As the previous discussion makes clear, some application processes are more complicated than others and the level of complexity varies by site and by type of benefit. The TANF/FSP/Medicaid application process typically includes more steps — and generally the more steps involved, the harder the system can be to understand and navigate. By all accounts this complexity probably affects participation, and this effect may be greater for immigrants and limited English speakers whose efforts to navigate the application process are frustrated by their lack of English proficiency, confusion about eligibility rules, and apprehension about the consequences to their immigration status. In particular, some application procedures may present more significant issues for non-citizens than for citizens. Finger imaging, home visits and overly rigorous eligibility verification can be particularly daunting for families who closely associate many of these procedures with the Immigration and Naturalization Service (INS).
Disaster Relief Medicaid in New York City:
A Simplified Application Process
In September 2001, New York implemented a temporary Disaster Relief Medicaid Program in response to the September 11 attacks. (New York also accepted applications for a more limited New York City Disaster Food Stamp Program through October 31, 2001.) This program temporarily replaced both Medicaid and Family Health Plus (the state’s Medicaid expansion program). The application form was limited to a single one-page application that applicants could submit at designated offices throughout the city. The eligibility process sharply reduced documentation and verification requirements — proof of immigration status was not required and income was not verified. Despite lack of public awareness campaigns or other forms of outreach, this greatly simplified eligibility process contributed to an influx of Medicaid applicants. Approximately 300,000 low-income individuals and families were enrolled over four months, greatly taxing Medical Assistance Program staff (P. Coltoff, letter, January 23, 2002). The Washington Post reported that many people applying for Disaster Relief Medicaid would have been eligible for Medicaid, SCHIP, or Family Health Plus prior to September 11, but were taking advantage of the simplified application process (Russakoff 2001).
New York City’s experience with this highly simplified application process provides an example of how application procedures and processes can affect the extent to which individuals seek and obtain assistance. Originally intended to be only a temporary measure, Disaster Relief Medicaid enrollment ended on January 31, 2002. However, based on this experience, New York City administrators are negotiating with the State of New York to simplify recertification and documentation requirements, and have implemented various enrollment simplification pilots.
At the same time, while immigration status and limited English proficiency are responsible for some differences in the type, sequence, and difficulty of steps that make up the application process, non-citizens and other limited English speakers are not, as a group, subject to different treatment in terms of what they are expected to do or longer waiting periods before benefits are authorized. In fact, newly arriving refugees in many of the study sites appeared to move through the application process more easily than non-refugees due to the additional help they receive from sponsoring agencies (see box).
New York’s Facilitated Enrollment Process:
Community-Based Access to Medicaid/SCHIP
The State of New York implemented a new concept called “facilitated enrollment” through which community-based organizations, with grant support from the state, provide application assistance to families applying for Medicaid/SCHIP. One goal of the process is to enroll hard-to-reach populations. Facilitated enrollers fulfill the face-to-face function required under state Medicaid requirements. Thirty-two organizations in New York are designated as “lead agencies” with more than 100 smaller CBOs throughout the city to facilitate enrollment. The facilitated enrollers walk individuals through the application process and help them organize the necessary documents for verification. They then submit the application to a lead agency for quality control. The lead agencies are responsible for submitting applications to the city’s Medicaid/SCHIP agency for eligibility determination.
Working with a facilitated enroller, who is typically located within the community, is potentially easier and less intimidating than having to go to the welfare office. Several facilitated enrollment agencies target their efforts toward specific non-citizen and limited-English speaking communities. For example, the Children’s Aid Society is the lead agency for four other CBOs, three of which target Chinese communities, and one that targets a Latino community.
Administrators, staff, and advocates included in this study commonly noted that non-refugee immigrants and mixed-status families are more likely to apply for benefits in community health clinics, hospitals, and other non-welfare settings. The need for immediate access to health care services makes it more likely that they will come into contact with these types of organizations than the welfare office. Once at the clinic, they may be more receptive to applying for health benefits because the process is typically much easier to complete than the integrated TANF/FSP/Medicaid application process, there are more likely to be bilingual staff available, and they are more likely to trust that the application will not cause immigration-related problems for themselves or their children. In sum, anecdotal evidence indicates that the combination of providing a simplified application process in a non-welfare office setting, supplemented with additional application assistance and language accommodations, results in greater levels of participation by these special populations.