CHIPRA Mandated Evaluation of Express Lane Eligibility: First Year Findings. B. What Is Express Lane Eligibility (ELE)?


Section 203 of CHIPRA authorizes ELE and permits states to rely on findings of other public agencies to determine whether a child satisfies one or more requirements for Medicaid or CHIP eligibility. In doing so, states can disregard technical differences in how these programs define the household members whose earnings are considered in determining eligibility, as well as other methodological differences in assessing whether children meet applicable requirements (Dorn et al. 2012). The criteria for Medicaid and CHIP eligibility include income, age, residency, and immigration status or U.S. citizenship; ELE can be used to meet any of these except U.S. citizenship.2

In adopting ELE, states can choose to partner with any of 11 listed state agencies; states also can select an unlisted agency that fits the definition of an Express Lane agency; and states also can obtain and use information directly from state income tax records or returns. Based on guidance from the Centers for Medicare & Medicaid Services (CMS), this definition includes an agency determining eligibility for assistance through any of the following programs: Temporary Assistance for Needy Families (TANF); child support enforcement; Medicaid; CHIP; Supplemental Nutrition Assistance Program (SNAP); the National School Lunch Program (NSLP); the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); the United States Housing Act of 1937; Head Start; child care under the Child Care and Development Block Grant Act of 1990; or the Native American Housing Assistance and Self-Determination Act of 1996 (Center for Medicaid and State Operations 2010). Unlisted agencies include another state government agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the state; or a public agency subject to an interagency agreement limiting the disclosure and use of information shared for determining Medicaid or CHIP eligibility (the public agency may be an agency administered by an Indian tribe recognized by the state or Federal government that determines eligibility for any of the programs listed). Express Lane agencies cannot be private for-profit organizations or agencies that only determine eligibility for programs funded under the Title XX Social Services Block Grant.3

With ELE, not only can the Express Lane agency vary, but so can ELE features. For example, states can apply ELE to CHIP and/or Medicaid, with a focus on enrollment, renewal, or both. In addition, in pursuing ELE, states can choose to include or exclude an “automatic enrollment” option that avoids the need for an application, possible when states have all the information they need from the Express Lane agency findings to make an eligibility determination or renew coverage.

To satisfy the CHIP “screen and enroll” requirements, which dictate that children do not qualify for CHIP unless they have been screened for Medicaid and found ineligible, states adopting ELE can either use traditional approaches or apply one of two new methods. In the first method, states can set a screening threshold 30 percentage points (or more) above the highest Medicaid eligibility threshold. Children with family income at or below the threshold, as found by the Express Lane agency, are considered to have met the Medicaid eligibility income test for the purpose of complying with the Title XXI screen and enroll requirements. For children with family income above this threshold, states must assess whether these children are income-eligible for CHIP, based on the Express Lane agency findings, but they need not be screened for Medicaid eligibility (Center for Medicaid and State Operations 2010). Using the second method, states can temporarily enroll children in CHIP if the child appears CHIP-eligible using the Express Lane agency findings; however, during the temporary enrollment period, states must conduct a full eligibility determination to establish either Medicaid or CHIP eligibility.4 Even for children ultimately found Medicaid-eligible, states can claim Title XXI matching funds for the temporary CHIP enrollment period; this is an advantage for states, because the Federal government matching rate is higher in CHIP than in Medicaid.

Federal rules offer several protections for families who might be subject to ELE. For example, Express Lane agencies must notify families that their information will be shared with the Medicaid or CHIP agencies, solely to determine Medicaid or CHIP eligibility, and families must be able to opt out of sharing this information. To use the automatic enrollment option, states must obtain the family’s consent to enroll the child, and the family must be informed about the available services, how to access them, if there is cost sharing, how to maintain the coverage, etc.5 In addition, whether or not a state implements the automatic enrollment option, for children subject to premiums or cost sharing (common in CHIP programs), the state must provide notice to the family that the child might qualify for lower premiums or cost sharing if the child were evaluated for eligibility using “regular” procedures (Center for Medicaid and State Operations 2010). ELE cannot be used to deny coverage; CHIPRA requires states to initiate a standard eligibility determination for Medicaid and CHIP for any child found ineligible through the use of ELE.

To offset concerns that ELE could introduce enrollment errors—that is, that children who are ineligible might be enrolled in Medicaid or CHIP—CHIPRA also requires states to implement systems to track ELE enrollment, which permits states to calculate error rates. If auditing reveals error rates of 3 percent or more in the first two years of ELE operations, states must identify actions to reduce the error rate; rates in excess of 3 percent will result in reduced Federal payments to states for the amount above 3 percent.

As with other options, CMS approval is required to implement ELE as defined in the statute.6 States submit a state plan amendment (SPA) to CMS specifying the state’s ELE plans. The SPA must provide detail on how the ELE option will operate, which partner agency (or agencies) were selected, how the screen and enroll requirements will be satisfied, and how the Express Lane agency differs with regard to income eligibility determination. ELE SPAs are required for both Medicaid and CHIP, depending on the health program to which ELE applies.

2 CHIPRA extended the citizenship verification requirements already used in Medicaid to CHIP effective January 1, 2010. CHIPRA also permits a new option for states to meet this requirement through a data-matching process with the Social Security Administration (CHIPRA 111-3 section 211).

3 Title XX block grants cover programs to prevent child abuse, increase the availability of child care, and provide community-based care for the elderly and disabled (Social Security Administration 2012).

4 States must use simplified procedures to minimize the family burden for this full eligibility determination. For example, the State cannot require the family to submit or verify information already provided by the Express Lane partner agency or available to the state from another source, unless the State believes that information to be false (Centers for Medicaid and State Operations 2010).

5 CMS permits a wide range of consent methods for states using automatic enrollment, including oral, written, electronic signature, signature on an Express Lane agency application, or other means that CMS approves (Centers for Medicaid and State Operations 2010).

6 Arizona, California, and Illinois report an ELE partnership in their Federal fiscal year (FFY) 2011 annual CHIP reports, although these partnerships are not approved by CMS (Mathematica analysis of FFY 2011 CHIP Annual Report Template Reports, June 11, 2012). States that are approved can use ELE as one of the five of eight qualifying simplifications for a CHIPRA performance bonus, so it can be financially advantageous to a state to seek approval.

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