This section provides a fairly in-depth, site-by-site description of the integrated TANF/FSP/Medicaid application process and then highlights how Medicaid/SCHIP or food stamp only application processes differ from the integrated application process. (As noted earlier, families applying for TANF typically are also simultaneously applying for food stamps and medical assistance.)
Exhibit 3-5 outlines the steps involved in the application process for families applying for TANF/FSP/Medicaid benefits in each of our sites as they were as of June – December 2001. In Exhibit 3-5, steps specific to the TANF/FSP/Medicaid process that are not required for individuals applying only for food stamps and/or Medicaid/SCHIP are shaded. As Exhibit 3-5 shows, the Medicaid, and particularly the SCHIP, application processes are often more streamlined. In addition, there tend to be multiple ways to access and apply for these programs (e.g., through health clinics and CBOs).
Sample TANF and Food Stamp-Only Application Process by Office*
Among our study sites, the two offices visited in Seattle have the simplest TANF/FSP/Medicaid application process — it is made up of three basic steps (reception, eligibility interview, and eligibility determination) and there are no additional up-front requirements. The other sites have additional steps that either facilitate the application process or stress the work first nature of the TANF program.
Of all our sites, New York has the most complicated and lengthy process for TANF applicants, requiring applicants to attend two eligibility interviews in two different locations, receive a home visit, and participate in up-front work activities. Finger imaging is completed during the first eligibility interview. However, depending on the Job Center, photographing the applicant may require an additional visit to a separate office.
The steps involved in applying for benefits may take more or less time for applicants depending on what procedures they must follow and the order in which they must be completed. In some cases, there may be several steps but they all occur within one location and within a single day. For example, in Raleigh, Sedalia, and the Seattle/Kent office, applicants typically complete their in-person eligibility interview on the same day that they submit an application. In other locations (Arlington, Dallas, New York, and Seattle/Rainier office), the eligibility interview is scheduled to take place at a later date — often but not always within the same week.
In Dallas, for example, applicants are scheduled for an eligibility interview within two to three weeks of submitting an application.14 TANF applicants in New York must complete interviews in at least two different offices and over a period of several days or longer, before their application process is considered complete. They must also participate in job search activities over the entire time that their application is pending.
In all locations, regardless of the number of formal steps in the process, there are additional efforts associated with providing required documentation for eligibility determination purposes. Often, these documents can be sent by mail or dropped off with the receptionist. At times, complying with verification procedures can involve trips to banks, former employers, and the department of motor vehicles. Both workers and focus group participants noted that, despite the additional effort required, applicants often prefer to go to the office to drop off their documentation and obtain a receipt from their eligibility worker, thereby ensuring that the documentation is received but also adding an additional step in the process.
While the diagrams in Exhibit 3-5 appear very linear, applicants often view the steps they must follow as confusing and complicated. This is because the steps often do not occur in the exact sequence shown in the diagrams (e.g., appointments get rescheduled for various reasons). For example, there may be variations within offices when an applicant has limited English proficiency and requires language assistance. Variations due to applicants’ language needs or citizenship status are noted within the site-specific discussions that follow.
TANF/FSP/Medicaid. As of July 2001, the application process in the Seattle/Kent office was the most straightforward of all the study sites. In a single day, English proficient applicants could submit an application for benefits and complete an eligibility interview.15 The same day eligibility appointment was not an option for limited English speakers requiring interpretation assistance because scheduling the off-site interpreters contracted for this purpose requires a few days’ advance notice. Subsequent to our visit, the Seattle/Kent office has shifted to scheduling eligibility interviews on the day following application submission and adopted an enhanced intake process similar to the one used in the Seattle/Rainier office (described below).
The Seattle/Rainier office offers an enhanced screening at initial reception/intake, designed to increase administrative efficiency and decrease client burden. Experienced eligibility workers are assigned to provide screenings and customer assistance. These “information referral specialists” work alongside receptionist/intake clerks at the front desk. They handle many tasks normally requiring the attention of an eligibility worker but that can be dispensed with quickly and do not actually require a formal appointment or a full eligibility interview. For example, the information referral specialists handle all Medicaid applications for pregnant women and screen applications for expedited food stamps. They also answer questions, inform applicants about additional programs they might be eligible for, and handle a variety of smaller issues such as documenting changes of address. Additionally, the information referral specialists provide applicants with necessary application paperwork, schedule eligibility interviews, and inform applicants about the documents they should bring to the eligibility interview. Since the July 2001 site visit, the Seattle/Kent office added a similar enhanced intake component to their application process.
Both offices visited in Seattle further streamlined the TANF/FSP/Medicaid application process by the absence of a separate group orientation.(16) The same types of information about TANF work program rules, participation requirements, sanctions and the availability of support services provided in the larger group orientations in other sites (e.g., Arlington, Dallas, and Raleigh), as well as an initial assessment of work history and employment barriers, are covered one-on-one during the eligibility determination interview.
Medicaid/SCHIP. The state of Washington has a single integrated application process for both Medicaid and SCHIP. Individuals may apply on-line and submit applications directly to the Department of Social and Health Services. Completed applications may also be mailed to the centralized Medical Eligibility Determination Services office that serves the entire state or dropped off in person at the local welfare office. A toll-free number within the state is available to assist with filling out the application or to answer questions. If determined eligible for Medicaid, applicants are required to enroll in a managed care plan. If applicants’ income is too high, their applications are then screened for SCHIP eligibility. If the income falls within the SCHIP range, applicants are sent a letter stating that they are not eligible for Medicaid but may be eligible for SCHIP. A form requesting information about private medical insurance, and information about the monthly premium and co-pays accompanies the letter. Applicants must complete and sign this form and return it to the centralized Medical Eligibility Determination Services office. Medicaid and SCHIP application assistance is available in public health centers and community health centers throughout the Seattle area.
TANF/FSP/Medicaid. The application process in Arlington is somewhat more complicated than Seattle in that it includes two additional steps — a screening and an orientation. Both steps occur prior to the eligibility interview and are intended to facilitate the application process. Applicant screenings are typically conducted the same day that the applicant initially comes to the welfare office and makes contact with an intake/reception worker (see box, “Pre-Eligibility Determination Screening in Arlington”). After the screening, applicants receive an appointment for an orientation and eligibility interview that they attend on the same day. The appointment letter states when and where the orientation session and interview will be held and what documents to bring for verification. During the orientation, case aides help applicants review, complete, and sign the application and other necessary forms. This group orientation includes a review of TANF eligibility rules and expectations.
Pre-Eligibility Determination Screening in Arlington
In Arlington, screenings are conducted for TANF/FSP/Medicaid (as well as food stamp-only or Medicaid-only) after the applicant makes initial contact with the reception/intake clerk — usually on the same day. The county welfare agency implemented screenings to increase the speed and efficiency of the eligibility determination process by ensuring that clients understand what they may apply for, how they should complete the application, and which documents are needed for the eligibility interview. Although these screenings constitute an additional step in the application process, they appear to help offset some of the difficulty applicants would normally encounter with the state’s relatively long and complicated integrated application (available only in English). In order to help applicants determine exactly which parts of the application they need to complete, screeners go through the form, highlighting the parts that the applicant needs to fill out and crossing out the parts they do not need to complete. Tenured eligibility workers with strong knowledge of eligibility rules and documentation requirements fill the screener positions.
Food Stamps and Medicaid/SCHIP. Individuals applying only for food stamps (or food stamps and Medicaid) follow a process that is similar to the integrated application process. One key difference is that the “group” orientation is more individualized than the TANF orientation. Although applicants are instructed to show up at the same time and sit together in one room, case aides see them on an individual basis and go over their application and paperwork to make sure it is in order. Following the orientation, applicants meet individually with an eligibility worker for their eligibility determination interview.
The application process for individuals applying only for Medicaid or SCHIP is greatly simplified. These individuals may mail in their application to the welfare office. Medicaid applicants do not need to go through the screening or orientation processes, but they still must come to the welfare office for a face-to-face eligibility interview. SCHIP applicants are also encouraged to come to the welfare office for assistance with the application and verification process. Recent changes in Virginia’s SCHIP program transferred responsibility for processing SCHIP applications from local welfare offices to a centralized private enrollment broker.17 The enrollment broker (BENOVA) determines eligibility via phone and mail for SCHIP applications across the state.
Applicants are screened over the phone, first for Medicaid and then for SCHIP. If eligible for Medicaid-only, the enrollment broker is supposed to send the application to the welfare office where it is treated like other Medicaid-only applications. If eligible for SCHIP, the application is completed over the phone and mailed to the applicant for signature. The Arlington welfare office will accept SCHIP applications (with income documentation) and send it on behalf of applicants to the enrollment broker’s central processing unit. The same process is used if families applying for Medicaid at the welfare office are determined ineligible because they are over income. The Medicaid-only application process can also be completed at a local public hospital, which houses an out-stationed Medicaid eligibility worker.
Raleigh, North Carolina
TANF/FSP/Medicaid. Raleigh, like Arlington, requires applicants to participate in an up-front screening process prior to the eligibility interview. The primary purpose of the screening is to determine if applicants qualify for a one-time lump sum payment (called “Benefit Diversion”) in lieu of going on cash assistance. Applicants are also screened for a county-funded program for working families whose income is below 150 percent of poverty and a TANF-funded program for those with income below 200 percent of poverty. Spanish-speaking TANF applicants, however, do not have to go through the screening process unless one of the two bilingual screeners is on duty. If no bilingual screener is available, Spanish-speakers meet with an interpreter who prepares the information needed by the case manager to complete the application and verification process.
Following the meeting with the screener, applicants participate in an eligibility interview. After the interview, but while their application is pending, applicants must register for work with an on-site representative from the Employment Services Commission. Typically, this happens during the same day as the eligibility interview, but if not, it must occur within ten days of the interview. Applicants are encouraged but not required to attend a work orientation and visit the on-site resource area to start a job search.
Food Stamp-Only. The food stamp-only application process is simpler than the TANF application process. Food stamp-only applicants do not participate in a screening interview and are not subject to any additional up-front requirements that must be met prior to eligibility determination. Instead, they register with the receptionist to start the application process and then meet briefly with a verification clerk who records basic household composition, income, and work history information. After completing an application, applicants are interviewed by an eligibility worker. If food stamp applicants would also like to apply for Medicaid, they may do so at the same time.
Medicaid/SCHIP. In Raleigh, as with the other sites, Medicaid-only and SCHIP individuals may submit applications by mail or apply for either program through out-stationed eligibility workers. At the time of our visit (August 2001), food stamp and Medicaid/SCHIP applications for Spanish-speaking families were only taken two days per week (but subsequent to our site visit were taken five days per week). Raleigh officials noted that even though face-to-face interviews are no longer required for eligibility determination, the Latino population tends to prefer face-to-face interviews to the mail-in option. Administrators said it is rare for Latino applicants to mail in their applications, and they believe that staff encourage this practice because they are able to obtain better information through face-to-face interviews and to address other service needs. Additionally, most staff indicated a preference to take Spanish-language applications in person due to the high volume of mistakes in mail-in forms. Medicaid eligibility workers are also out-stationed at public health clinics and hospitals throughout the county.
TANF/FSP/Medicaid. In Dallas, the receptionists screen the completed applications to determine eligibility for expedited food stamps and emergency Medicaid. If applicants do not appear eligible for expedited services, they receive an eligibility interview appointment for some time in the next two to three weeks. One Dallas office visited for this study holds “group appointments” for eligibility interviews because of staffing shortages and the need to process all applications in a timely manner. Appointment notices mark the date of the interview, instruct applicants to arrive at the office by 8:00 a.m., and state that applicants would be seen on a first come, first served basis. Staff noted that the line starts forming by 7:00 a.m. and all eligibility interviews are typically completed by early afternoon. Those that do not check in by 8:15 a.m. are considered “no-shows” and can either contact the office to reschedule an appointment or could wait until the end of the day to see if an interview slot had opened.
The TANF/FSP/Medicaid application process in Dallas reflects and reinforces the high priority Texas places on fraud prevention and quality control. Both TANF and food stamp applicants must be finger imaged, either before or after the eligibility interview, as part of the application process. Following the eligibility interview, TANF applicants are required to participate in a Workforce Orientation if it appears that they will be required to participate in TANF work activities. The orientation is not held within the welfare office, although applicants have to return to the welfare office with proof of participation before benefits can be authorized. Accommodations are not routinely made for non-English speakers — they must attend orientation if they appear to be work mandatory TANF applicants, even if it is held in English and no interpreter is available.
Medicaid/SCHIP. Medicaid/SCHIP applications are typically handled through a mail-in application process — roughly three-quarters of SCHIP applicants enroll by mail. Similar to Virginia, applications are mailed directly to a private contractor that serves as the state’s SCHIP enrollment broker. Individuals seeking application assistance can utilize the services of local outreach workers, and receive help by phone from the private enrollment broker’s help-line. Completed applications are screened first for Medicaid, and then for SCHIP. If eligible for SCHIP, the family is sent an enrollment packet; if eligible for Medicaid, the application information is forwarded to the local welfare office that, until January 2002, had to arrange face-to-face eligibility interviews for all Medicaid applicants.18 Those who do not use the mail-in application enrollment option can apply for SCHIP at county welfare offices or other sites, primarily hospitals or clinics, where welfare workers are outstationed. If a family applying for Medicaid is determined ineligible due to income, the application is forwarded to the private contractor to determine SCHIP eligibility.
Most Medicaid-only applications taken at the area’s largest public hospital (Parkland Hospital) are for deliveries and other obstetrics, and the majority of these are emergency Medicaid for undocumented women. The welfare agency has Medicaid eligibility workers out-stationed at the hospital but this unit was short-staffed at the time of our visit. Hospital financial counselors conduct an initial financial screening and assist patients that appear Medicaid-eligible with the Medicaid application before referring them to the out-stationed Medicaid unit. Although this division of labor somewhat eases the out-stationed Medicaid unit’s workload, screenings and eligibility determination interviews cannot always be carried out on the same day and, until January 2002, applicants often made an additional trip to the hospital later in the week for their face-to-face eligibility interview.
TANF/FSP/Medicaid. Sedalia’s application process involves many steps, but they can all be completed within the welfare office, and often in a single day. Clerical staff at the reception desk conduct preliminary screenings to determine which benefit programs they appear eligible for and give applicants the appropriate program application. After completing the application, applicants typically are seen for an eligibility determination interview that same day, although final determination is delayed pending completion of the TANF work program orientation and job search.
TANF/FSP/Medicaid applicants must attend a one-on-one orientation, held once a week at the welfare office that covers program benefits, services, and requirements. Applicants must then meet with a representative from the Employment Security Commission who is co-located at the welfare office. The Employment Security representative registers applicants for work and helps them start a mandatory up-front job search requirement consisting of ten contacts per week for four weeks. If the application for assistance is processed prior to the completion of four weeks of job search, the eligibility worker certifies the applicant for TANF and starts issuing benefits. If an applicant fails to fulfill the up-front job search requirement, the case is still approved, but the adult caretaker’s portion of the cash grant is sanctioned (i.e., removed from the grant).
Food Stamps and Medicaid/SCHIP. The application process is much simpler for food stamps and Medicaid/SCHIP. Individuals may submit an application at the welfare office but do not have to go through any of the steps described above. They may also apply for Medicaid/SCHIP by fax or mail — face-to-face interviews are not required. Medicaid/SCHIP applications are available through a local health center, hospital, and a community-based organization.
New York, New York
Food Stamps. The application process in New York City varies significantly by the type of assistance individuals want to receive. Applicants applying only for food stamps must go to one of the specialized food stamp-only offices to obtain an application. The receptionist pre-screens completed applications and asks applicants additional questions to determine if they need expedited food stamps. Applicants then receive an appointment for an eligibility interview, typically within five days and even sooner if eligible for expedited food stamps.
Special Assistance for Refugees Applying for Benefits
Sponsor agencies play a key role in ensuring that refugees quickly access benefits by facilitating the application process. This makes the application process generally easier for refugees to navigate than is true for other non-citizens.
Most refugees are sponsored by organizations (rather than the employers or individuals that sponsor other immigrants). These refugee sponsors are often non-profit organizations who have Reception and Placement grants from the U.S. Department of State to aid refugees in resettling in the United States. These agencies either sponsor the refugees themselves or find family members or others to sponsor them in the communities where they resettle. According to welfare agency staff in the six study sites, refugees that apply for benefits are almost always sponsored by agencies as opposed to individuals.
Refugees are usually destitute upon arrival and therefore eligible for the full package of benefits: TANF, food stamps, and Medicaid/SCHIP. Single refugees and others not eligible for TANF because of family composition usually receive Refugee Cash Assistance and Refugee Medical Assistance (an insurance program similar to Medicaid) instead during their first eight months in the country. If they still need assistance at the end of their resettlement period, refugees may transition to regular public benefits (i.e., TANF, food stamps, and Medicaid/SCHIP) if they are eligible.
Sponsor agencies generally provide initial cash and other assistance immediately upon arrival, and then help refugees and their families apply for public benefits. For example, sponsor agency staff will accompany refugees to the welfare office, help them fill out application forms, show them what documentation needs to be assembled, make sure their paperwork is in order, and provide language interpretation and translation if needed. In New York, for example, representatives from the New York Association for New Americans (NYANA) accompany new refugees to apply for benefits. They assist applicants in completing the application and provide interpretation assistance, when necessary. In Raleigh, an eligibility worker from the welfare office regularly goes to Lutheran Family Services, a resettlement agency, to process refugee benefit applications.
TANF/FSP/Medicaid. In contrast, families applying for TANF/FSP/Medicaid must complete a several steps prior to eligibility determination:
- Individuals give the completed application to the Job Center receptionist who asks preliminary questions.
- A Job Opportunity Specialist (i.e., eligibility worker) screens applicants, explains the programs, and offers alternative services to cash assistance.
- If the applicant would still like to apply for cash assistance, the Job Opportunity Specialist conducts an eligibility interview, prepares an initial assessment and work plan, and refers the applicant to:
- An eligibility verification review (EVR) performed at a different office location and subsequent home visit,
- A workforce orientation,
- Finger imaging and photographing,
- Mandatory daily job search classes for the duration of the 30-day eligibility determination period, and if necessary,
- Additional medical and substance abuse reviews at other locations.
Depending upon the particular Job Center, orientation, finger imaging, photographing, orientation, and job search may take place at the Job Center or at other locations. Medical and substance reviews do not take place at the Job Centers.
The EVR represents the high priority New York City places on deterring and controlling fraud. EVR Investigators are responsible for identifying those who are not eligible, and they review documents and verify information provided to staff at the Job Centers (e.g., household composition, income, and city residency).
New York City transitioned its welfare offices to “Job Centers” in July 2001, which resulted in a somewhat less cumbersome application process for families applying for cash assistance and other services. The transition integrated pre-screening, meeting with an employment counselor, and the initial eligibility interviews into a single interview. All TANF applicants must still go through the separate EVR before their applications are approved. As noted earlier, non-Spanish speaking refugees and other non-citizens applying for TANF/FSP/Medicaid are required to go to one of two specialized Job Centers.19 Although the location is different, the application process is very similar to that in the non-specialized Job Centers — applicants must also meet up-front requirements and participate in EVR.
Medicaid/SCHIP. The application process for individuals seeking only Medicaid/SCHIP in New York City is much simpler than the TANF/FSP/Medicaid process. Families may apply for Medicaid/SCHIP through the city’s Medicaid-only offices, directly through a private or non- profit health plan, or through a facilitated enrollment agency (which includes some of the health plans). SCHIP applications may also be mailed, but then require a face-to-face eligibility interview conducted by a Medicaid-only eligibility worker at the welfare office or a facilitated enroller in a non-welfare office setting. Medicaid/SCHIP applicants are not required to go through the EVR and home visit, or be fingerprinted.