The Children’s Health Insurance Program (CHIP), a landmark initiative to help close the health insurance coverage gap for low-income children, celebrated its 15th anniversary in August 2012. Together with Medicaid, CHIP has helped fuel a decline in the number of uninsured children, which has fallen from 11.4 million (15.1 percent of children) in 1997 when CHIP was enacted to 8.0 million (10.0 percent of children) in 2010 (Current Population Survey, Annual Social and Economic Supplement 2011).
Initially authorized with bipartisan support through the Balanced Budget Act of 1997, CHIP was set to expire in 2007 unless reauthorized by Congress. Congress gave CHIP a temporary reprieve in December 2007: the Medicare, Medicaid, and SCHIP Extension Act of 2007 extended the program and funded it through March 2009 (Kaiser Commission on Medicaid and the Uninsured 2009). In February 2009, the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) reauthorized CHIP and funded it through 2013. Funding for CHIP was further extended to 2015 by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act).
Concerned about the many children eligible but not enrolled in public coverage—estimated at 4.7 million children as of 2008 (Kenney et al. 2010)—Congress provided states with new tools and new funds through CHIPRA to address shortfalls in enrollment, as well as in access to, and quality of, care (Harrington et al. 2011). One of these new options is a policy called Express Lane Eligibility (ELE). With ELE, a state’s Medicaid and/or CHIP program can rely on another agency’s eligibility findings to qualify children for public health coverage, despite their different methods of assessing income or otherwise determining eligibility. ELE thus gives states another way to try to identify, enroll, and retain children who are eligible for Medicaid or CHIP but who remain uninsured. The concept of using data from existing government databases and other means-tested programs to expedite and simplify enrollment in CHIP and Medicaid has been promoted for more than a decade; before CHIPRA, however, Federal law limited state reliance on information from other agencies by requiring such information to be cross-walked into the Medicaid and CHIP eligibility methodologies (Families USA 2010; The Children’s Partnership 2012).
Although the Affordable Care Act extended CHIP funding to 2015, CHIPRA slated the ELE policy option to end September 30, 2013, unless Congress acts to extend or modify it. Despite this possible end to the policy option, CHIPRA also gave states an incentive to adopt ELE by making it one of the eight policies states could adopt to qualify for performance bonus payments (CHIPRA section 104).1
1 Section 104 of CHIPRA specifies that the performance bonus money is intended to offset the additional costs resulting from enrollment and retention efforts. To qualify for CHIPRA performance bonuses, states must increase Medicaid enrollment beyond a specified target and implement at least five of eight administrative policies considered best practices for simplifying enrollment and renewal. See http://insurekidsnow.gov/ (2011) for more information on the bonus criteria.
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A. Purpose of This Report
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CHIPRA further authorized a comprehensive, independent, and rigorous evaluation of ELE, with reports of evaluation findings to be submitted to Congress; this is the first of two reports that will fulfill the mandate. This report has three purposes:
- To describe existing ELE programs, including the costs and new enrollment trends associated with ELE implementation
- To estimate the impact of ELE adoption on total enrollment
- To preview the issues that will be examined through future evaluation activities and presented in the final evaluation report, due to Congress in September 2013
Federal and state policymakers are keenly interested in understanding the full implications of ELE as a route to enrolling children, or keeping them enrolled, in public coverage. This evaluation provides an important opportunity to document ELE implementation and understand the implications of adopting the policy. In its later phases, the study will also provide an opportunity to understand other methods of simplified or streamlined enrollment that states have pursued and to assess the benefits and potential costs of these methods compared with those of ELE. Taken together, findings from the study will help Congress and the nation better understand ELE and assess its value.
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B. What Is Express Lane Eligibility (ELE)?
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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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C. Potential Benefits of ELE
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Although ELE’s primary goal is to facilitate eligible children’s participation in Medicaid or CHIP, a number of other benefits could accrue to states from adopting the policy. Here, we review these potential benefits.
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D. Overview of the ELE Evaluation
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In September 2011, Mathematica Policy Research and its subcontractors, the Urban Institute and Health Management Associates, were awarded the contract to conduct the congressionally mandated evaluation of ELE. The contract runs through September 2013. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is overseeing this contract.
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E. Road Map for the Report
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Chapter II describes the designs of the ELE programs approved as of April 1, 2012, discussing states’ design approaches, presenting a detailed review of the ELE processes of the six states in the cost and enrollment study, and reviewing the potential benefits of ELE for beneficiaries. Chapter III presents the descriptive analysis of administrative costs and new enrollment and retention in six states. Chapter IV presents findings from the analysis of SEDS data on ELE’s impact on enrollment. Chapter V summarizes and synthesizes findings from the evaluation’s first year, discusses the implications of these findings, and reviews future work to be conducted in the second year of the evaluation, to be reported to Congress in 2013.
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