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State Policy and SystemsState Policy and Systems

Working Poor Families Project Policy AcademyWorking Poor Families Project Policy Academy

June 30, 2011

Elizabeth Lower-BaschElizabeth Lower-BaschSenior Policy AnalystSenior Policy Analyst

Stacy DeanStacy DeanVice President forVice President for Food Assistance PolicyFood Assistance Policy

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Image thanks to Shelley Waters Boots

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Eligibility Threshold

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• States choose whether to provide state EITCs• States have full control over eligibility rules in

TANF, child care subsidies• Health care programs have required minimum

levels of coverage, but many state options for additional coverage

• States have more flexibility than generally acknowledged under SNAP

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Range from 3.5 % of federal credit (Louisiana) to 40% (Washington, DC)

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• TANF benefit cuts approved in California, District of Columbia, New Mexico, South Carolina, Washington. Other cuts, such as shorter time limits, are also in play.

• State EITCs under threat, especially in Michigan and New Jersey

• Large UI cuts under consideration• Medicaid/CHIP eligibility protected by “MOE” requirement, but not

reimbursement rates, benefit package

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AK

AL

ARAZ

CA CO

CT

DCDE

FL

GAHI

IA

ID

IL IN

KSKY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PA

RI

SC

SD

TN

TX

UT

VA

VT

W A

W I

W V

W Y

N o Food S tam p Asset Test (34)*

R aised asset lim it (1)

P lan to Im plem ent (3)

N o Food S tam p AssetTest for M ost (3)

U ses federa l asset test (10)*V irg in Is lands and G uam have a lso e lim inated the asset test.

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AK

AL

ARAZ

C A C O

C T

D CD E

FL

G AH I

IA

ID

IL IN

KS KY

LA

M A

M D

M E

M IM N

M O

M S

M T

N C

N D

N E

N H

N J

N M

N V

N Y

O H

O K

O R

PA

R I

SC

SD

TN

TX

U T

VA

VT

W A

W I

W V

W Y

G ross Incom e Lim it is 200% of Poverty G uidelines (12)

G ross Incom e L im it is Betw een 130% and 200% (12)

Categorical Eligibility: Gross Income Limit

U pdated 4 M ar 2011

G ross Incom e L im it is 200% of Poverty G uidelines for C erta in H ouseholds (1)

DC

Note: Information based on state agency reports to CBPP.

G ross Incom e L im it is Betw een 130% and 200% for m ost (2)

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• Outreach and application assistance

1.Passive enrollment

2.Removing barriers to enrollment

3.Simplifying rules to streamline documentation

4.Longer recertification periods

5.Smarter recertification processes

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• Direct certification under National School Lunch Program Children in families receiving SNAP, TANF, or Food

Distribution Program on Indian Reservations (FDPIR) automatically eligible for free lunch.

Under Healthy, Hunger-Free Kids Act of 2010, states must directly match with SNAP data – not enough to send families letter to bring in.

• Express Lane Eligibility for CHIP

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• Allows use of findings from other public benefit programs to determine eligibility for Medicaid and CHIP

• Screen and enroll options• Can’t find a child ineligible• Must notify if child would qualify for less

costly coverage under standard method

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• Income, immigration status, state residence, household composition

• Income can be used even if not defined exactly the same as under CHIP

• Not U.S. citizenship

• Findings “within a reasonable period of time” can be used (state defines)

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• State-initiated enrollment without a formal application

• Family must give consent in writing, orally, electronic signature or other means

• State must inform family of services, premiums, other obligations

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• Allowing telephone or internet-based interviews instead of requiring face-to-face interviews.

• Dropping fingerprinting requirements

• Using SSA match for citizen documentation instead of requiring birth certificates or passports

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• Deficit Reduction Act of 2005 — U.S. citizens applying for Medicaid must present proof of citizenship and identity

• Some groups exempt; Children, parents and pregnant women most affected

• States have found substantial declines in enrollment

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Monthly Enrollment in Medicaid for Children

SOURCE: Presentation by Linda Nablo, Virginia Department of Medical Assistance Services, April 26, 2007

CitizenshipDocumentation is Required

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A L

A ZA R

C A C O

C T

D ED C

F L

G A

I D

I L I N

I A

K SK Y

L A

M E

M D

M AM I

M N

M S

M O

M T

N E

N V

N H

N J

N M

N Y

N C

N D

O H

O K

O R

P A

R I

S C

S D

T N

T X

U T

V T

V AW V

W I

W Y

H I

W A

A K

H a s N o t I m p l e m e n t e d ( 2 3 s t a t e s )

U s i n g M a t c h ( 1 9 s t a t e s )

T e s t i n g t h e O p t i o n ( 9 s t a t e s )

D C

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• Few TANF families have countable assets – but all applicants must be asked about them 5 states have dropped TANF asset limits

• Standard Utility Allowance (SUA) Increases benefit, but also reduces documentation Any LIHEAP benefit qualifies recipient for SUA

• Illinois waiver to use standard medical deduction

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• Only applies to households with a member age 60 or older, or disabled

• Must verify $36 a month of allowable medical expenses

• Standard medical deduction of $245 a month, $485 a month for residents in group homes

• Can use actual medical expenses if higher

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• Every time you make people recertify eligibility, some people fail to complete process

• Large share of those who fail to recertify are still eligible for benefits. Many will reapply within a short time period.

