Examples of Promising Practices for Integrating and Coordinating Eligibility, Enrollment and Retention: Human Services and Health Programs Under the Affordable Care Act. Challenges and lessons learned


The state had to overcome various challenges to implement ELE effectively. As with much interagency collaboration, South Carolina’s DHHS and DSS offices had to resolve differences in data collection methods before they could share information efficiently. DHHS also needed to decide how to handle cases that did not easily fit into the automated ELE process. For example, children who do not have Social Security Numbers create the potential for duplicate enrollment. DHHS decided to manually process these cases to see if the children appear in open SNAP and TANF cases.25

South Carolina also recognized potential limits in provider capacity when the state enrolled thousands of new children. The state accordingly decided to implement ELE for enrollment gradually by county, rather than immediately implementing ELE enrollment state-wide, as had been done for ELE renewal.26 Focus groups with parents of ELE-enrolled children indicated that their children enjoyed good access to Medicaid providers.27

An additional challenge resulted from state officials’ determination that staff training was unnecessary for ELE because of its automated nature. Caseworker confusion about ELE caused unnecessary manual editing in the ELE system in the early stages of the process. In retrospect, DHHS recognized that providing more information to staff prior to implementing ELE could have prevented this confusion.28


Using ELE best practices to strengthen ACA targeted enrollment

To cover the uninsured as part of ACA implementation, several states are now applying policies like ELE to both children and adults. In May 2013, CMS issued a State Health Official (SHO) letter that permits states to provide consumers with Medicaid based on their receipt of SNAP, using waivers under Social Security Act §1902(e)(14)(A) to bypass the normal requirement of individualized income determinations. States can qualify all or some SNAP recipients who meet Medicaid’s non-financial requirements. By October 2013, five states were approved for such waivers, including three that were also  approved for similar waivers providing parents with Medicaid based on data from family members’ Medicaid and CHIP records. Four out of the 5 states began implementation before October 2013, enrolling nearly a quarter of a million people by November 15 (table 3).

Table 3. Results of targeted enrollment initiatives reported by 11/15/13

State Target group: SNAP recipients Target group: People with family members enrolled in Medicaid or CHIP Phone response accepted? People sent mailings Mailing response rate People found eligible for Medicaid and enrolled
Arkansas Y     154,000 41% 63,465
Illinois Y     123,000 33% 35,500
Oregon Y Y Y 260,000 27% 70,000
West Virginia Y Y Y 118,000 46% 54,100
Total: 655,000 34% 223,065

Source: Manatt Health Solutions and the Kaiser Commission on Medicaid and the Uninsured, 2013. Note: total response rate is the average for all states, weighted based on the number of mailing recipients.

States implementing targeted enrollment can build on these early successes to incorporate lessons learned from ELE. Requiring consumers to respond to a mailing before they receive Medicaid greatly limits coverage gains. The initial response rates to mailings in Oregon, West Virginia, and Arkansas, for example, averaged 34 percent (table 3). Moreover, the most successful states, Arkansas and West Virginia, had state staff call every non-responsive mailing recipient to encourage form completion. States could likely cover many more consumers at much lower administrative cost if, as in South Carolina, (a) states enroll all targeted, eligible consumers not participating in Medicaid and (b) accessing fee-for-service care both gives consent to coverage and triggers mandatory managed care assignment.

Sources: “Facilitating Medicaid and CHIP Enrollment and Renewal in 2014,” Center for Medicare and Medicaid Services (CMS), Department of Health and Human Services (HHS), May 17, 2013.

http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf; CMS. New State Medicaid & CHIP Targeted Enrollment Strategies (As of October 1, 2013) http://medicaid.gov/AffordableCareAct/Medicaid- