for families affected by these restrictions.

• Developing streamlined documentation require-ments for families as allowed under federal law.

• Understanding the federal verification andMedicaid Eligibility Quality Control rules toensure continued compliance.

• Targeting different funding sources to ensurethe successful implementation of Express LaneEligibility and the participation of non-healthinsurance program agencies.

Legislative Precedents

There are specific precedents where the conceptof linking eligibility for one program with otherprograms has been incorporated into law andpractice. The primary intent of connecting pro-gram eligibility is to make it easier for eligible fam-ilies to enroll in programs and to cut down onadministrative paperwork.

• WIC’s Adjunctive Eligibility accepts an appli-cant’s documented participation in Medicaid,Food Stamps and Temporary Assistance to NeedyFamilies (TANF) as evidence of income eligibilityfor WIC.

• NSLP’s Categorical Eligibility and DirectCertification deems children receiving FoodStamps, the Food Distribution Program on IndianReservations (FDPIR) and TANF automatically eli-gible for free meals or milk.

Recommendations and Conclusion

While there are certain challenges to designing anExpress Lane for children into health care, theeffort seems worth it given the potential benefits.To get started a state or county can:

✓ Create an Express Lane for Children through theFood Stamp Program. States should start with theFood Stamp Program because it holds the best likeli-hood of achieving Automatic Eligibility. FoodStamps has a sufficiently low income threshold (netincome of 100 percent of the FPL) that most childenrollees are also income-eligible for Medicaid. Inaddition, its citizenship guidelines are similar tothose of Medicaid, and in many states and counties,the same agency administers both Food Stamps andMedicaid.

✓ Create an Express Lane through other Programsin Your State. Communities should undertake theresearch, analysis and legwork required to movebeyond Food Stamps to other programs. While theFood Stamp Program may be the simplest pro-gram to start with, a state or county need not stopthere. There are a number of other steps you cantake to move forward with Express Lane Eligibility,including analysis, planning and gaining supportfrom different stakeholders.

Above all, successful implementation of ExpressLane Eligibility requires policymakers and admin-istrators at the state and local level to continue tobe strong leaders for reform. The payoff will bemore than worth it, as Express Lane Eligibilitybreaks down many of the obstacles that keep mil-lions of children from health insurance.

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Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive SummaryIN

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NFor many decades, the principal chal-lenge facing leaders working to improvethe health of America’s children was find-ing the resources necessary to providehealth insurance to the millions of kidswho had none. Today things are dramati-cally different. For the first time in thehistory of our country, there is a nationalcommitment to cover the vast majority ofour nation’s uninsured children.

The serious challenge that confrontsleaders today is how to reach and enrollthe roughly 8 million children who lackhealth coverage but are eligible forMedicaid and the new Children’s HealthInsurance Program (CHIP) enacted byCongress in the summer of 1997.1

Approximately 70 percent of uninsuredchildren nationally now qualify for thesehealth insurance programs, but are cur-rently not participating in them.2

Simple though it may sound, many barri-ers exist to enrolling these children intothe health insurance programs. Studiesshow that besides a lack of knowledgeabout the programs, families do notapply because it can be time consuming,confusing, and sometimes demeaning todo so.3

This publication describes one way toaddress these enrollment hurdles. Thestrategy is called Express Lane Eligibilityand, like the Express Lane in the super-market or on the highway, it refers to amethod for expediting health insuranceenrollment for uninsured children.

I N T R O D U C T I O N

Express Lane Eligibility works by establishing con-nections with programs that have similar income eli-gibility rules to Medicaid and CHIP -- such as FoodStamps, the Special Supplemental NutritionProgram for Women, Infants, and Children (WIC),and the National School Lunch Program (NSLP) --to find and more quickly enroll uninsured childrenin the health insurance programs.

The notion of linking different programs tostreamline application processes is not new. Forexample, in 1989 Congress allowed WIC to acceptan applicant’s participation in Medicaid, FoodStamps and Temporary Assistance to NeedyFamilies (TANF) as evidence of income eligibilityfor WIC. This adjunctive eligibility process has sig-nificantly streamlined WIC’s application andenrollment process for both families and staff.(See Chapter 5 Legislative Precedents for additionalinformation.)

In addition, the ability to execute Express LaneEligibility between Medicaid/CHIP and other publicprograms has recently taken on a growing legitimacyas national attention is focused on finding solutionsfor enrolling eligible children in health insurance.In a September 10, 1998 letter, the Health CareFinancing Administration (HCFA) encouraged statehealth officials to "establish an effective referral sys-tem between the State’s CHIP eligibility agency, theMedicaid and maternal and child health programs,schools as well as other Federal and State agenciesthat serve low-income families.”4 The followingrecent developments have added to the increasedviability of Express Lane Eligibility.

Introduction

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C H I P W a i v e r s

On July 31, 2000, HCFA issued guidance permit-ting states for the first time to submit waivers forCHIP demonstration projects under section 1115of the Social Security Act.5 Under the rules, statescan submit proposals to HCFA to undertake inno-vative strategies that are not otherwise permittedunder the law for accomplishing the goals of theCHIP program. HCFA specifically stipulated itwould consider “proposals to promote enrollmentof children, who are eligible for benefits underother income-based benefit programs, such as freeand reduced school lunch program.” The guid-ance sets the stage for states to put together cre-ative models for implementing Express LaneEligibility. The ideas presented in this report willassist in these efforts.

F e d e r a l G u i d a n c e

On June 26, 2000, HCFA announced a new one-year state grant program to identify and test inno-vative ways to increase enrollment in Medicaid andCHIP by simplifying the eligibility and enrollmentprocess.6 The program will make awards to aboutfive states of approximately $80,000 each. Whilethe funding level is not substantial, the establish-ment of the grant program indicates HCFA’sincreased interest in states undertaking ExpressLane Eligibility. States are encouraged to create“linkages with other public programs, such asschool lunch, WIC, child care subsidies, or Stateearned income tax credits, with relatively similareligibility criteria.”

In addition, guidance issued by HCFA on April 7,2000 approved a state’s ability to rely on informa-tion from other public programs in determiningMedicaid eligibility, thereby knocking down a pre-vious barrier to making Express Lane Eligibility areality.7 (See Chapter 4 Implementation Issues toAddress, “Documentation Requirements,” for addi-tional information.)

S t a t e A c t i o n

State and local leaders are also seriously exploringExpress Lane Eligibility. For example, California’sFiscal Year 2000-2001 state budget allocated staffresources to the development of options for imple-menting Express Lane Eligibility.8 New York’sUnited Hospital Fund has also conducted ananalysis on the feasibility of implementing ExpressLane Eligibility in New York State.9 Other exam-ples are included within this report.

These recent developments, coupled with pastprecedents, open the door wide for states and local-ities to implement Express Lane Eligibility. We hopethis briefing book and guide will serve as a resourcefor those looking to take on this important avenuefor increasing coverage of uninsured children.

About This Publication

The Children’s Partnership first explored ExpressLane Eligibility in the publication Express LaneEligibility: How to Enroll Large Groups of UninsuredChildren in Medicaid and CHIP.10 That publicationprovided a general overview of the issue and, forthose readers new to the idea, serves as a usefulstarting place.

This current publication takes readers to the nextlevel, providing technical information that a stateor locality needs to know to undertake ExpressLane Eligibility. It includes an array of tools toassist in these efforts, including functional appen-dices and an extensive endnote section of Web-based resources. The briefing book and guidesummarizes:

• How Express Lane Eligibility works -- detailingwhat it means in states with a Medicaid-only pro-gram as well as states with both Medicaid and sepa-rate CHIP programs;

• What steps can be taken under current law touse Express Lane Eligibility -- whether to performmore targeted outreach, to streamline the applica-tion process for families or to provide automaticeligibility for eligible children;

• Challenging implementation issues and how toaddress them, including confidentiality, immigra-tion, quality control and funding; and

• Steps for getting started.

The information that follows is quite technical attimes because the programs are complex. Readersshould understand that implementing ExpressLane Eligibility requires knowledgeable staff whocan work on the effort in a sustained way. The pay-off will be more than worth the time as ExpressLane Eligibility starts to topple some of the barri-ers that keep so many children from the healthcare they need.

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

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As many as 8 million uninsured childrenare eligible for Medicaid or theChildren’s Health Insurance Program(CHIP) but not enrolled.11 According toThe Urban Institute, the majority ofuninsured children are enrolled in otherpublic programs.12 They estimate:

• Over 70 percent of all low-incomeuninsured children (those with familyincomes below 200 percent of theFederal Poverty Level - FPL) live in fami-lies that participate in the NationalSchool Lunch Program (NSLP), theSpecial Supplemental Nutrition Programfor Women, Infants, and Children(WIC), Food Stamps or UnemploymentCompensation.

• Breaking the figures down further, 60percent of all low-income uninsured chil-dren are in families enrolled in theNSLP; 24 percent are in families enrolledin WIC; 10 percent are in families receiv-ing Food Stamps; and almost 10 percentare in families receiving unemploymentcompensation.

UNINSURED CHILDREN ALREADY ENROLLED IN PUBLIC PROGRAMS

With 3.9 million low-income uninsured children infamilies receiving benefits through the NSLP, thisprogram seems to hold the greatest promise forreaching uninsured children. WIC follows with 1.5million low-income uninsured children enrolled.(See Table 1.)

While the numbers of uninsured children reachedthrough Food Stamps (651,000) is relatively small,most if not all of these children are eligible forMedicaid. The Food Stamp Program’s grossincome eligibility standard is 130 percent of theFPL and many states have already extended theirMedicaid programs to serve children of all ages upto 130 percent of the FPL or higher. In addition,both programs have similar immigration guide-lines, making Food Stamps an important avenuefor reaching uninsured Medicaid-eligible children.

Among the 13 states reported on by The UrbanInstitute, Alabama, California and Mississippi (atabout 80 percent) exhibit the highest percentageof low-income uninsured children who could bereached through the National School Lunch, WIC,Food Stamp or Unemployment Compensationprograms. Massachusetts, Colorado andWashington exhibit the lowest proportion, atabout 61 percent. (See Table 2.)

It is evident by the high numbers involved that useof income-comparable public programs holdsgreat promise as a vehicle for reaching uninsuredand potentially eligible children and connectingthem with health coverage.

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T A B L E 1

Public Program Participation of Families with Low-Income Uninsured Children, 1996-97

E s t i m a t e s b y T h e U r b a n I n s t i t u t e

School Lunch WICb Food Stampsc Unemployment Any of Four Programa Compensationd Programse

Federal Income Up to Up to Up to N/A N/AGuidelines 185% FPL 185% FPL 130% FPL (percent of (Gross)Federal PovertyLevel)

Low-Income 3.9 million 1.5 million 651,000 629,000 4.7 millionUninsuredChildrena

Age0-5 19% 62% 26% 22% 29%6-11 42% 19% 26% 36% 36%12-17 39% 19% 48% 42% 36%

Family IncomeLess than 100% FPL 51% 52% 78% 48% 49%100-200% FPL 49% 48% 22% 52% 51%

Immigration Statusf

U.S. Born 85% 89% 84% 93% 87%Foreign Born 15% 11% 16% 7% 13%

RegionNortheast 10% 9% 10% 13% 10%Midwest 15% 16% 12% 18% 16%South 44% 37% 52% 29% 44%West 31% 38% 26% 40% 31%

Source: The Urban Institute calculations from the 1997 National Survey of America’s Families (NSAF), a national household survey on over100,000 children and nonelderly adults. Insurance coverage was measured at the time of the survey.a. Represents children age 17 and under with family incomes below 200 percent of the FPL.b. Represents uninsured children in families in which at least one child received benefits from the School Lunch Program or WIC program in1996, respectively. In determining the potential reach of these programs, it was assumed that all children in the household could be reachedthrough the given program. Thus, although the WIC program serves only pregnant women and children age 0-5, the survey counted older unin-sured children in the household as reachable through the program.c. Represents uninsured children in families that were receiving Food Stamp benefits at the time the NSAF was administered in 1997.d. Represents uninsured children in families in which at least one person received Unemployment Compensation in 1996.e. Represents low-income uninsured children in families that participate in either the School Lunch Program, WIC, Food Stamps orUnemployment Compensation, taking into account duplicates among the four programs.f. Foreign-born status does not mean a child is ineligible for Medicaid or CHIP, since qualified immigrants are eligible for the two programs.

T A B L E 2

Public Program Participation of Families with Low-Income Uninsured ChildrenWithin 13 States, 1996-97a

E s t i m a t e s b y T h e U r b a n I n s t i t u t e

School Lunch WICb Food Unemployment Any of Four Percentage of Programa Stampsc Compensationd Programse State’s Low-

Income Uninsured Children (S.E.)f

California 700,323 314,980 92,151 115,318 854,048 81% (3.3)

Mississippi 85,077 28,723 37,214 12,025 100,324 79% (3.4)

Alabama 82,473 19,597 40,069 9,410 98,757 79% (4.4)

Texas 589,108 204,591 115,480 57,982 682,203 74% (2.8)

Michigan 58,910 13,329 8,337 17,428 77,356 74% (5.8)

Minnesota 24,786 12,170 1,412 4,584 33,091 72% (7.2)

New York 194,224 63,585 34,624 37,891 239,765 70% (3.4)

New Jersey 65,136 12,791 10,663 13,998 79,603 69% (4.4)

Florida 248,409 128,574 38,531 14,847 317,709 68% (3.8)

Wisconsin 35,203 10,135 3,284 10,478 41,634 65% (3.6)

Colorado 53,083 14,650 9,235 4,938 64,400 62% (4.2)

Washington 24,252 16,727 6,354 10,963 38,756 62% (4.1)

Massachusetts 26,980 10,319 6,371 4,950 35,531 61% (7.7)

Source: The Urban Institute calculations from the 1997 National Survey of America’s Families (NSAF), a national household survey on over100,000 children and nonelderly adults. Insurance coverage was measured at the time of the survey. Represents children age 17 and underwith family incomes below 200 percent of the federal poverty level (FPL).a. The NSAF oversamples the population of 13 states in order to obtain reliable state-specific samples.b. Represents uninsured children in families in which at least one child received benefits from the School Lunch Program or WIC program in1996, respectively. c. Represents uninsured children in families that were receiving Food Stamp benefits at the time the NSAF was administered in 1997.d. Represents uninsured children in families in which at least one person received Unemployment Compensation in 1996.e. Represents low-income uninsured children in families that participate in either the School Lunch Program, WIC, Food Stamps orUnemployment Compensation, taking into account duplicates among the four programs.f. Represents the percentage of uninsured children enrolled in any one of the four programs, with the standard error.

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

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AN OVERVIEW OF EXPRESS LANE ELIGIBILITY

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2 Express Lane Eligibility is a term used to describe aprocess for utilizing income-comparable public pro-grams to increase outreach and enrollment for chil-dren’s health insurance programs. At a minimum, itcan be used to target outreach to uninsured chil-dren in public programs. When fully realized, it canbe used to define a group of children enrolled inan income-comparable program as automaticallyeligible for Medicaid and/or the Children’s HealthInsurance Program (CHIP).

Express Lane Eligibility is not “one size fits all.” Theultimate design will depend on a number of factors,from the state’s current Medicaid and CHIP eligibil-ity guidelines to the income-comparable programsthat are chosen to the administrative systemsalready in place. However, this section presentsthree basic models from which a state could start.

Ta r g e t e d O u t r e a ch

The most basic way a state can take advantage ofthe fact that uninsured children are enrolled inpublic programs with eligibility guidelines similarto Medicaid and CHIP is to use the public pro-grams as outreach mechanisms.

Targeted Outreach has been used most effectivelywith the National School Lunch Program(NSLP), where a number of states have utilizedthe program as a referral tool for children’shealth insurance.13 Either health insurance pro-gram information is included with the schoollunch applications, as in Alaska, Arkansas andConnecticut, or school lunch applicants canauthorize the sharing of their names and address-es with Medicaid and CHIP in order to receive ahealth insurance application. The approach ismost successful when coupled with proceduresthat ensure families also have assistance with theenrollment process, such as linking families withcommunity groups to assist in completing appli-cations, as has been done in Georgia and Florida.

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Consumers Union’s Healthy Kids,Health Schools, CaliforniaIn 1999 the San Francisco office ofConsumers Union, California’sDepartments of Education (CDE) andHealth Services (DHS), the Managed RiskMedical Insurance Board, and DHS’ SchoolHealth Connections office collaborated toconnect children enrolled in the SchoolLunch Program with the state’s Medicaidand CHIP programs (Medi-Cal and HealthyFamilies, respectively). In April of that year,CDE sent School Food Service Directors inCalifornia information about how theycould help enroll children in the healthinsurance programs. Included was a sampleRequest for Information (RFI) form thatcould be attached to the school lunch appli-cation. Parents who wish to obtain a Medi-Cal and Healthy Families application com-plete the RFI form and return it to theFood Service Director or other school staff,who then forward the forms to DHS on amonthly basis for processing. Some schoolschose to have parents return the RFIsdirectly to DHS. To date, more than 140school districts have participated in this pro-gram and outreach through the SchoolLunch Program accounts for over 30 per-cent of all requests for Medi-Cal/HealthyFamilies applications.

To assist families in enrolling in Medi-Cal orHealthy Families, Consumers Union’sHealthy Kids, Healthy Schools project alsoworks closely with school districts in ContraCosta, Los Angeles, San Mateo and SantaClara Counties to provide more extensivefollow-up to families who completed theRFIs. For example, all four districts and/ortheir community partners provide directassistance to the families in completing theMedi-Cal/Healthy Families application.

For more information, contact: Consumers Union, West Coast Regional Office, 415-431-6747; www.healthykidsproject.org.

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

The use of the NSLP as an effective outreach toolwas facilitated by guidance released by the UnitedStates Department of Agriculture (USDA) in thefall of 1998 on ways states and school officials canuse the NSLP as a referral mechanism forMedicaid or CHIP. The USDA created prototypeapplications for schools that ask parents whetherthey want to waive confidentiality to permit theschool to share information from the NSLP appli-cation with Medicaid or CHIP. (See Appendix B.)Recently enacted federal legislation14 facilitatesthese efforts by further streamlining the processwhereby states and school food personnel shareinformation from school lunch applications withMedicaid and CHIP programs. (See Chapter 4Implementation Issues to Address, “Confidentiality,”for additional information.)

S t r e a m l i n e d A p p l i c a t i o n

Under this approach, the child’s application forenrollment in the income-comparable program isused to provide income eligibility information tothe Medicaid or CHIP program. Additional rele-vant eligibility information collected by a program,such as immigration status or state residency, couldalso be shared. The state, however, would still needto collect any other information from the familythat is necessary to make a final eligibility determi-nation. The process could work in a few ways:

• On the income-comparable program’s applica-tion, a parent could consent that the family’sincome information be released to the stateMedicaid and CHIP agency for purposes of apply-ing for the health programs. For example, in 1998the Chicago Public Schools System modified itsschool lunch application, allowing parents to con-sent to the release of information to the stateMedicaid agency for purposes of applying forMedicaid and CHIP.

For more information, contact: Denise Taylor, ChicagoPublic Schools System, 773-553-1839,[email protected].


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Washington State’s School Lunch PilotProgramFor a number of years, Washington State hasincluded a check-off box on the school lunchapplication allowing families to request infor-mation about health programs. BetweenSeptember and December 1999, this programbrought 980 referrals to the Medicaid agency,197 of whom eventually applied. In an effort to reach more children, in 1999state officials began a pilot program in 15school districts where the school lunch applica-tion is printed on an NCR (duplicating copy)form. (See Appendix C.) By checking a box onthe form, families authorize the schools tosend a copy of the application to the Medicaidagency. Upon receipt, the Medicaid agencyenters the family into the computer and mailsthem a simple follow-up application to gatheradditional information needed to assessMedicaid eligibility. (See Appendix C.) Theschool lunch application gathers income andfamily composition information and the follow-up application gathers citizenship information. In the pilot program, copies of 3,787 families’school lunch forms were sent to the Medicaidagency. Of these, 1,066 were interested inhealth coverage and were not already receiv-ing Medicaid. The agency sent the specialapplication to these families and received 330back for processing. Approximately two-thirdsof those who completed the process weredetermined eligible.The biggest difficulties with the pilot programhave been: 1) the majority of families do notfollow through with the full applicationprocess; and 2) families have not understoodwhich health program is being offered – sothey apply even though they already receiveMedicaid. Work is currently underway tochange language on the school lunch multi-useform so that the latter will not happen so fre-quently. In addition, administrators have foundthat more education is needed for school staff,since some have misunderstood the processand forwarded a copy of the application evenwhen a family did not request a referral tohealth coverage.

For more information, contact: The Children’sAlliance, Children’s Health Outreach Project, 206-324-0340; www.childrensalliance.org.

• A parent could authorize Medicaid or CHIP todirectly access the child’s comparable program casefile for purposes of making an income determination.For example, Los Angeles County’s Department ofPublic Social Services made Medicaid eligibility deter-minations on behalf of children in households receiv-ing Food Stamps whose parents authorized thedepartment to use the information in the family’sFood Stamps case file.

For more information, contact: Lynn Kohoutek, Los AngelesCounty/DPSS, 562-908-8307.

• Under newly enacted legislation that impacts theSchool Lunch Program, a school district couldestablish an agreement with state Medicaid andCHIP agencies that allows the sharing of a child’sschool lunch application with Medicaid/CHIP forpurposes of determining the child’s eligibility forthe health insurance programs. Instead of obtain-ing the parent’s consent for the disclosure, schoolfood authorities can disclose the informationunless the parent declines, upon proper notifica-tion, to have their information shared.15 (SeeChapter 4 Implementation Issues to Address,“Confidentiality,” for additional information.)

Automatic Eligibility

Under this system, the child’s enrollment in theincome-comparable program would be used as thebasis for determining the child to be income-eligiblefor Medicaid or CHIP. In cases where a program col-lects additional information, such as immigrationstatus or state residency, these aspects of the eligibili-ty determination could also be made automatic.

While the Streamlined Approach simplifies theapplication process for families, it still requires thestate to access or obtain and analyze informationfrom the income-comparable program to makethe final Medicaid/CHIP determination, thus notnecessarily reducing the administrative burden onthe state to the maximum extent possible. Withthe Automatic Eligibility approach, however, astate would determine which public programs fallwithin the income guidelines and methodology ofits Medicaid/CHIP program, and allow a childenrolled in the income-comparable program to beautomatically income-eligible for Medicaid.

Guidance issued by the Health Care FinancingAdministration (HCFA) on April 7, 2000 establish-es a precedent for this idea.16 HCFA clarified that astate can accept another public programs’ specificeligibility determination in determining Medicaideligibility if the eligibility requirement under theprogram is equal to or more restrictive thanMedicaid’s. (This is discussed further in Chapter 4Implementation Issues to Address, “DocumentationRequirements.”) In addition, the new ability ofstates to seek waivers under CHIP may provideadditional flexibility in designing an AutomaticEligibility model.17 The Automatic Eligibilityprocess is explored further in the next section.

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IMPLEMENTING EXPRESS LANE ELIGIBILITY UNDER CURRENT LAW

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3 This section describes what states can dounder current law to implement theStreamlined Application and AutomaticEligibility approaches to Express LaneEligibility previously described. While theTargeted Outreach model can be used asan effective outreach tool, much isalready being done in that arena and lit-erature exists to assist itsimplementation.18 It is the last two modelsthat we believe have the greatestuntapped potential for making the healthinsurance application process simple forfamilies, thereby reaching more children.

This section begins by reviewing the eli-gibility requirements for children thatare common to all state Medicaid pro-grams and Children’s Health InsurancePrograms (CHIP). It then examines thepossibilities for Express Lane Eligibilitywithin two different state examples:those with Medicaid income eligibilitythresholds well above the federal mini-mums (illustrated by Washington State)and those with Medicaid income eligibil-ity thresholds close to the federal mini-mum and/or with separate CHIP pro-grams (illustrated by California).

Basic Medicaid and CHIPEligibility Requirements

Under Federal Medicaid and CHIP law,states have a great deal of flexibility insetting eligibility rules for children.19

As a consequence, Medicaid and CHIPincome eligibility guidelines vary fromstate to state. (See Appendix D forMedicaid and CHIP income eligibilityguidelines by state.) There are, however,a few eligibility requirements common toall states that affect the implementationof Express Lane Eligibility. These are:

Medicaid

W r i t t e n A p p l i c a t i o n

The state (or local) Medicaid agency must requirea “written application” from “someone actingresponsibly for the applicant [child].”20 Theagency has broad discretion as to what constitutesa “written application,” and federal authoritieshave expressly encouraged simple applicationforms.21 The application form must be signedunder penalty of perjury.22

S o c i a l S e c u r i t y N u m b e r

The state (or local) Medicaid agency must requireeach applicant child to furnish a social securitynumber (SSN).23 States are not allowed to requirethe SSN of non-applicant family members as a con-dition of eligibility, although a state may ask forvoluntary disclosure of that information in orderto speed up the eligibility determination process.24

I n c o m e I n f o r m a t i o n

States must collect information on earned andunearned income of the applying child’s family. The definition of “income” – that is, what types ofincome are counted – is specific to each state’sMedicaid plan,25 but certain federal rules limit theextent to which income can preclude eligibility.26

The definitions of “families” and “children” aretied to the former Aid to Families with DependentChildren (AFDC) rules, except in the case of chil-dren eligible on the basis of disability to whichSupplement Security Income (SSI) rules apply.27

States are not required to apply a resource (orassets) test to children; if they elect to do so, how-ever, they must collect the relevant information.

I m m i g r a t i o n S t a t u s

States must provide full-scope Medicaid coverageto eligible citizens and certain mandatory qualifiedaliens.28 The state has the option to provide othernon-mandatory qualified aliens who entered theUS before August 22, 1996 with full-scopeMedicaid.29 Non-mandatory qualified aliens enter-

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary


11

ing after that date can be eligible after five yearsbut only at state discretion.30 Children who are citi-zens may establish their citizenship “on the basis ofself-declaration,” regardless of the immigration sta-tus of their parents or other members of theirhouseholds who are not applying for Medicaid. Inthe case of children who are qualified aliens, statesare required to obtain documentation of immigra-tion status and to verify the immigration status ofthe child with the Immigration and NaturalizationService (INS).31

V e r i f i c a t i o n

State Medicaid agencies must verify the income ofan individual who has been found to be eligiblefor Medicaid by requesting specified informationfrom other state and federal agencies regardingincome, including wage information from theSocial Security Administration (SSA), unearnedincome information from the Internal RevenueService (IRS), and unemployment compensationinformation from the appropriate state agency.Applicants are required, as a condition of eligibili-ty, to consent to the disclosure of this informationto the Medicaid agency for this purpose. Theseverification requirements apply to poverty-levelchildren but not to children receiving cash assis-tance under SSI or Temporary Assistance to NeedyFamilies (TANF).32 (See Chapter 4 ImplementationIssues to Address, “Federal Verification Rules,” foradditional information.)

Non-Medicaid CHIP33

W r i t t e n A p p l i c a t i o n

States can utilize either a joint Medicaid/CHIPapplication or a separate CHIP application. TheHealth Care Financing Administration (HCFA)has encouraged simple application forms forCHIP, as it does for Medicaid.34 The applicationform must be signed under penalty of perjury.35

S o c i a l S e c u r i t y N u m b e r

States cannot require a SSN of an applicant childor their family members as a condition of eligibili-ty, although a state may ask for voluntary disclo-sure of that information.36

I n c o m e I n f o r m a t i o n

States are given discretion to define income andset what to include, exclude and disregard; todefine “family” for purposes of determiningincome; and to apply or not apply a resource test.37

I m m i g r a t i o n S t a t u s

States must provide CHIP coverage to eligible citi-zens and qualified aliens, including legal immi-grants who entered the US before August 22, 1996and those arriving on or after that date who havebeen in continuous residence for five years.38 Self-declaration can be accepted as proof of US citizen-ship, while documentation of satisfactory immigra-tion status is required for qualified aliens.39

V e r i f i c a t i o n

HCFA encourages, but does not require, states touse the same systems as for Medicaid (see above).40

I n s u r a n c e S t a t u s

States cannot use CHIP funds to cover Medicaid-eligible children or children insured by other thana pre-existing state-funded plan. Children also can-not be covered by CHIP if they are eligible for astate health benefits plan on the basis of a familymember’s employment in a public agency thatoffers more than a nominal employer contribu-tion.41 The CHIP statute does not require any par-ticular documentation of such insurance status.

States with Medicaid EligibilityThresholds Well Above the FederalMinimums

States with the highest potential for implementingExpress Lane Eligibility are those with Medicaideligibility thresholds for children that are signifi-cantly higher than the minimums required underFederal Medicaid law (133 percent of the FederalPoverty Level for children up to age 6, and 100percent of the Federal Poverty Level for ages 6through 16.) In addition, states that do not apply aresource or assets test to children are best situatedfor implementing Express Lane Eligibility.42

12

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

With a higher threshold, there is a greater chancethat a child who has established eligibility for anincome-comparable program is by definition eligi-ble for Medicaid in that state, thus enhancing thepotential for smoothly implementing theAutomatic Eligibility approach. To provide anexample of how this could work, we looked atWashington State’s Medicaid and Food Stampsprograms. (See Appendix E for charts outliningthe eligibility guidelines for Washington State’sMedicaid and Food Stamp programs.)

Washington: A Case Model Washington’s Medicaid program covers all chil-dren in families with incomes up to 200 percent ofthe Federal Poverty Level (FPL; $34,100 for a fami-ly of 4 in 2000). This is a net income standard.That is, in determining whether a child’s familyincome is at or below this standard, the state usesa methodology for determining monthly incomethat deducts certain income. Specifically,Washington deducts:

• cash assistance the family receives under TANF or SSI;

• the first $90 of earned income for each working indi-vidual in the child’s family;

• all court-ordered child support payments made; and

• all work-related child care expenses.

Thus, depending on the circumstances of the child’sfamily, its gross income (not disregarding any earnedor unearned income, and not deducting child careexpenses) might be higher than 200 percent of theFPL. In no case could a child with a gross familyincome lower than 200 percent of poverty be ineligi-ble for Medicaid on the basis of income.

Under the Food Stamp Program in Washington, achild cannot be eligible if its family’s gross income– counted without disregarding or excluding anyearned or unearned income – exceeds 130 per-cent of the FPL ($22,165 for a family of 4 in 2000).The child’s family must also meet a net incometest to qualify for Food Stamps – i.e., after speci-fied deductions are applied, the family’s incomemust be below 100 percent of the FPL – but this isirrelevant for Express Lane Eligibility purposes.

What are relevant are the gross income ceiling andthe definition of “family.” Washington’s FoodStamp Program defines a “household” as personsliving together and purchasing and preparing foodtogether. This is a broader definition that deemsavailable to the child more income than occursunder Washington’s Medicaid definition of a med-ical assistance unit: an unmarried minor child andits parent(s) (whether married or not) living withthe child.

Because the Food Stamp Program’s gross incomeceiling is well below the Medicaid net income stan-dard of 200 percent of the FPL, and because thesize of a family for Food Stamps purposes is gener-ally the same as or larger than that for Medicaidpurposes and would include more persons’income, virtually every child determined eligiblefor Food Stamps in Washington must also beincome-eligible for Medicaid.43

This analysis shows that, in a state like Washington,there is high potential for the Automatic Eligibilityapproach to Express Lane Eligibility. Such a statecould use the fact of a child’s enrollment in theFood Stamp Program to establish the child’s incomeeligibility for Medicaid. For example, instead ofrequiring such families to enter income informationon a Medicaid application, the family could simplybe asked to supply its Food Stamps’ case number orthe applicant’s social security number.

In addition, in Washington the Food StampProgram could be used to implement theAutomatic Eligibility approach to Express LaneEligibility for children beyond just income. That isbecause, in addition to income eligibility, a childin a family eligible for Food Stamps would meet allof the Medicaid eligibility requirements:

• ResourcesTo qualify for Food Stamps in Washington, achild’s family must also show that its countableresources are less than $2,000. Washington doesnot impose a resource test on the families of chil-dren applying for Medicaid. Thus, a child eligiblefor Food Stamps could not be ineligible forMedicaid on the basis of excess resources.


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• InformationEach of the elements of information that theWashington Medicaid program requires from chil-dren applying for benefits (declaration of age, iden-tity, and residency; declaration of income; proof ofimmigration status; and a social security number) isalso required of families applying for Food Stamps,which has an even higher level of verification.

• Immigration StatusLegal immigrant children who are eligible forFood Stamps (those who entered the US on orbefore August 22, 1996) are also eligible forMedicaid in Washington. Although Washingtonalso operates state-financed Medicaid and FoodAssistance programs for other legal immigrant chil-dren, no legal immigrant child who qualifies forthe Food Stamp Program would be ineligible forthe federally matched Medicaid program on thebasis of immigration status.

In short, because the eligibility criteria for FoodStamps in Washington are as restrictive, or morerestrictive, than those applicable to children underthe state’s Medicaid program, there appears to beno reason why the state could not implement anAutomatic Eligibility approach to Express LaneEligibility for children in Food Stamps households.It looks as though all that Washington (or anyother state in a similar circumstance) would needfrom such a family is an application form on whichthe family supplies:

• the child’s name and social security number;

• the child’s Food Stamps case number;

• an agreement to cooperate in pursuing thirdparty liability44;

• an agreement to release personal and financialinformation in the application for purposes ofverification of eligibility; and

• a certification under penalty of perjury that thisinformation is truthful.

A Word about States that Expanded Medicaid through CHIP

The 24 states that utilized CHIP funds to expandtheir Medicaid programs may be able to imple-ment Express Lane Eligibility in the method previ-ously described more easily than those with sepa-rate state programs.45 However, there are someconsiderations these states would need to take intoaccount. Under the CHIP statute, states receive anenhanced federal match for children becomingnewly eligible for health coverage after March 31,1997. Thus, the state receives an enhanced federalmatch for children enrolled under these CHIPexpansions, whether in Medicaid or a separatestate program. Where there is a Medicaid expan-sion, the state is free of CHIP’s screen and enrollrequirement. (See discussion following.) However,enhanced federal match is available only for chil-dren who would not have qualified for Medicaidunder standards in effect on March 31, 1997.46

One possibility is for a state to use a statisticallyvalid sample of its relevant caseload, i.e. to sampleonly a percentage of Express Lane eligible childrento determine the proportion ineligible under theMarch 1997 eligibility rules, then multiply that pro-portion by total Express Lane costs to determinethe amount qualifying for the enhanced federalmatch.47 The use of sampling, however, requiresfurther federal guidance before implementing.Otherwise, these states need to first review theirincome guidelines prior to and after CHIP todetermine which approach, the StreamlinedApplication or Automatic Eligibility, works best.

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Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

States with Medicaid EligibilityThresholds Close to the FederalMinimums and/or with Separate CHIPPrograms

In states that have set their Medicaid eligibilitythresholds for children at or close to the federalminimums, the implementation of Express LaneEligibility could use the Streamlined Applicationapproach. One reason is that the Federal minimumincome standard drops from 133 percent of theFPL ($22,676 for a family of 4 in 2000) for children6 and younger to 100 percent of the FPL ($17,050for a family of 4 in 2000) for children ages 6through 16. Because the 100 percent standard issubstantially lower than that used in such programsas Food Stamps or School Lunch (130 percent ofthe FPL and 185 percent of the FPL respectively),children age 6 or older who are eligible for theseprograms would not necessarily be income-eligiblefor Medicaid.

In addition, states with separate CHIP programsare required by federal law to screen all childrenfor Medicaid eligibility before they are enrolled inCHIP. Children who are determined to beMedicaid eligible must be enrolled in Medicaidrather than CHIP. Thus, under the “screen andenroll” process, a state would need to know achild’s exact income in order to place him or herin the appropriate program. Automatic Eligibilitycould work, however, if it is used only to enrollchildren in the Medicaid program (such as in theexample of Washington, which has a separateCHIP program with such a high income thresholdthat Food Stamp recipients could not be eligible).

For an example of how this would work in a state,we looked at California’s Medicaid, CHIP and FoodStamp programs. (See Appendix F for charts outlin-ing the eligibility guidelines for California’s Medi-Cal, Healthy Families and Food Stamp programs.)

California: A Case ModelThe Medi-Cal program (as Medicaid is known inCalifornia) covers infants up to age 1 in familieswith incomes up to 200 percent of the FPL, chil-dren ages 1 through 5 in families with incomes upto 133 percent of the FPL, and children ages 6through 18 in families with incomes up to 100 per-cent of the FPL. Healthy Families (California’sCHIP program) provides coverage to children noteligible for Medi-Cal but with family incomes at orbelow 250 percent of the FPL. In counting familyincome for this purpose, California deducts cer-tain types of income and a portion of child careexpenses. California’s Food Stamp Program coverschildren in households with gross incomes that donot exceed 130 percent of the FPL. The definitionof “household” for Food Stamps purposes (relatedand unrelated individuals living together and pur-chasing/preparing meals together) is broaderthan California’s definition of “medical assistanceunit” for Medicaid purposes (related persons liv-ing in the same home with some responsibility foreach other).

Thus, as in the case of Washington State, there isstrong potential in California for the implementa-tion of Express Lane Eligibility for infants up toage 1, and for children ages 1 through 5 in FoodStamp households. That is because, with respect tothese two groups of infants and children, the grossincome eligibility standard for Food Stamps is lessthan the net income eligibility standard for Medi-Cal. An infant or child under age 6 who is receiv-ing Food Stamps can virtually never be in a familythat has more income than what is permissibleunder Medi-Cal. Both the Streamlined Applicationand the Automatic Eligibility approach to ExpressLane Eligibility would be available to Californiaand similar states with respect to this population.


15

This is not, however, the case for children 6 andolder. These children are eligible for either Medi-Cal or Healthy Families. To make an eligibilitydetermination, California would need to obtainthe family’s exact income information, whichcould be accomplished through a StreamlinedApplication approach. As previously discussed, theStreamlined Application approach can be imple-mented in various ways, depending on a numberof different program variables including eligibilityguidelines, program administration and techno-logical ability to link between programs. In addi-tion, there are different access points for imple-mentation, whether the goal is to reach childrencurrently enrolled in public programs or thosenewly enrolling. For illustrative purposes, the fol-lowing is an outline of how this process could workin California.

1. Family Notified of Possible Eligibility: The fami-ly of a child enrolled in the Food Stamp Programwould be notified that their child is potentially eli-gible for Medi-Cal or Healthy Families.Notification could be done through the mail or inperson when the family is enrolling or recertifyingfor Food Stamps. To eliminate confidentialityissues, the administrative entity for Food Stampswould be responsible for contacting the families.Wherever possible, the entity would also run acomputer database cross-match to determinewhich children in its program are already enrolledin Medi-Cal or Healthy Families.

2. Family Completes a Short Form: If the familywants to enroll their child in Medi-Cal or HealthyFamilies, the parent would need to complete ashort application that asks for permission to accessthe family’s Food Stamps case file to make an eligi-bility determination, along with:

• the child’s name;

• the child’s social security number (optional forHealthy Families);

• the child’s health insurance status;

• an agreement to cooperate in pursuing third partyliability (required only for Medi-Cal);48

• an agreement to release personal and financialinformation in the application for purposes of verifi-cation of eligibility; and

• a certification under penalty of perjury that thisinformation is truthful.

Since the information that California’s Medi-Caland Healthy Families program requires from chil-dren applying for benefits (proof of age, identity,residency, income and immigration status) are alsorequired of families applying for Food Stamps, thestate would not have to seek such informationagain. However, this is probably not the case withother public programs, and the state would needto obtain additional information at this time, par-ticularly immigration documentation. In addition,a state may also need to seek any additional ormissing information required from families in afollow-up contact. For example, in the case ofCalifornia, families must choose a health plan andprovide premium payments to the state’s HealthyFamilies program, but this step could only beaccomplished once it is known for which programthe child is eligible.

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IMPLEMENTATION ISSUES TO ADDRESS

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4 If a state decides to undertake ExpressLane Eligibility, there are a number ofimplementation issues it will need toaddress. The following is a review ofthese issues, along with recommenda-tions for addressing them.

Confidentiality

Information exchange is essential to thesuccess of Express Lane Eligibility.However, each program’s rules and regu-lations contain confidentiality provisionsthat are intended to protect families’legitimate rights to privacy. Some confi-dentiality provisions are dictated at thefederal level, while others are decided atthe state or even the individual programlevel. A single agency can have differentconfidentiality rules depending on whichagency makes the request, what informa-tion is requested, and for what purpose.In any case, efforts to design an ExpressLane Eligibility system must address theseprovisions in a manner that allows foreffective and practical informationexchange on a wide scale while stillrespecting families’ privacy concerns.

Interagency collaborative efforts havesuccessfully addressed this challenge fora number of years, using flexible and creative approaches. In most cases,informed consent has been the basis forinformation sharing; in some cases, thelaw has been revised to allow for sharingbetween certain relevant programs, with-out the client’s consent.49

As a state designs the information sharing aspect ofits Express Lane Eligibility program, some pro-grams will have confidentiality rules that ease theprocess, while others will frustrate it. (SeeAppendix G for an overview of some relevant pro-grams’ confidentiality provisions.) Regardless ofthe programs involved, interagency agreements willprobably be required, including assurances that theinformation obtained will be used only for out-reach and/or enrollment purposes. In addition,staff for the programs will need to be educatedabout the reason for the information sharing, theagreements made, and how the process will work.

Most important, the client’s and/or parent’sinformed consent should be built into the process.Guidance released by the United StatesDepartment of Agriculture (USDA) in the fall of1998 on ways state and school officials can use theNational School Lunch Program (NSLP) as areferral mechanism for Medicaid or the Children’sHealth Insurance Program (CHIP) is a usefulexample of how a parent’s waiver of confidentialitycan be obtained. (See Appendix B.)

In addition, recent federal legislation (effectiveOctober 1, 2000) further facilitates the sharing ofinformation between the NSLP and Medicaid andCHIP by authorizing states and school food per-sonnel to share information from school lunchapplications with the health programs for outreachand enrollment activities.50 The legislation requiresthat school food authorities who wish to partici-pate inform families that their school lunch infor-mation will be shared with health agencies toenroll their children in a health program, and pro-vide the families with the opportunity to elect notto disclose this information. States must also havea written agreement in place between school foodauthorities and state or local child health agenciesto assure that shared information will be used onlyfor enrollment purposes.

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary


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Although the final regulations have not been issued,on July 6, 2000 the USDA issued guidance on thelegislation’s new rules concerning the disclosure ofchildren’s free and reduced price eligibility informa-tion for Medicaid and CHIP.51 In addition, theUSDA released a prototype parent notification anda prototype of the required disclosure of informa-tion agreement between school food authorities andstate or local child health agencies.52

Immigration Restrictions

One of the most important issues to consider whenimplementing Express Lane Eligibility is the differ-ent immigration requirements of some public pro-grams and those of Medicaid and CHIP. For exam-ple, while Medicaid and CHIP restrict general eligi-bility to US citizens and certain “qualified aliens,” anumber of public programs, including the SpecialSupplemental Nutrition Program for Women,Infants and Children (WIC) and NSLP, do not.Under these instances, additional immigrationinformation about the child must be obtainedfrom the family to determine his or her eligibilityfor full-scope Medicaid or CHIP. However, it isimportant to ensure that any linkage between theseprograms and Medicaid and CHIP is not detrimen-tal to the trust established between families andthe other agencies.

One possibility is to make families aware of the immi-gration requirements for Medicaid and CHIP whenthe Express Lane Eligibility process is being imple-mented. For example, if a streamlined form is sentto families enrolled in another public programinforming them that their child is potentially eligiblefor full-scope Medicaid or CHIP, it could include astatement concerning the immigration rules. If afamily were concerned, they would have the optionof not pursuing Express Lane Eligibility.

It is also important to ensure that the informationcollected by the Medicaid and CHIP agency fromanother public program will not be used for anyother purpose than to determine eligibility for thoseprograms. This could be accomplished through statelegislation or through interagency agreements.

Documentation Requirements

Federal rules do not require families seeking cover-age for their children under Medicaid or CHIP toprovide documentation of information provided inthe application, except when the person seekingcoverage is not a citizen, in which case documenta-tion of the non-citizen’s immigration status isrequired.53 Therefore, states have significant flexi-bility in allowing families to self-certify most of theinformation included on the application. Thisshould allow a state to accept the information pro-vided by a family to another public program as aform of self-certification for purposes of making aMedicaid or CHIP eligibility determination.

A growing number of states including Washington,Maryland and Georgia already allow applicants toself-certify income and other information presentedin their health applications.54 Washington, for exam-ple, has eliminated all documentation requirementsfor its Medicaid for children program except foralien status. A recent analysis of Washington’s appli-cation found that most misstatements of incomewere due to mistakes and that even when peoplefailed to verify their income information, they werestill income-eligible for the program.55

In addition, recent guidance issued by the HealthCare Financing Administration (HCFA) in anApril 7, 2000 State Medicaid Directors’ letterincludes clarification on whether a state can relyon other public programs’ information and eligi-bility determinations to make Medicaid determina-tions.56 Although the comments were provided inthe context of ex parte reviews for establishingMedicaid eligibility for former TemporaryAssistance to Needy Families (TANF) recipients,HCFA has indicated that the guidance can beapplied in other circumstances, including ExpressLane Eligibility. The guidance stipulates that astate can:

• Use accurate information available from otherpublic programs to make Medicaid eligibilitydeterminations, without contacting the family. Theletter states that “information that the State orFederal government currently relies on to providebenefits under other programs, such as TANF,Food Stamps, or SSI, should be considered accu-

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Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

rate to the extent that those programs require reg-ular redeterminations of eligibility and promptreporting of changes in circumstances.”

• Utilize another program’s eligibility determina-tion in determining eligibility for Medicaid.The guidance stipulates that “when an eligibilityrequirement under another program appliesequally to the Medicaid program, the State mayaccept the other program’s determination withrespect to this particular eligibility requirement.”

Using this letter as a precedent, a state can utilizeinformation from another public program thatmakes regular determinations and requires report-ing of changes in circumstances to make aMedicaid eligibility determination. A state can alsoaccept the eligibility determination of another pro-gram with respect to specific eligibility require-ments when making its own Medicaid eligibilitydetermination, if the eligibility requirement underthe program is equal to or more restrictive thanMedicaid’s. Further guidance is expected fromHCFA on how a state determines which public pro-grams can be used for these purposes, i.e. the defi-nition of “regular determinations of eligibility andprompt reporting of changes in circumstance.”

Federal Verification Rules

When the state finally makes an eligibility determi-nation using information provided from otherprograms, it is still required to meet the federalrules for verifying such information.

As previously mentioned, federal Medicaid rulesrequire states to conduct a post-eligibility verifica-tion of income through an income and eligibilityverification system (IEVS). Under IEVS, the statemust request information from other federal andstate agencies to verify the applicant’s income.This requirement is necessary whether an appli-cant has provided documentation or self-certifiedtheir income.

However, states have some flexibility in implement-ing IEVS, since federal law requires income andother information to “be requested and utilized tothe extent that [it] may be useful in verifying eligi-bility for, and the amount of, benefits available.”57

What is “useful” is not defined. As a result, somestates run every applicant’s name through IEVS,while others only run those with certain types orlevels of income.

Express Lane Eligibility does not change a state’sverification system. More specifically, the informa-tion received on the child’s family income wouldsimply be verified through IEVS. However, ininstances in which the comparable public programbeing used for Express Lane Eligibility already ver-ifies income through IEVS, there should be lessneed to run an IEVS check on that participant forMedicaid purposes. For example, since most, if notall, Food Stamp programs require the same post-eligibility requirements for IEVS as Medicaid, astate can make the case that it is not “useful” torun these applicants through IEVS, and that thepost-eligibility verification standards have alreadybeen met.

The CHIP program does not have post-eligibilityverification rules, although states are encouraged toimplement a system similar to the one they operatefor Medicaid. Thus, under Express Lane Eligibility,a state could simply use the child’s enrollment inanother public program as verification for CHIP. Toensure quality control, the state would require doc-umentation or some other verification that thechild is enrolled in the other program.

Medicaid Eligibility Quality Control

Separate from IEVS, states are required to operatea Medicaid Eligibility Quality Control (MEQC)program. MEQC is required by federal law, andallows sanctions to be imposed on states for MEQCerrors where payments under the state plan aremade to ineligible individuals and families at unac-ceptable rates. Random sampling is used to revieweligibility and determine whether a state has unac-ceptable error rates, in an effort to reduce erro-neous federal expenditures.


19

The question arises, then, whether states would beable to meet these quality control guidelines if theyimplement Express Lane Eligibility. Would a statebe liable for MEQC errors that are based on themistaken eligibility findings of other governmentprograms and agencies? Would an Express LaneEligibility program raise error rates beyond accept-able levels?

Since a 1994 Department of Appeals Board (DAB)ruling made it extremely cumbersome for HCFA tomeet the sampling standard needed for calculatingerror rates, HCFA has allowed pilot programs thatgive states room to design their own MEQC pro-gram. Significantly, over half of the states are oper-ating under such pilot programs and their MEQCerror rates are frozen at the level achieved beforethe pilot programs were implemented.58 As long asthe state operates the pilot program, there is nothreat of MEQC disallowances.

In addition, states that still operate traditionalMEQC programs are under minimal threat ofMEQC disallowance, given that it has been over 10years since HCFA has taken an MEQC disal-lowance. HCFA has stated that states that maintain“prudent administrative control over theirMedicaid programs” have “little likelihood” ofbeing “held disallowance liable.”59 If a state’s errorrate does exceed the allowable 3 percent tolerancerate and the state is found liable, it can still appeal,at which point HCFA will take into account theprudence of the state’s program in assessing liabili-ty. In addition, in its CHIP regulations HCFA hasproposed that it waive any errors that a state canshow were linked to new legislation (i.e., CHIP andwelfare reform).60

Given the current application of MEQC and HCFA’sstated desire to make eligibility policies more familyfriendly, Express Lane Eligibility is unlikely to lead toMEQC problems. In fact, recent HCFA guidance sug-gests that HCFA officials are more concerned withimproper terminations of eligibility than erroneousapprovals.61

Funding Resources

Express Lane Eligibility requires state and localentities other than Medicaid or CHIP, such asschool nutrition programs, etc., to becomeinvolved in activities to identify and/or assist withenrolling children in health coverage. This raisesquestions about the ability of such entities to imple-ment Express Lane Eligibility without receiving theadditional resources necessary to carry out the newresponsibilities being placed on them, particularlyif children’s health insurance is not part of theircharge. This is especially true when an entity is pro-hibited from allocating any of its funding to non-related activities, as is the case with WIC.

Another example is the National School LunchProgram. The USDA made an important step byissuing prototype school lunch applications allow-ing the exchange of information between schoollunch and Medicaid and CHIP agencies. (SeeAppendix B.) However, processing the new appli-cations and forms adds administrative responsibili-ties for school personnel responsible for adminis-tering the school lunch programs, whose time isalready spread thin. Even under a simple referralprocess, an application that is returned to schoolpersonnel with the box checked saying the familywants to receive information on children’s healthcoverage must be forwarded to the Medicaid/CHIP agency. This involves staff time, photocopy-ing, mailing costs, etc. As a result, some schoolshave decided not to use the form, while othershave had difficulties implementing the proceduresrequired to process the form.

These same resource issues would arise if the state,for example, worked with the Food StampProgram to send out a mailing to all of its unin-sured children seeking their approval to accesstheir Food Stamp case file. This process wouldinvolve staff time, printing and mailing costs.

It is important, therefore, for a state to considerthe different administrative requirements ofExpress Lane Eligibility and ensure that the neces-sary resources are targeted to it. Several existingfunding strategies can be used:62

20

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

C H I P A l l o c a t i o n

A state is allowed to spend up to 10 percent of itstotal CHIP expenditures (federal and state) on non-benefit activities, including outreach. Outreachactivities are defined as activities to inform familiesof CHIP or other public/private health coverageprograms. Thus, a state has flexibility in claimingcosts associated with joint Medicaid and CHIP out-reach efforts through its CHIP allotment. Theseexpenditures are matched at the CHIP rate, whichvaries by state but ranges from 65 to 85 percent.However, a number of state officials have alreadyvoiced concerns that this percentage does not covertheir current outreach activities.

M e d i c a i d A d m i n i s t r a t i v e M a t c h 6 3

Medicaid law does not limit the amount of moneya state can spend on outreach efforts to enrollpeople in Medicaid. The Federal government willmatch such spending at a 50 percent rate. Someof the activities a state can undertake to claim thismatch are: informing families about Medicaidthrough brochures or other promotional materi-als; assisting families in completing Medicaid appli-cations; and providing the necessary forms andpackaging for Medicaid eligibility determinations.64

A state implementing Express Lane Eligibilitycould claim either the Medicaid or CHIP matchfor a number of joint Medicaid and CHIP out-reach activities.65 This is also true if the activitieswere undertaken by another entity, such as a FoodStamp office, WIC site or school. This couldinclude costs associated with informing familiesabout their children’s potential eligibility forMedicaid/CHIP, developing written materials andsimplified forms, transfer of information to theMedicaid/CHIP agency in order to determine eli-gibility, training of staff, and assistance provided tochildren in enrolling.

For a state to claim expenses conducted by anotherentity under Medicaid or CHIP, it would need todevelop an interagency agreement or contract withthe state Medicaid or CHIP agency.66 This agree-ment or contract would specify the activities theentity will undertake, what funding will be provid-ed, and on what basis the payment will be made. Inaddition, it would be possible for the agreement tospecify that the entity will provide the requiredstate match, if the funds (state or local) are notbeing used as a federal match for another pro-gram. Rules regarding what a state can utilize tocover a non-federal share would apply in this situa-tion.67

The $500 Million Fund: In addition to the CHIPand Medicaid federal matching funds, it might bepossible for a state to fund its Express LaneEligibility activities through a special $500 millionMedicaid fund created to assist states in ensuringthat children and parents do not lose Medicaidcoverage as a result of welfare reform’s delinkageof Medicaid eligibility from cash assistance. Eachstate was allocated a portion of the $500 million,from which it can claim matching funds at rates of75 or 90 percent. In November 1999, Congresspassed legislation that eliminated any time limitsplaced on this fund. As of September 30, 1999,states had utilized 20 percent of the fund.68

Although this fund targets families directly affectedby the delinking of welfare and Medicaid, on March22, 1999, HCFA issued guidance clarifying that astate is still eligible for these funds even if its activi-ties to identify these individuals result in the individ-uals becoming enrolled in other health coverageprograms. Thus, a state has some flexibility indesigning an outreach program through this fund.69


21

22

LEGISLATIVE PRECEDENTS

CH

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5There are specific precedents where the conceptof linking eligibility for one program with anotherhas been incorporated into law and practice. Theprimary intent of doing so was to make it easierfor eligible families to enroll in programs and to cutdown on administrative paperwork.

In addition, some of the difficulties in implement-ing Express Lane Eligibility raised in this reporthave been addressed legislatively. In the followingexamples of the Special Supplemental NutritionProgram for Women, Infants and Children (WIC)and the National School Lunch Program (NSLP),confidentiality concerns became nonexistent whenlegislation allowed one program to share informa-tion with another program. In these cases, legisla-tive or regulatory language was also clarified toensure that any information shared would be usedfor eligibility purposes only. Documentation andverification issues have also previously beenaddressed legislatively by stipulating that one pro-gram could rely on the documentation and verifi-cation of another program.

In some instances, legislation has authorized indi-viduals’ eligibility for a program for which theywould not otherwise be eligible. For example,since 1980, school districts with large proportionsof low-income children have been allowed to offerfree meals to all children, no matter what theirincome.70 In addition, Food Stamp law requiresthat any time all members of a Food Stamp house-hold receive Temporary Assistance to NeedyFamilies (TANF) benefits, the household is cate-gorically eligible for Food Stamps. Since manystates now allow families that are moving from wel-fare to work to have assets, such as a car, andremain eligible for TANF, this link allows familiesto receive Food Stamps even if their assets wouldotherwise disqualify them.71

The following provides examples of two programs,the Special Supplemental Nutrition Program forWomen, Infants and Children (WIC) and theNational School Lunch Program (NSLP), that havesuccessfully used a legislative mandated linkagewith another program to find eligible children.

WIC Adjunctive Eligibility

In 1989 Congress authorized WIC agencies to acceptan applicant’s documented participation inMedicaid, Food Stamps and TANF 72 as evidence ofincome eligibility for WIC. Although an applicant isstill required to meet WIC’s additional eligibilityrequirements — that the applicant is nutritionally at-risk and a state resident — this so-called adjunctiveeligibility has substantially streamlined the WICapplication process.

In 1998, 57 percent of WIC recipients (whichincludes women and children ages 0-5) werereceiving benefits from at least one program —Medicaid, Food Stamps or TANF — at the time oftheir WIC certification. Almost half (48 percent)received Medicaid benefits.73

Adjunctive eligibility is not, however, allowed inthe opposite direction; i.e., Medicaid cannotaccept an applicant’s documented participation inWIC as evidence of income eligibility for Medicaid.Thus, an estimated 24 percent of all uninsuredchildren who are potentially eligible for Medicaidand CHIP participate in the WIC program (seeChapter 1 Uninsured Children Already Enrolled inPublic Programs).74

W h a t t h e L a w S a y s

Congress’s intent for establishing adjunctive eligi-bility for WIC was to reduce the administrative bur-den on WIC staff, expedite an applicant’s entryinto the program, remove potential barriers to pro-gram participation, and increase referrals betweenWIC and other health and social service programs.

22

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary

When the legislation was initially authorized, thethree programs chosen for inclusion had federalincome guidelines below WIC’s income limit of185 percent of the FPL. Since that time, manystates have expanded Medicaid income eligibilitybeyond 185 percent of the FPL. However, becauseof the way the law was drafted, women or childrenapplying to WIC today who are in a Medicaid pro-gram that has income guidelines above 185 per-cent of the FPL are also automatically deemedincome-eligible for WIC.

The text is as follows:

(A) The State agency shall accept as income-eligible for theprogram any applicant who documents that he/she is:

(1) Certified as fully eligible to receive food stamps underthe Food Stamp Act of 1977, or certified as fully eligible,or preemptively eligible pending completion of the eligibil-ity determination process, to receive Aid to Families withDependent Children (AFDC) under Part A of Title IV ofthe Social Security Act or Medical Assistance (i.e.,Medicaid) under Title XIX of the Social Security Act; or

(2) A member of a family that is certified eligible toreceive assistance under AFDC, or a member of a familyin which a pregnant woman or an infant is certified eli-gible to receive assistance under Medicaid.

(B) The State agency may accept, as evidence of incomewithin Program guidelines, documentation of the appli-cant’s participation in State-administered programs notspecified in this paragraph that routinely require docu-mentation of income, provided that those programs haveincome eligibility guidelines at or below the State agency’sProgram income guidelines.

(C) Persons who are adjunctively income eligible, as setforth in paragraphs (d)(2)(vi)(A) of this section, shallnot be subject to the income limits established underparagraph (d)(1) of this section.75

H o w I t W o r k s

Each state, and in some cases local agencies, oper-ates the WIC program’s adjunctive eligibility provi-sion differently. Generally, however, when a personcomes into a local WIC agency to apply for bene-fits, WIC staff will determine their income eligibili-ty by first asking whether they are enrolled inMedicaid, Food Stamps and/or TANF.

If the applicant reports enrollment in one of theprograms, WIC staff must confirm their participa-tion.76 Proof can be provided by the applicant inthe form of documentation from the adjunctiveprogram or can be acquired by the state through acomputer system. If the applicant is not enrolledin any of the programs, the staff makes the incomedetermination based on information (and docu-mentation) provided by the applicant regardingtheir income, household size, etc. In either case,prior to making a final eligibility determination,the applicant must undergo an in-person interviewand be determined to meet other programrequirements, including that they are nutritionallyat-risk and a state resident.

School Lunch Categorical Eligibility &Direct Certification

The School Lunch Program has two ways in whichstates can streamline the school lunch applicationprocess for recipients of Food Stamps, TANF orthe Food Distribution Program on IndianReservations (FDPIR).77 In addition to these threeprograms, the Head Start program, which has anincome limit of 100 percent of the FPL, is alsoincluded when the Head Start program is locatedin a school or if a school has access to Head Startenrollment information.

C a t e g o r i c a l E l i g i b i l i t y

“… if application is being made for a child who is amember of a food stamp, FDPIR or TANF household, theapplication shall enable the household to provide theappropriate food stamp or TANF case number or FDPIRcase number or other identifier in lieu of names of allhousehold members, household income information andsocial security number.” 78

In 1986 Congress approved an amendment to theNational School Lunch Act (NSLA) that allowschildren receiving Food Stamps, FDPIR and TANFto be automatically eligible for free meals or milkwithout further application or eligibility determi-nation. These provisions relate only to free mealsand milk, not to the reduced price meals, becausethe income guidelines (up to 130 percent of theFPL) for free meals and milk are similar to thosefor Food Stamps. The law also specifies that cate-gorical eligibility can be granted for TANF recipi-


23

ents only when the state’s TANF income guidelinesdo not exceed 130 percent of the FPL. There is noattention given to or mention made of how eachprogram determines family income, although eachprogram does so differently.

Based on the law, families filling out the schoollunch application who are enrolled in these pro-grams are allowed to list their Food Stamp, FDPIRor TANF case number instead of providing detailedhousehold size and income information.79 Officialsestimate that 85 to 90 percent of school districtshave implemented this procedure, whereas the restuse direct certification (see below).80

A state is required to verify the applicant’s enroll-ment in the program, either by confirming it withthe local food stamp or welfare office or by obtain-ing a copy of the applicants’ official enrollment doc-umentation. An identification card for either pro-gram is only acceptable as verification if it containsan expiration date. Under this process, no other ver-ification by the state is required to determine theapplicant’s eligibility for free meals and milk.

D i r e c t C e r t i f i c a t i o n

“In lieu of determining eligibility based on informationprovided by the household on the free and reduced pricemeal or milk application, school food authorities maydetermine children eligible for free meals or milk based ondocumentation obtained from the appropriate State orlocal agency responsible for the administration of theFood Stamp Program, FDPIR and/or the TANFProgram, hereafter referred to as direct certification.” 81

In 1989 the NSLA was again amended to furthersimplify the ability of Food Stamp, FDPIR andTANF families to obtain free meals and milk fortheir children. Under direct certification, schoollunch authorities can certify children eligible forfree meals or milk by obtaining documentation ofa child’s receipt of Food Stamps, FDPIR or TANFdirectly from the appropriate agency. A family thatis certified under this procedure is not required tocomplete an application.

Not only is the intent of direct certification to sim-plify the application process for families, it is alsomeant to cut down on a school district’s paper-work. A school district commonly takes the follow-ing steps to implement direct certification:

• FirstThe Food Stamp, FDPIR or TANF agency cross-ref-erences student lists obtained from the school dis-trict against their enrollment files. To validate thecross-reference, at least one piece of identifyinginformation, besides the child’s name, must beused to make the match. This identifier couldinclude addresses, date of birth, parents’ names,social security numbers, etc. A signature or otherverification is also required from the Food Stamp,FDPIR or TANF officer certifying that each child isa member of a Food Stamp, FDPIR or TANFhousehold.

• SecondThose children who are not already enrolled inthe School Lunch Program but who are enrolledin the Food Stamp, FDPIR or TANF program areautomatically certified as eligible for free mealsand milk. The school district then notifies the fam-ily in writing that their child(ren) are certified.The family is not required to submit any otherinformation and must only respond if they do notwant their children to receive the benefits.

Rules that went into effect on January 27, 2000 alsoallow a family to receive documentation directlyfrom a Food Stamp, FDPIR or TANF agency certify-ing their child’s enrollment in Food Stamps,FDPIR or TANF. In this instance, the family wouldprovide the documentation to the school lunchofficials and would not be required to submit anyadditional information prior to being enrolled.

Although officials estimate that direct certificationis only used in 10 to 15 percent of school districts,the numbers are growing.82 It seems to work mostefficiently in large school districts with high ratiosof low-income children. In California, for exam-ple, almost a third of its 902 school districts usedirect certification and efforts are underway toincrease this number.83

24

RECOMMENDATIONS FOR GETTING STARTED AND CONCLUSION

CH

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6 While there are certain challenges todesigning an Express Lane for childreninto health care, the effort seems wellworth it given the potential benefits.However, because much of this isuncharted territory, a state or countywishing to get started may want to thinkabout chipping off one area at a time.Based on our research, we believe thatthe Food Stamp Program holds the bestlikelihood of working in most states andwe recommend it as a starting point. Inaddition, communities can start toundertake the research, analysis and leg-work required to move beyond FoodStamps to other programs. The follow-ing outlines the two implementationsteps a state or county could undertake.

Implementation Step 1: Createan Express Lane for Childrenthrough Food Stamps

From a nationwide perspective, the FoodStamp Program seems the easiest to fitinto an Express Lane Eligibility model.Food Stamps has a sufficiently lowincome threshold (net income of 100percent of the Federal Poverty Level)that most child enrollees are alsoincome-eligible for Medicaid — thus sim-plifying Express Lane Eligibility’s admin-istration and easing the way to meetingCHIP’s “screen and enroll” require-ments. In addition, its citizenship guide-lines are similar to those of Medicaidand, in many states and counties, thesame agency administers both FoodStamps and Medicaid. Finally, the FoodStamp Program’s confidentiality guide-lines allow Medicaid agencies to useinformation in its case files to establish orverify eligibility. (See Appendix G.)

Steps to take include:

✓ Review the guidelines and administrative sys-tems of Medicaid, the Children’s Health InsuranceProgram (CHIP) and Food Stamps to determinewhether the Streamlined or Automatic modelworks best for your state. This should includedetermining how each agency maintains itsrecords (electronic vs. paper) to assess the ease ordifficulty of sharing client information. Attempt toreconcile program differences that may impedeExpress Lane Eligibility.

✓ Seek the support of the governor and the headof the state health and welfare agencies.

✓ Form an Interagency Task Force with FoodStamp and Medicaid agency staff to develop andimplement the system. Include directors and per-sonnel with decisionmaking authority, as well asappropriate agency staff from both the state andlocal levels. Involve information systems and eligi-bility specialists for both programs.

✓ Develop any necessary interagency or intra-agency agreements, detailing each agency’s rolesand responsibilities as well as identifying fundingsources for the activities and the non-federal shareof the match.

✓ Determine whether the agencies’ databases canbe coordinated to automate any part of theprocess.

✓ Obtain any federal approval necessary to changethe state Medicaid plan to eliminate minor ruledifferences — such as some income-counting dif-ferences. Or, consider applying for a waiver underCHIP or Medicaid to eliminate any barriers.

Introduction






Appendices A,B,C

Appendices D,E,F

Appendices G,H,I

Executive Summary


25

Implementation Step 2: Create anExpress Lane through other Programsin Your State

While Food Stamps may be the simplest programto start with, a state or county need not stop there.There are a number of other steps you can take tomove forward with Express Lane Eligibility. Wherepossible, we have attempted to provide you withsome necessary tools for getting started.

✓ Use Appendix H to make a quick determinationof which programs best align with your state’sMedicaid and CHIP guidelines. Review the specificguidelines within your state for these potentialpublic programs to determine which will bestaccommodate Express Lane Eligibility options inyour state or local community – use theWashington and California models provided in thispublication as examples of how to undertake theanalysis. (See Chapter 3 and Appendices E and F.)

✓ Examine the programs’ administrative struc-tures, including how each program maintains itsclient records, to decide which allow Express LaneEligibility to be implemented most efficiently andeffectively.

✓ Determine whether the Express Lane modelshould be implemented on a statewide basis or at acounty/local level, based on administrative struc-tures and authorities.

✓ Acquire the support of each agency directorand/or commissioner. If possible, obtain the sup-port of the governor or other high-level stateadministrators.

✓ Form an Interagency Task Force with the agen-cies that will be involved in structuring ExpressLane Eligibility. Involve information systems staffand eligibility specialists from relevant agencies, includ-ing personnel from both the state and local levels.

✓ Examine the possibility of seeking a federal waiv-er under CHIP or Medicaid to implement theExpress Lane Eligibility model.

✓ If needed, develop legislative or budget lan-guage to provide your Medicaid/CHIP agency withthe resources and authority necessary to designand implement an Express Lane Eligibility system.For sample legislative language used in California,see Appendix I.

✓ Develop and work for legislative changes in yourstate to streamline Medicaid and CHIP and improvethe potential success of Express Lane Eligibility,such as implementing 12 months of continuous eli-gibility, eliminating the assets test and allowing fami-lies to self-certify their income.

Conclusion

Express Lane Eligibility holds the potential to simpli-fy public programs for families and to enroll manymore children in needed health care. But as thisbriefing book and guide has shown, this common-sense idea is not as straightforward to put into placeas it would seem, because a number of bureaucraticchallenges requiring persistence and creativity willarise between the starting and finish lines.

More than anything, successful implementation ofExpress Lane Eligibility requires policymakers andadministrators at the state and local level to bestrong leaders for reform. But challenges like thisare nothing new. States and local communitieshave worked for years to fashion interagencyagreements that grease the wheels so public pro-grams can work together more smoothly. Now isthe time to continue this resolve and vision toadapting the Express Lane idea, which has benefit-ed so many Americans on highways and in super-markets, to public health programs.

26

APPENDIX AENDNOTES

Note: Links to all web site addresses are available at www.childrenspartnership.org

1 US Census Bureau, Current Population Survey, 1999, cal-culations by the Center on Budget and Policy Priorities.3.4 million uninsured children would be eligible for CHIPand 4.6 million would be eligible for Medicaid. Reflectsnumber of uninsured children in 1998 who would havebeen eligible for coverage under the income thresholdsused by states in November 1999 or under income thresh-olds slated to go into effect in early 2000. They do nottake into account other eligibility requirements, such asimmigration status. Also, some of these uninsured chil-dren may have enrolled in coverage since 1998.

2 Ibid. The total number of uninsured children in the USis estimated at 11.5 million.

3 See Michael Perry, R. Burciaga Valdez and ChristinaChang, Medicaid and Children: Overcoming Barriers toEnrollment, The Kaiser Commission on Medicaid and theUninsured, January 2000, www.kff.org/content/2000/2174and Speaking Out...What Beneficiaries Say About the Medi-CalProgram, Medi-Cal Policy Institute, February 2000,www.medi-cal.org/publications/viewpub.cfm?itemID=1317.

4 Health Care Financing Administration, Letter to StateHealth Officials, September 10, 1998,www.hcfa.gov/init/chpelig.htm.

5 Health Care Financing Administration, Letter to StateHealth Officials, July 31, 2000,www.hcfa.gov/init/ch73100.htm.

6 Health Care Financing Administration, Letter to StateHealth Officials, June 26, 2000,www.hcfa.gov/init/ch62600.htm.

7 Health Care Financing Administration, Letter to StateMedicaid Directors, April 7, 2000, www.hcfa.gov/medicaid/smd40700.htm.

8 See www.100percentcampaign.org/express.html for addi-tional information.

9 Deborah Bachrach, Katherine Lee Yang, Clarke Brunoand Anthony Tassi, Implementing Express Lane Eligibility inNew York State, United Hospital Fund, May 2000.

10 Available at www.childrenspartnership.org/pub/expresslane/index.htmlor by calling (310) 260-1220.

11 See Endnote 1.

12 Genevieve M. Kenney, Jennifer M. Haley and FrankUllman, Most Uninsured Children Are in Families Served byGovernment Programs, The Urban Institute, December1999, www.urban.org. Estimates drawn from the 1997National Survey of America’s Families (NSAF), a nationalhousehold survey that provides information on over100,000 children and nonelderly adults. In determiningthe potential reach of the NSLP or WIC program, it wasassumed that all children in the household could be tar-geted through the given program. Note: The UrbanInstitute expects to update its analysis using 1999 NSAFdata in the fall of 2000, and is considering the potential ofincluding other public programs.

13 Different resources are available on current state effortsto conduct school-based health insurance outreach,specifically through the NSLP. Seewww.fns.usda.gov/cnd/menu/whatsnew/WhatsNew.htm;Families USA, Promising Ideas in Children’s Health Insurance:Coordination with School Lunch Programs, May 1999,www.familiesusa.org/schbrief.htm; and Donna CohenRoss, Fostering A Close Connection: Report to Covering Kids onOptions for Conducting Child Health Insurance Outreach andEnrollment Through the National School Lunch Program,Center on Budget and Policy Priorities, January 2000,www.cbpp.org/1-20-00health.htm.

14 Agricultural Risk Protection Act of 2000 (H.R. 2559),enacted June 20, 2000 (Public Law 106-224). The fall of1998 USDA prototype applications are still relevant, sinceit is at the discretion of school food service operatorswhether or not to implement the new rules establishedthrough the federal legislation. In addition, the proto-types are good examples for use by other programs.

15 Ibid. For guidance on the new legislation see USDA,Child Nutrition Programs: CHIP-Medicaid PolicyMemorandum, July 6, 2000, www.fns.usda.gov/cnd/SCHIP/SCHIP_Medicaid.policy.htm.

16 Health Care Financing Administration, Letter to StateMedicaid Directors, April 7, 2000, ibid.

17 Health Care Financing Administration, Letter to StateHealth Officials, July 31, 2000, ibid.

18 See Endnote 13.

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

27

Appendices A,B,C

19 For an overview of the various Medicaid eligibility path-ways, see Andy Schneider, Kristen Fennel, and PeterLong, Medicaid Eligibility for Families and Children, KaiserCommission on Medicaid and the Uninsured, September1998, www.kff.org/content/archive/2106/eligibility.html.Under federal CHIP law, states have much more flexibilityto set eligibility rules than they do under Medicaid; statesare allowed to establish different eligibility standards fordifferent groups of children, with some exceptions.

20 42 CFR 435.907.

21 Health Care Financing Administration, Letter to StateHealth Officials, September 10, 1998, ibid.

22 42 CFR 435.907(b).

23 42 CFR 435.910. An applicant’s social security number isnot required if the applicant is seeking coverage of emer-gency Medicaid services.

24 Health Care Financing Administration, Letter to StateHealth Officials, September 10, 1998, ibid.

25 42 CFR 435.601(d).

26 For example, a state’s rules may not take into accountincome or assets that are not available, may not usemethodologies that are more restrictive than thoseemployed in the most closely related cash assistance pro-gram, etc. See 42 USC 396a(a)(10).

27 42 CFR 435.4. Medicaid counts income and assets forrelated persons living in the same home who have finan-cial responsibility for the health of the applicant (spousefor spouse, parent for child.)

28 42 CFR 436.406(b). Mandatory qualified aliens includeveterans or persons on active military duty and theirdependents; refugees, asylees and Cuban and Haitianentrants for seven years after entry; aliens whose deporta-tion has been withheld; Amerasian immigrants for five yearsafter entry; and lawful permanent residents who can becredited with 40 quarters of social security coverage.Otherwise eligible aliens qualify for coverage of emergencyservices, regardless of immigration status.

29 Only one state, Wyoming, has not retained eligibility forthis group of qualified aliens.

30 Health Care Financing Administration, Link BetweenMedicaid and the Immigration Provisions of the PersonalResponsibility and Work Opportunity Act of 1996,www.hcfa.gov/medicaid/wrfs3.htm.

31 Health Care Financing Administration, Letter to StateHealth Directors, September 10, 1998, ibid.

32 42 CFR 435.948.

33 Regulations governing non-Medicaid CHIP programsare still in proposed form at Federal Register, November8, 1999 (Volume 64, Number 215), to be set forth in regu-lations at 42 CFR 457, Subchapter D. Seewww.hcfa.gov/init/chnprm.htm. Note: CHIP-relatedMedicaid programs are governed by Medicaid regulations.


35 Addressed in Title XI.


37 Health Care Financing Administration, Administration’sResponses to Questions about the State Children’s HealthInsurance Program, July 29, 1998, Q #105,www.hcfa.gov/init/qa/q&a7-29.htm.

38 Health Care Financing Administration, Letter to StateHealth Officials, January 14, 1998,www.hcfa.gov/init/chipimms.htm.

39 What constitutes adequate verification of immigrationstatus is still being finalized in federal regulations; howev-er, HCFA has already issued clarification on this point.See HCFA, Letter to State Health Officials, September 10,1998, ibid.

40 Shuptrine and Hartvigsen, The Burden of Proof: HowMuch Is Too Much for Child Health Coverage?, The SouthernInstitute on Children and Families, December 1998, pp. 3,6, www.kidsouth.org/burden.html.

41 Health Care Financing Administration, Letter to StateHealth Officials, August 27, 1997, www.hcfa.gov/init/schiplt3.htm and Health Care Financing Administration,Administration’s Responses to Questions about the StateChildren’s Health Insurance Program, July 29, 1998, ibid.

42 Andy Schneider, ibid. About 10 states still apply anassets test for children, which means they identify andvalue resources the child’s family owns for purposes ofdetermining Medicaid eligibility.

43 It is possible that some Food Stamp households couldhave the same income as the Medicaid budget unit and,yet, be at a lower percentage of the federal poverty level.This could occur if additional children who do not bringin income are counted for the Food Stamp household(they live and purchase/prepare meals together) but notfor the Medicaid family (they are not the responsibility, orchild, of the income-earning adult). However, this sce-nario is probably rare and may not move the unit aboveMedicaid qualifying levels in any case given that: a) the

28

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

children in the household would likely be that adult’slegal responsibility, b) it is to the financial advantage ofgroups to split into as many Food Stamp households aspossible, and c) any independent children could qualifyas separate Medicaid units if no adult is legally responsi-ble for their health care. Concern about this possibilityshould not deter the implementation of AutomaticEligibility. First, information to make an individual assess-ment should be available in the Food Stamp file, allowingstates to examine questionable cases. In addition, a statecould possibly seek a waiver under CHIP or Medicaid toaddress this issue. Last, HCFA has indicated its willingnessto work with a state on this issue when a state’s goal is toincrease coverage to uninsured children.

44 Medicaid also requires cooperation in establishing pater-nity and obtaining medical support, except in the case ofpoverty level pregnant women and persons who havegood cause to refuse to cooperate. However, children can-not be denied or terminated due to lack of cooperationon the part of an adult. CHIP has no such requirement.See Shuptrine and Hartvigsen, ibid., p. 16.

45 States or territories with approved Medicaid expansionsthrough CHIP, as of July 24, 2000 include: Alaska,American Somoa, Arkansas, North Mariana Islands,District of Columbia, Guam, Hawaii, Idaho, Louisiana,Maryland, Minnesota, Montana, Nebraska, New Mexico,Ohio, Oklahoma, Puerto Rico, Rhode Island, SouthCarolina, South Dakota, Tennessee, Virgin Islands andWisconsin. See: www.hcfa.gov/init/chip-map.htm.

46 Health Care Financing Administration, Letter to StateHealth Officials, February 13, 1998,www.hcfa.gov/init/chsub213.htm.

47 There is a precedent for the use of sampling to claim afederal match. In New York State Department of SocialServices, DAB No. 1134 (1990), the court ruled that fed-eral authorities must accept sampling to claim Medicaidfederal financial participation for health coverage origi-nally provided under a non-Medicaid program for chil-dren and others.

48 See Endnote 44. See also California Welfare &Institutions Code Section 14008.7.

49 For further discussion of these issues, see JoiningForces, Center for Law and Social Policy, American PublicWelfare Association, Council of Chief State SchoolOfficers, Education Commission of the States,Confidentiality and Collaboration: Information Sharing inInteragency Efforts, January 1992.

50 Agricultural Risk Protection Act of 2000 (H.R. 2559),enacted June 20, 2000 (Public Law 106-224).

51 See Endnote 15.

52 The Prototype Letter to Parents and the Prototype DisclosureAgreement Between School and Medicaid or SCHIP Officials canbe downloaded as an MS Word document atwww.fns.usda.gov/cnd/menu/whatsnew/WhatsNew.htmor www.fns.usda.gov/fns.

53 Shuptrine and Hartvigsen, ibid.

54 See www.cbpp.org/shsh/stateverify.htm for a list ofstates that allow self-declaration of income.

55 Washington Department of Social Health Services,Medical Assistance Administration, MEDS Code 80Denials: Medicaid Eligibility Quality Control (MEQC)Project, February 1998.

56 Health Care Financing Administration, Letter to StateMedicaid Directors, April 7, 2000, ibid. See also LizSchott, Issues for Consideration as States Reinstate Families thatwere Improperly Terminated from Medicaid Under WelfareReform, Center on Budget and Policy Priorities, June 12,2000, www.cbpp.org/5-30-00wel.pdf.

57 42 USC section 1320b-7(a).

58 For information on state pilot programs and HCFArequirements, seewww.hcfa.gov/medicaid/regions/mqchmpg.htm.

59 Shuptrine and Hartvigsen, ibid., pp. 3, 6, 7.

60 Preamble to proposed regulations, Federal Register,November 8, 1999 (Volume 64, Number 215), p. 60937.

61 Health Care Financing Administration, Letter to StateMedicaid Directors, April 7, 2000, ibid.

62 For additional information, see HCFA, Letter to StateHealth Officials, January 23, 1998,www.hcfa.gov/init/choutrch.htm.

63 We are grateful to Donna Cohen Ross of the Center ofBudget Policy and Priorities for her research on the topicof school districts using Medicaid administrative federalmatching funds to cover the cost of children’s healthinsurance outreach activities conducted through theSchool Lunch Program. See: Donna Cohen Ross, FosteringA Close Connection: Report to Covering Kids on Options forConducting Child Health Insurance Outreach and EnrollmentThrough the National School Lunch Program, Center onBudget and Policy Priorities, January 2000,www.cbpp.org/1-20-00health.htm.

64 Health Care Financing Administration, Letter to StateHealth Officials, January 23, 1998, ibid.

Appendices A,B,C

29

30

65 Outreach activities cannot be funded through Medicaidif the activities are related to a non-Medicaid, CHIP-onlyprogram. However, joint outreach efforts for Medicaidand CHIP may be matched through either Medicaid orCHIP.

66 Please note that based on concerns over abuses, HCFA,the General Accounting Office (GAO) and Congress arereviewing the practices used by school districts to claimthe Medicaid administrative funds. In an attempt to clarifythe rules, HCFA has released a draft Medicaid School-BasedAdministrative Claiming Guide, February 2000,www.hcfa.gov/medicaid/schools/machmpg.htm.

67 There are specific rules governing what can constitute astate’s share of financial participation. For example, in-kind contributions are allowed, although contributionsmade by health care providers, etc. cannot be used,except in limited circumstances.

68 Donna Cohen Ross, Sources of Federal Funding forChildren’s Health Insurance Outreach, Center on Budget andPolicy Priorities, February 17, 2000, www.cbpp.org/2-17-00health.htm and Donna Cohen Ross and Jocelyn Guyer,Congress Lifts the Sunset on the “$500 Million Fund” ExtendsOpportunities for States to Ensure Parents and Children Do NotLose Health Coverage, Center on Budget and PolicyPriorities, December 1, 1999, www.cbpp.org/12-1-99wel.htm.

69 For additional information, see State Department ofHealth & Human Services, Supporting Families inTransition: A Guide to Expanding Health Coverage in the post-Welfare Reform World, March 22, 1999,www.acf.dhhs.gov/news/welfare/welfare.htm.

70 For more information seewww.fns.usda.gov/cnd/lunch/default.htm

71 For more information see www.fns.usda.gov/fsp/clintoninitiative/default.htm.

72 The Personal Responsibility and Work OpportunityReconciliation Act of 1996 replaced the Aid to Familieswith Dependent Children (AFDC) with the block grantprogram Temporary Assistance to Needy Families(TANF). In most cases, rules referring to AFDC weretransferred to TANF. For example, WIC adjunctive eligi-bility now applies to TANF and not AFDC. To alleviate anyconfusion between programs, in this section AFDC will bereferred to as TANF.

73 Abt Associates, WIC Participant and ProgramCharacteristics, 1998, The Office of Analysis, Nutrition andEvaluation, Food and Nutrition Services, USDA, May2000, p. 52 and Exhibit 4-4, www.fns.usda.gov/oane/menu/published/wic/wic.htm.

74 Genevieve M. Kenney, ibid.

75 7 CFR 246.7.

76 This is a recent change to the WIC program. Congressonly recently mandated that proof of enrollment in theadjunctive program be obtained. This change alsorequires WIC staff to obtain documentation of all incomeinformation provided by the client.

77 The FDPIR provides food benefits to households onIndian reservations. Eligible households may elect to par-ticipate in either the Food Stamp Program or the FDPIR,but may not participate in both. Originally, categorical eli-gibility and direct certification did not apply to theFDPIR. However, an administrative ruling was later madethat these provisions also applied to FDPIR participants,since the program has a similar purpose to the FoodStamp program.

78 7 CFR 245.6(a).

79 The law also specifies that families providing a FoodStamp or AFDC case number are not required to fill outthe line item requesting that either the social securitynumber of the household member signing the applicationbe provided or an indication be made that the householdmember does not have a social security number.

80 Conversation with Bob Eadie, Chief of Policy andProgram Development, Child Nutrition Program, USDA,May 1999.

81 7 CFR 245.6(b).

82 Conversation with Bob Eadie, ibid.

83 California Food Policy Advocates, Direct Certification inCalifornia, State of the State, June 1999. For information onefforts in California to increase direct certification, con-tact California Food Policy Advocates at 415-777-4422 orvisit their website for tools and sample letters atwww.cfpa.net.

31

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

Appendices A,B,C

APPENDIXBUSDA SCHOOL LUNCH PROTOTYPE APPLICATIONS

MULTI-USE FREE AND REDUCEDPRICE MEAL APPLICATION

Interested State agencies and school food authoritiesshould contact their State Children’s Health InsuranceProgram (CHIP) coordinator to discuss use of the freeand reduced price meal application to outreach to low-income children who may not have health insurance.USDA developed two prototype free and reduced pricemeal applications that may be used for this purpose.Although the two applications look similar, they are dif-ferent in the information that may be released withparental/guardian consent. Two additional prototypeforms were developed that may be distributed tohouseholds separately from the free and reduced priceapplication. These forms are intended for schools thathave already printed their free and reduced price mealapplication or who do not want to use a multi-use freeand reduced price meal application, but want to partic-ipate in Medicaid and CHIP outreach. These may bedistributed with the application package or separatelyanytime during the school year. Your State or localCHIP coordinator can tell you which of the prototypeforms would be best for outreaching and enrollingchildren in CHIP. State agencies and school foodauthorities may also develop their own forms whichmay better suit State and local needs.

V E R S I O N 1

This prototype free and reduced price meal applica-tion allows households to permit school food servicepersonnel to give all information contained on thefree and reduced price meal application to Medicaidand CHIP officials. This would include the child’sname, names of all household members, all incomeinformation or a program case number (food stamp,Temporary Assistance for Needy Families, FoodDistribution Program on Indian Reservations)address, social security number of the adult house-hold member. A photocopy of the application pro-vided to Medicaid/CHIP officials would also be per-mitted under this option. If the adult’s social securi-ty number is disclosed, the privacy act statementmust be changed to advise parents of this and theintended uses of the number.

V E R S I O N 2

This prototype free and reduced price meal appli-cation allows households to permit school foodservice personnel to give only their name andaddress, and an indication that the household hadapplied for free and reduced price meals, toMedicaid and CHIP officials to facilitate outreachto these families.

V E R S I O N 3

This prototype form may be distributed separatelyfrom the free and reduced price application.However, the form may be attached to the free andreduced price meal application and sent out at thesame time or distributed separately from the free andreduced price application and at a different time.Version 3, like Version 1, allows households to indicatethat they permit school food service personnel to giveall information contained on the free and reducedprice meal application to Medicaid and CHIP officials.This would include child’s name, names of all house-hold members, all income information or a programcase number (food stamp, Temporary Assistance forNeedy Families, Food Distribution Program on IndianReservations) address, social security number of theadult household member. A photocopy of the appli-cation provided to Medicaid/CHIP officials would alsobe permitted under this option. If the adult’s socialsecurity number is disclosed, the privacy act statementmust be changed to advise parents of this and theintended uses of the number.

V E R S I O N 4

This prototype form may be distributed separatelyfrom the free and reduced price application.However, the form may be attached to the free andreduced price meal application and sent out at thesame time or distributed separately from the free andreduced price application and at a different time.Version 4, like Version 2, allows households to indi-cate that they permit school food service personnel togive only their name and address, and an indicationthat the household had applied for free and reducedprice meals, to Medicaid and CHIP officials.

32

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

33

Appendices A,B,C

34

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

35

Appendices A,B,C

36

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

37

Appendices A,B,C

38

APPENDIX CWASHINGTON STATE’S FREE AND REDUCED-PRICE MEALS PILOTPROGRAM APPLICATIONS

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

39

Appendices A,B,C

40

Introduction







Appendices D,E,F

Appendices G,H,I

Executive Summary

41

Appendices A,B,C

42

APPENDIX DPrepared by the Center on Budget and Policy Priorities, July 1, 2000

(Percent of Federal Poverty Level; FPL)

STATE Medicaid Medicaid Medicaid Medicaid SeparateInfants (0-1)1 Children (1-5)1 Children (6-16)2 Children (17-19)2/7 State Program3

Alabama 133 133 100 100 200

Alaska 200 200 200 200

Arizona 140 133 100 29 200

Arkansas4/5/6 200 200 200 200

California 200 133 100 100 250

Colorado6 133 133 100 36 185

Connecticut 185 185 185 185 300

Delaware 185 133 100 100 200

D.C. 200 200 200 200

Florida8 200 133 100 100 200

Georgia 185 133 100 100 235

Hawaii 200 200 200 200

Idaho 150 150 150 150

Illinois10 200 133 133 133 185

Indiana 150 150 150 150 200

Iowa6 200 133 133 133 200

Kansas 150 133 100 100 200

Kentucky 185 150 150 150 200

Louisiana 150 150 150 150

Maine 200 150 150 150 200

Maryland 200 200 200 200

Massachusetts9 200 150 150 150 400

Michigan 185 150 150 150 200

Minnesota5 280 275 275 275

Mississippi 185 133 100 100 200

Missouri5 300 300 300 300

Montana6 133 133 100 40 150

Nebraska 185 185 185 185

Nevada6 133 133 100 70 200

New Hampshire 300 185 185 185 300

APPENDIX D: STATE INCOME ELIGIBILITY GUIDELINES FOR CHILDREN’SMEDICAID AND SEPARATE CHILD HEALTH INSURANCE PROGRAMS

Introduction







Appendices G,H,I

Executive Summary

New Jersey 185 133 133 133 350

New Mexico 235 235 235 235

New York 185 133 100 100 250

North Carolina 185 133 100 100 200

North Dakota6 133 133 100 100 140

Ohio 200 200 200 200

Oklahoma 185 185 185 185

Oregon6 133 133 100 100 170

Pennsylvania 185 133 100 36 235

Rhode Island5 250 250 250 250

South Carolina 185 150 150 150

South Dakota 140 140 140 140

Tennessee5 400 400 400 400

Texas6 185 133 100 100 200

Utah6 133 133 100 100 200

Vermont5 300 300 300 300

Virginia 133 133 100 100 185

Washington 200 200 200 200 250

West Virginia 150 150 100 100 150

Wisconsin5 185 185 185 185

Wyoming6 133 133 100 50 133

1. To be eligible in the infant category, a child is under age 1 and has not yet reached his or her first birthday. To be eligible in the 1-5 catego-ry, the child is age 1 or older, but has not yet reached his or her sixth birthday. Minnesota covers children under age 2 in the infant category.

2. As required by federal law, states provide Medicaid to children age six or older who were born after September 30, 1983 and who havefamily incomes below 100 percent of the FPL. By October 1, 2002 all poor children under age 19 will be covered. If the state covers children inthis age group who have family incomes higher than 100 percent of the FPL, or the state covers children born before September 30, 1983,thereby accelerating the phase-in period, it is noted in this column. States that have taken such steps have done so either through Medicaidwaivers or the 1902(r)(2) provision of the Social Security Act.

3. The states listed use federal child health block grant funds to operate separate child health insurance programs for children not eligible forMedicaid. Such programs may provide benefits similar to Medicaid or they may provide a limited benefit package. They may also impose pre-miums or other cost-sharing obligations on some or all families with eligible children.

4. Children covered under Medicaid expansion programs in Arkansas receive a reduced benefits package pursuant to federal waivers.

5. The Medicaid programs in AR, MN, MO, RI, TN, VT and WI may impose some cost sharing — premiums and/or co-payments for some chil-dren pursuant to federal waivers.

Appendices A,B,C

43

Appendices D,E,F

6. The states noted count assets in addition to income in determining Medicaid eligibility for children; Utah does not consider assets foryoung children. An assets test is not imposed on children covered under the Medicaid expansion program in Arkansas. Oregon countsassets in addition to income in determining eligibility for Medicaid and their separate child health insurance programs.

7. To be eligible in this category, a child was born before September 30, 1983 and has not yet reached his or her 19th birthday. States arerequired to provide Medicaid coverage to these children if their families would have qualified for AFDC under rules in effect in their state inJuly 1996. These standards typically require families to meet three income tests. First, they must have net income below the state’s “standardof need,” a measure of the amount of income determined by the state to be essential for a minimum standard of living. Second, they musthave net income below the state’s “payment standard,” the maximum amount of assistance the state would grant a family with no income. Inmost states, the payment standard falls below the need standard. Finally, the family must pass a gross income test which requires that grossincome (net of up to $50 in child support payments, EITC payments, and optional exclusions of a dependent child’s income) fall below 185 per-cent of the state’s standard of need.

8. Florida operates two separate CHIP-funded state programs. Healthy Kids is available in most counties and covers children age 5 through19, as well as younger siblings of enrolled children in some areas. Medi-Kids covers children age 0 through 4 and is available statewide.

9. Children between ages 1 and 19 in families with income between 150 and 200 percent of the FPL will receive either slightly reducedMassHealth benefits or assistance paying premiums for employer-based plans.

10. Illinois covers infants in families with income at or below 200 percent of the FPL who are born to mothers enrolled in Medicaid. Illinoiscovers other infants in families with income at or below 133 percent of the FPL.

Researched and prepared by the Center on Budget and Policy Priorities, July 1, 2000.

44

Income/Eligibility Standards

IncomeDeductions,Disregards & Exclusions

AllowableResources/Assets

Medicaid for Children1

Medical Assistance Units (MAU) with netincomes up to 200% of the Federal PovertyLevel (FPL) are eligible.

Recipients must cooperate with the state inpursuing third party liability unless good causeprohibits pursuit.

Deductions are allowed as follows:• $90 per month for each working household

member• monthly work-related child care expenses• monthly court-ordered child support payments

Excluded from income: public cash assistance,the Earned Income Tax Credit (EITC), FoodStamps, energy assistance payments, someeducational loans, Supplemental SecurityIncome (SSI), the Special SupplementalNutrition Program for Women, Infants andChildren (WIC) and some other federal benefits.

No assets test is required.

Food Stamp Program

Households up to 130% of the FPL gross incomeand 100% of the FPL net income are eligible.Households with an elderly person or person withcertain disability payments must only meet thenet income test.

SSI and Temporary Assistance to NeedyFamilies (TANF) recipients are automatically eli-gible, regardless of resources, as well as thosereceiving state family assistance and certainstate general assistance.

Deductions are as follows:• 20% standard deduction from earned income• $134 standard deduction for all households• dependent care when needed for work, train-ing, education: up to $200 for each child under2 and $175 for each other child or disabledadult, per month• medical expenses for elderly and disabledabove $35 per month, if not covered by insur-ance or other sources• legally owed child support payments• excess shelter costs (more than half ofhousehold income after other deductions, up to$275 in households with no elderly or disabledmembers), including fuel, electricity, water, onetelephone, rent or mortgage and property taxes

Allows up to $2,000 in countable resources(bank account, cash, stocks/bonds, some carsand trucks), or up to $3,000 if one householdmember is age 60+.

Not counted as resources: a home and lot,one vehicle valued up to $4,650, and licensedvehicles used for the following purposes: ahome, long distance travel for work (other thandaily commute), transporting physically dis-abled household member, carrying household’sfuel or water, or over 50% used for income pro-ducing purposes.

APPENDIX EAPPENDIX E: WASHINGTON STATE’S MEDICAID & FOOD STAMPPROGRAM ELIGIBILITY GUIDELINES (SEPTEMBER 2000)

Introduction







Appendices A,B,C

Appendices G,H,I

Executive Summary

Appendices D,E,F

45

Unit forDeterminingIncomeEligibility

Eligible Ages

DocumentationRequirements

VerificationRules(re. Income and Resources)

CitizenshipLimitations

Redetermin-ation Periods

Medicaid for Children1

MAUs are defined as married persons living togeth-er, or parents and unmarried minor children.Separate MAUs are established for other groupingssuch as a child of unmarried parents when both par-ents live with the child, children with income, etc.

0 through 19 (and up to 21 for some cases)

Declaration of:• age, identity, and residency• income and deductions

social security number (for applicant or beneficiary)

Proof of:• pregnancy• immigration status

Utilize Income and Eligibility Verification System(IEVS) and Statewide Alien Verification Eligibility(SAVE) to perform post-eligibility review.

Federal law allows only citizens and qualified alienswho entered the US before August 22, 1996 to beeligible for Medicaid, with some exceptions.Qualified aliens entering after that date become eli-gible after five years. State funds provide Medicaideligibility to legal immigrant children no matterwhen they entered the US.

Annually, beginning on the first day of the monththat the client becomes eligible.

Food Stamp Program

Households are defined as persons living togetherand purchasing and preparing food together.

Eligibility is determined by household, with all agesbeing eligible.

Interview is required and proof of:• immigration status of all household members• social security numbers of all household members• information on resources, income, and deductions• residency and identity• disability

Utilize IEVS and SAVE.

Federal law provides food stamp benefits for citizens,nationals, and specified qualified and non-qualifiedaliens. Washington uses state funds to provide bene-fits to legal immigrants who do not qualify for federalFood Stamp benefits.

Up to 12 months for elderly and/or disabled house-holds with no earned income.

Up to 3 months if the household is homeless, hasmigrants, non-exempt able-bodied Adult(s) withoutDependents, where expenses exceed income or arein a non-ADATSA drug and alcohol treatment center.

1 Since February 2000, Washington has operated a Children’s Health Insurance Program (CHIP) serving children between 200%and 250% of the FPL that treats income the same as under Medicaid.

46

APPENDIX FIntroduction







Appendices A,B,C

Appendices G,H,I

Executive Summary


IncomeDeductions,Disregards & Exclusions

AllowableResources/Assets

Medi-Cal for Children

Households with the followingincomes, by age, are eligible:• infants at or below 200% of the

Federal Poverty Level (FPL)• 1 through 5 at or below 133%

of the FPL• 6 through 19 at or below 100%

of the FPL

Recipients must cooperate withthe state in pursuing third partyliability unless good cause pro-hibits pursuit.

Deductions are allowed as follows:• $90 per month for each work-

ing household member• monthly child care expenses

(max. of $200/month for chil-dren under 2; $175/month forages 2 and older)

• monthly court-ordered alimonypayments

• monthly court-ordered childsupport payments

• $50 per month for receipt ofalimony and/or child support

Excluded from income:Supplemental SecurityIncome/State SupplementalPayment (SSI/SSP), CalWORKS(CA’s Temporary Assistance toNeedy Families program),General Relief (CA’s GeneralAssistance program), grants orscholarships for college, earn-ings of a child under age 14 orin school and some governmentbenefits payments.


Healthy Families

Households with the followingincomes, by age, are eligible:• infants, 201% to 250% of the FPL• 1 through 5, 134% to 250% of

the FPL• 6 through 18, 101% to 250% of

the FPL

Child cannot be Medi-Cal eligi-ble nor have had employer cov-erage in the last 90 days (withsome exceptions).

Deductions are allowed as follows:• $90 per month for each work-

ing household member• monthly child care expenses

(max. of $200/mo. for childrenunder 2; $175/mo for ages 2and older)

• monthly court-ordered alimonypayments

• monthly court-ordered childsupport payments

• $50 per month for receipt ofalimony and/or child support.

Excluded from income: SSI/SSP,CalWORKS, general relief,grants or scholarships for col-lege, earnings of a child underage 14 or in school and somegovernment benefits payments.


Food Stamp Program

Households up to 130% of theFPL gross income and 100% ofthe FPL net income are eligible.Households with an elderly per-son or person with certain dis-ability payments must only meetthe net income test.

CalWORKS recipients are auto-matically eligible, regardless ofresources. SSI recipients inCalifornia are not eligiblebecause the state includesextra money in the amount itadds to the federal SSI paymentinstead of issuing food stamps.

With some exceptions, able-bodied adults between 16 and60 must register for work, takepart in an employment and train-ing program and accept or con-tinue suitable employment.

Deductions are as follows:• 20% standard deduction from

earned income• $134 standard deduction for all

households• dependent care when needed

for work, training, education:up to $200 for each child under2 and $175 for each other childor disabled adult, per month

• medical expenses for elderlyand disabled above $35 permonth, if not covered by insur-ance or other sources

• legally owed child supportpayments

• excess shelter costs (morethan 1/2 of household incomeafter other deductions, up to$275 in households with noelderly or disabled members),including fuel, electricity,water, one telephone, rent ormortgage and property taxes

Allows up to $2,000 in countableresources (bank account, cash,stocks/bonds, some cars andtrucks), or up to $3,000 if onehousehold member is age 60+.

Appendices D,E,F

47

APPENDIX F: WASHINTON STATE’S MEDICAID & FOOD STAMP PROGRAM ELIGIBILITY GUIDELINES (SEPTEMBER 2000)

AllowableResources/Assets (cont.)

Unit forDeterminingIncomeEligibility

Eligible Ages

DocumentationRequirements

VerificationRules(re. Income and Resources)

CitizenshipLimitations

Redetermin-ation Periods

Medi-Cal for Children.

The Medi-Cal household budget unitis defined as related persons livingin the same home who have finan-cial responsibility for health care forthe applicant (spouse for spouse,parent for child). (Note: Medi-Calstarts with gross income; afterapplying certain income disregards,Medi-Cal ends up with "countable"income. Countable income is usedto determine eligibility.)

0 through 20 for Medically Needyand Medically Indigent Programs.

Social security number of appli-cant and proof of:• identity and CA residency• income and deductions• pregnancy• immigration status

Utilize Income and EligibilityVerification System (IEVS) andStatewide Alien VerificationEligibility (SAVE) to perform post-eligibility review.

Federal law allows only citizensand qualified aliens who enteredthe US before August 22, 1996 tobe eligible for Medicaid, withsome exemptions. Qualifiedaliens entering after that datebecome eligible after five years.State funds provide Medi-Cal eligibility to legal immigrant children no matter when theyentered the US.

Every 12 months. Recipientsrequired to report any change incircumstances that might affecteligibility.

Healthy Families

The household budget unit isdefined as related persons livingin the same home who havesome financial responsibility forhealth care for the applicant.Some exceptions are set out inlaw, including such situations aswhen responsible adults live sep-arately, etc.

0 through 18

Birth certificate and proof of:• income and deductions• immigration status

Utilize IEVS and SAVE to performpost-eligibility review.

Federal law allows only citizensand qualified aliens who enteredthe US before August 22, 1996 tobe eligible for Healthy Families,with some exemptions. Qualifiedaliens entering after that datebecome eligible after five years.State funds currently provideHealthy Families eligibility to legalimmigrant children no matterwhen they entered the US.

Every 12 months.

Food Stamp Program

Not counted as resources: ahome and lot, one vehicle valuedup to $4,650, and licensed vehi-cles used for the following pur-poses: a home, long distancetravel for work (other than dailycommute), transporting a physi-cally disabled household member,carrying household’s fuel orwater, or over 50% used forincome producing purposes.

Households are defined as per-sons living together and purchas-ing and preparing food together.

Eligibility is determined by house-hold, with all ages being eligible.

Interview is required and proof of:• immigration status of all house-

hold members• social security numbers of all

household members• information on resources,

income, and deductions• residency and identity• disability

Utilize IEVS and SAVE.

Federal law provides food stampbenefits for citizens, nationals,and specified qualified and non-qualified aliens. California usesstate funds to provide benefits tolegal immigrants who do notqualify for federal Food Stampbenefits.

Generally every 12 months fornon-elderly households.

48

Food StampProgram

Head Start

NationalSchool LunchProgram(NSLP)

SpecialSupplementalNutritionProgram for Women,Infants, andChildren (WIC)

TemporaryAssistance toNeedy Families(TANF)

The following is a review of confidentiality provisions for a sampling offederal public programs.

Use or disclosure of information obtained from Food Stamp applicants or recipient householdsis allowed for persons directly connected with other federal assistance programs and federally-assisted state programs providing assistance on a means-tested basis to low income individu-als, as well as with programs required to participate in the state income and eligibility verifica-tion system (IEVS) to the extent that Food Stamp information is useful in establishing or verifyingeligibility under those programs.Source: 7 CFR section 272.1(c); 7 USC section 2020(e)(8).

Head Start does not have national guidelines regarding confidentiality, except to require eachprogram to develop its own set of confidentiality guidelines. So, variation in confidentialityguidelines is immense and is dictated at the program level.Source: Rita Schwartz, DHHS, National Head Start Bureau, 202-205-8572.

Disclosure of names and eligibility information is permitted, at the option of each school district,to persons directly connected with the administration of state Medicaid or Children’s HealthInsurance Program (CHIP) programs for purposes of eligibility determination and enrollment.School food authorities are required to inform families that school lunch information will beshared for this limited purpose, as well as to provide families with the opportunity to elect not tohave the information disclosed. To take advantage of the new option, states must have a writ-ten agreement in place between school food authorities and state or local child health agenciesto assure that shared information actually facilitates enrollment.Source: Agricultural Risk Protection Act of 2000 (H.R. 2559), enacted June 20, 2000. Seealso, National School Lunch Act, Chapter 281, Sec. 9(b)(2)(c)(iii)-(iv); 7 CFR section245.8(a), (b); 42 USC section 1758(b)(4).

Use or disclosure of information obtained from applicants and participants is allowed to“[r]epresentatives of public organizations designated by the chief State health officer … whichadminister health or welfare programs that serve persons categorically eligible for the WIC pro-gram.” Information can be disclosed only after a written agreement is executed with the desig-nated organization, specifying that the information will be used only to establish eligibility for thehealth or welfare program that the organization administers and to conduct outreach for theprogram, and that information will not be disclosed to a third party.Source: 7 CFR section 246.26(d); 42 USC section 1786.

TANF regulations do not contain any confidentiality provisions. Under section 402(a)(1)(A)(iv) ofthe Social Security Act, the State’s TANF plan must address the reasonable steps the state willtake to restrict disclosure about individuals and families receiving TANF-funded assistance.Thus, TANF gives states discretion in deciding what disclosure is appropriate.

The regulations in effect under the prior Aid to Families with Dependent Children (AFDC) pro-gram specifically allowed sharing of AFDC information with Medicaid for Medicaid eligibilitydetermination purposes. TANF statute allows states flexibility to disclose TANF information on asimilar basis.Source: Ann Burek, DHHS, Office of Family Assistance, 202-401-4528. See also 45 CFR205.50 for prior AFDC rules.

APPENDIX GAPPENDIX G: FEDERAL PROGRAM CONFIDENTIALITY PROVISIONS

Introduction







Appendices A,B,C

Appendices D,E,F

Executive Summary

Appendices G,H,I

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Medicaid(for children)

Effectively, no upper limit isimposed for coverage of children throughage 18 if a stateelects to use more liberal income disregards.

Depends on eligi-bility category.States may utilizesection 1931 andsection 1902(r)(2)to establish lessrestrictive method-ologies than thoseof the former Aidto Families withDependentChildren (AFDC)program.

Children’sHealthInsuranceProgram(CHIP)

Effectively, noupper limit isimposed when astate elects to usemore liberalincome disregards.

At state discretionexcept for incomeprovided undercertain federalstatutes, whichmust be excludedunder the terms ofthe statutes.

Food StampProgram

Must meet monthlygross income test(130% of theFederal PovertyLevel; FPL) andmonthly netincome test (100% of the FPL),i.e., gross incomeminus allowabledeductions.

• $134 standarddeduction for allhouseholds;• 20% earnedincome deduction;• dependent carecosts when neces-sary for work,training, educa-tion, to maximumallowed;• legally owedchild support pay-ments;• medical costs forelderly and dis-abled;

Head Start

Up to 100% of theFPL (for at least90% of enrollees).

Not applicable.

National SchoolLunch Program(NSLP)

Free Meals: Grossincome up to 130%of the FPL.Reduced-PriceMeals: Grossincome between130% and 185% ofthe FPL.

Exclusions: stu-dent financial aid,loans, in-kind com-pensation, irregu-lar earnings, cashvalue of certainfederal benefitssuch as from theJob TrainingPartnership Act(JTPA), FoodStamps, Child CareDevelopmentBlock Grant(CDBG), and oth-ers; other incomeexcluded by legis-lation.

SpecialSupplementalNutrition Programfor Women,Infants andChildren (WIC)

Must meet guide-lines set by theNSLP for reduced-price school meals(i.e., up to 185% ofthe FPL).

Exclusions:numerous — e.g.,in-kind housingbenefits, studentfinancial aid, ener-gy assistance,Food Stamps,NSLP, CDBG,JTPA, and somesmaller programs.


At state discretion.


The following is designed to provide a comparison of the eligibility guidelines for a sampling of federal public programs. Medicaid guidelines are presented with reference to the most expansive policy allowable under federal law.


Income Deductions, Disregards, &Exclusions

Introduction







Appendices A,B,C

Appendices D,E,F

Executive Summary


Depends on eligibil-ity category. Stateshave the option toeliminate theassets test for low-income children.

Family: Childrenand specified rela-tives per formerAFDC program.



Family: At statediscretion.

Food StampProgram

• excess sheltercosts;• most educationalassistance;• many other spe-cific disregards.

• $2,000 (or $3,000if household has anelderly member);• one vehicle val-ued up to $4,650(with exceptions)and licensed vehi-cles used for spec-ified purposes;• home and lot;• resources arenot counted if thehouseholdreceives SSIand/or TemporaryAssistance toNeedy Families(TANF).

Household: Personsliving together andpurchasing andpreparing mealstogether.

Head Start

Not applicable.

Family: All per-sons living in thesame householdwho are:


Not applicable.

Households: Relatedand unrelated indi-viduals living as oneeconomic unit.


Not applicable.

Family: Group ofrelated and non-related personsliving together asone economic unit.



Family: Definitionis at state discre-tion, except that itmust, at a mini-mum, have a

Income Deductions, Disregards, &Exclusions (cont.)

Allowable Resources/Assets

Unit forDetermining Income Eligibility

AppendicesG,H,I

51

52


Income and assetsare counted forrelated persons living in the samehome who havefinancial responsi-bility for healthcare for the appli-cant (spouse forspouse, parent forchild.)

Under 21 years of age.

At state discretionexcept for immigra-tion status of non-citizens and socialsecurity number.Requires use ofcertain automatedsystems to checkincome. On allother matters,self-verification is allowed.


Under 19 years of age.

At state discretionexcept for verifica-tion of immigrationstatus.

Food StampProgram

All ages.

• proof of income,resources, anddeductions;• social securitynumbers for allhousehold members;• proof of residency;• proof of identity;• proof of disability;• proof of immigration status for all house-hold members;

Head Start

1) supported bythe income of theparent(s) orguardian(s) of thechild enrolling orparticipating in theprogram; and 2) related to theparent(s) orguardian(s) byblood, marriage, oradoption.

Ages 3 to 5 andsome infants ortoddlers with dis-abilities.

Proof of incomeand age.


Students in highschool grade orunder; residents ofresidential childcare facility up toage 21.

No verification isrequired at time ofapplication.However, a samplepopulation ofenrollees areapproached byDecember 15 ofeach year andasked for verifica-tion.


Pregnant, postpar-tum, and breast-feeding women;infants and chil-dren to age 5.

• proof of residency;• proof of incomefor all members offamily/economicunit (or, documen-tation of currenteligibility in one ofthe three allow-able adjunct pro-grams or otherallowable means-tested programs);


minor child resid-ing with parent orother caretakerrelative or a preg-nant individual.

Under age 18 orunder age 19 whenfull-time student insecondary schoolor equivalentvocational training.


Unit forDetermining Income Eligibility (cont.)

Eligible Ages

Documentation Requirements

Introduction







Appendices A,B,C

Appendices D,E,F

Executive Summary


States must have anIncome and EligibilityVerification System(IEVS) in place toperform post-eligi-bility verification.

States must covercitizens and cer-tain mandatoryqualified aliens.At state discretionwhether to covernon-manda toryqualified alienswho entered theUS before 8/22/96.Non-mandatoryqualified aliensentering after thatdate can be eligi-ble after five yearsof continuous resi-dence, but only atstate discretion.



States must covercitizens and quali-fied aliens, includ-ing legal immi-grants whoentered the USbefore August 22,1996, and thosearriving on or afterthat date whohave been in con-tinuous residencefor five years.

Food StampProgram

• verification ofquestionable infor-mation;• interview isrequired.

Optional for statesto use IEVS forverification.

States must covercitizens, non-citi-zen nationals, cer-tain qualifiedaliens and speci-fied non-qualifiedaliens. Eligibilityfor many cate-gories of qualifiedalien has a 7-yeartime limit.Immigrants lawful-ly admitted forpermanent resi-dence can gaineligibility with 40qualifying quartersof work.

Head Start

Not applicable.

Not applicable.



Not applicable.


• proof of identity;• self-declaration of income is notallowed as ofOctober 1, 1998,except for homeless,migrant workers, andcash employees.


The state agencyhas the option toprohibit WIC serv-ices for personsother than citizensor qualified aliens.


States must verifyinformation provid-ed by the appli-cant through theIEVS system.

States must covercitizens and cer-tain mandatoryqualified aliens.At state discretionwhether to covernon-mandatoryqualified alienswho entered theUS before 8/22/96.Non-mandatoryqualified aliensentering after thatdate can be eligi-ble after five yearsof continuous resi-dence, but only atstate discretion.

Documentation Requirements(cont.)

Verification Rules(re. Income andResources)

Citizenship Limitations

Appendices G,H,I

53


Emergency-relatedservices must beavailable to allpersons.

Whenever recipi-ent’s circum-stances change,unless a statechooses to pro-vide one year ofcontinuous eligibil-ity. At least every12 months.

Those receivingSupplementalSecurity Income(SSI), in moststates, and recipi-ents of adoptionassistance andfoster care underTitle IV-E of theSocial SecurityAct are automati-cally eligible.


At state discretion,but at least onceevery 12 months.

Not Applicable.

Food StampProgram

May be up to 12months or up to 24 months if alladults are elderlyor disabled.

Those receivingSSI (except inCalifornia) orTANF, as well asGeneralAssistance (GA) insome cases, areautomaticallyincome eligible.

Head Start

• every 2 years forpre-school; • every 3 years forearly Head Start.

• foster children;• participants incertain aspects ofthe TANF program(e.g., childcare,etc.).


Annually, at thebeginning of theschool year.

• Those who arereceiving FoodStamps, FoodDistributionProgram on IndianReservations(FDPIR) or TANF, inmost states, or areenrolled in HeadStart are automati-cally/categoricallyeligible for freemeals.

• Direct certifica-tion is allowed forFood Stamps,FDPIR, and TANF.


Approximatelyevery 6 months.However, statesmay permit locali-ties to shorten orlengthen the peri-od in some cir-cumstances.

Those individualswho are certifiedeligible for TANF,Food Stamps,Medicaid or otherselect means-test-ed programs areadjunctively orautomaticallyincome eligible.They must also bedetermined to benutritionally at-riskand meet residen-cy requirements tobe enrolled.


• At state discretion.Recipients mustwork after 2 yearsof TANF, with fewexceptions.• Five year cumula-tive limit for TANFassistance (for80% of caseload).

Not applicable.

Citizenship Limitations (cont.)

Redetermination Periods

Adjunct,Categorical orAutomaticEligibility

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APPENDIX ISAMPLE STATE LEGISLATION

The following language was introduced in theCalifornia Legislature by The 100% Campaign (acollaborative of Children Now, Children’s DefenseFund and The Children’s Partnership). Its pur-pose was to implement Express Lane Eligibility uti-lizing the National School Lunch Program, FoodStamps and the Special Supplemental NutritionProgram for Women, Infants and Children (WIC).It is offered as sample legislation for a state wish-ing to develop an Express Lane Eligibility model.For information on progress on Express LaneEligibility in California, see www.100percentcampaign.org/express.html.

SENATE BILL NO. 1821

Introduced by Senators Sher, Bowen, Escutia,Figueroa, Murray, Soto, and Speier (Coauthor:Assembly Members Alquist, Aroner, Cardenas,Davis, Keeley, Knox, Kuehl, Longville, Mazzoni,Romero, Strom-Martin, and Villaraigosa)

February 24, 2000

An act to add Section 10618.5 to the Welfare andInstitutions Code, relating to health.

The people of the State of California do enact as follows:

SECTION 1. (a) The Legislature finds anddeclares all of the following:

(1) Approximately 1.48 million of California’s over2 million uninsured children are eligible for eitherthe Medi-Cal program or the Healthy FamiliesProgram.

(2) Lack of insurance coverage for children resultsin reduced access to medical services, resulting inrestricted access to primary and preventive careand increased reliance on emergency rooms andhospitals for treatment.

(3) Almost 50 percent of uninsured children whoare eligible for the Medi-Cal program or theHealthy Families Program are already enrolled inthe California Special Supplemental FoodProgram for Women, Infants, and Children, thefederal school lunch programs, or the Food StampProgram. Not only have these families been certi-fied as income-eligible for these programs, theyhave provided extensive information to enroll inthe programs.

(b) It is the intent of the Legislature, therefore, tomake the Medi-Cal program and Healthy FamiliesProgram enrollment process more user-friendlyand efficient for children currently enrolled inprograms with income eligibility guidelines similarto the Medi-Cal program and the Healthy FamiliesProgram, and thus make the process more accessi-ble for those in need of care.

SEC. 2. Section 10618.5 is added to the Welfareand Institutions Code, to read:

10618.5. (a) Any child who is enrolled in any ofthe following programs shall be deemed to havemet income eligibility requirements for participa-tion in the Healthy Families Program and theMedi-Cal program:

(1) The Food Stamp Program, provided for pur-suant to Chapter 10 (commencing with Section18900) of Part 6 of Division 9 of the Welfare andInstitutions Code.

(2) The California Special Supplemental FoodProgram for Women, Infants, and Children, pro-vided for pursuant to Article 2 (commencing withSection 123275) of Chapter 1 of Part 2 of Division106 of the Health and Safety Code.

(3) The federal school lunch programs, providedfor pursuant to Chapter 13 (commencing withSection 1751) of Title 42 of the United States Code.

Introduction







Appendices A,B,C

Appendices D,E,F

Executive Summary

55

Appendices G,H,I

(b) Agencies administering programs specified insubdivision (a), the State Department of HealthServices, and the Managed Risk Medical InsuranceBoard shall implement streamlined processes forestablishing eligibility of a child enrolled in orapplying for participation in programs specified insubdivision (a) for the Medi-Cal program or theHealthy Families Program, and shall not requirean applicant on behalf of the child to provide anyunnecessary or duplicative information. The StateDepartment of Health Services shall be the leadagency in charge of this effort.

(c) Agencies administering the programs specifiedin subdivision (a) shall fully cooperate in distribut-ing information and providing enrollment infor-mation to the State Department of Health Servicesand the Managed Risk Medical Insurance Board ortheir designees to the maximum extent permittedby federal and state law. The information shall beused by the State Department of Health Servicesand the Managed Risk Medical Insurance Board ortheir designees for the sole purpose of determininga child’s eligibility for benefits under the Medi-Calprogram or the Healthy Families Program.

(d) With the exception of documentation of immi-gration status of noncitizen children, an applicanton behalf of a child specified in subdivision (a) shallnot be required to provide any documentation.

(e) Agencies administering the programs specifiedin subdivision (a), the State Department of HealthServices, and the Managed Risk Medical InsuranceBoard shall implement subdivisions (a), (b), and(c) by July 1, 2001.

(f) The State Department of Health Services shallassess what other public programs may be imple-mented in the manner specified in subdivisions(a), (b), and (c), shall develop a plan for thatimplementation, and shall submit the plan to theappropriate committees of the Legislature byMarch 1, 2002.

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The Kaiser Commission onMedicaid and the Uninsuredwww.kff.org

1450 G Street, NW, Suite 250Washington, DC 20005202-347-5270202-347-5274 fax

The Children's Partnershipwww.childrenspartnership.org

1351 3rd Street Promenade, Suite 206Santa Monica, CA 90401-1321310-260-1220310-260-1921 [email protected]

Documents

Putting Express Lane Eligibility into Practice · 2019-02-08 · A Briefing Book and Guide for Enrolling Uninsured Children Who Receive Other Public Benefits into Medicaid and CHIP