• Churning has large cost in time and effort to both recipients and state agencies

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Churning of subsidies reduces continuity of care for children

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• Coordinate renewals across benefit programs• When clients provide updated information,

states can use it to recertify for multiple programs.

• Ex-parte renewals — using available information to renew health benefits.

Ex. LA first looks at the SNAP case to renew children’s Medicaid before contacting the family.

• Express Lane Eligibility can be used for renewal as well as initial application

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Ford Foundation effort, led by the Urban Institute to improve participation amongst eligible families in a package of work supports: SNAP, health and child care.

http://www.urban.org/worksupport/

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• Bringing Eligible Families to the “front door”

• Limiting in-person requirements

• Reducing documentation requirements

• Improving reporting rules

• Simplifying renewals/improving retention

• Business Process Reengineering

• Using data to provide feedback loop

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• Multi-program screeners• Prompts to clients and workers• Outreach to 1-program clients• One program as a gateway to another – “no wrong door”• Unless consumers opt-out, they are routed to other appropriate

benefit programs• Using renewals as a chance to leverage other benefits• E-application “smart” forms that limit questions, based on earlier

answers• One agency’s findings establish eligibility for other programs

Note: Health Care Reform may change how many clients interact with the state for Medicaid.

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• Many states offer “same day” service for in-person or phone applicants. WA, ID, and UT 4/5 applicants receive benefits on the

same day NM 80% are processed within 24 hours. AZ 65% of applicants in pilot offices can be processed in

a single visit (down from 3 to 5 visits). OK local offices offered same day service for SNAP, MA

and child care

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Should experienced staff be up front or in the back room? Who can resolve an issue? How long does an interview need to be? Where does it

need to take place? Do we require unnecessary verification?

oCan I make a decision today based on what I know?oDid the client already provide the information to

another program? How many of the steps clients must complete did we

create?

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80% of apps are dropped off in-person

80% of apps are dropped off in-person

Takes 12 steps and 2 weeks to get an appointment, or clients walk out in 2 hours

with a full package

Takes 12 steps and 2 weeks to get an appointment, or clients walk out in 2 hours

with a full package

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• Support adoption of specific high impact policies, such as Express Lane Eligibility

• Encourage inclusion of participant and advocate voices in systems redesign

• Advocate for and monitor performance goals Reduced coverage gap Same day service Reduced churning

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• Estimated to expand coverage to 32 million uninsured Americans by 2019

• Individual mandates

• Two buckets of coverage:o Medicaid (and CHIP)o The “exchanges”

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• Beginning January 1, 2014, states must expand Medicaid to all non-elderly adults and children up to 133% of the federal poverty level ($14,403 for an individual, or $33,729 for a family of

four in 2010)

• The Medicaid expansion could reduce the rate of uninsured adults with income <133% FPL by 69.5% (Kaiser/Urban, May 2010).

• CHIP continues at 2009 eligibility levels (at least for a while)

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235%

185%

75% 64%38%

0%

Children Pregnant Women

Elderly and Individuals with

Disabilities

Working Parents

Non-Working Parents

Childless Adults

SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission on Medicaid and the Uninsured, 2009.

Medicaid Eligibility underHealth Reform = 133%FPL

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Assistance for those who are not eligible for Medicaid and cannot afford coverage in the exchange

Starting in 2014, individuals and families earning up to 400% FPL ($88,200 for a family of four in 2010), will get help paying their health insurance premiums in the form of tax credits

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• Modified Adjusted Gross Income (MAGI)

• No disregards other than 5%

• Eliminates assets tests

• Based on information already available to the state, e.g. previous year’s tax returns

• Can apply based on more recent info if circumstances have changed

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• Single application form for Medicaid, CHIP, and subsidies in the exchange

• Can file on-line, by mail, in person, by phone

• Medicaid, CHIP, exchanges work together behind the scenes to determine eligibility seamlessly

• Presumptive eligibility option

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• Vast majority of states will have to develop new IT systems in order to support new rules

• HHS is providing 90% federal funding for Medicaid eligibility IT infrastructure development through 2015

• Opportunity to build framework for modernized eligibility systems across programs “Interoperability” HHS Eligibility and Enrollment Workgroup

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§1561. HIT Enrollment, Standards and Protocols. Not later than 180 days after the enactment, the Secretary, in consultation with the HIT Policy and Standards Committees, shall develop interoperable and secure standards and protocols that facilitate enrollment in Federal and State health and human services programs through methods that include providing individuals and authorized 3rd parties notification of eligibility and verification of eligibility.

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• 2014 is coming fast• Some states are still resisting ACA• “Horizontal and vertical integration”• “Woodwork” concern

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• If states don’t build in capacity to expand to other programs, will be harder to add it later. 90% federal funding only available for limited time

• If advocates don’t insist that human service programs are included in the planning process, it probably won’t happen

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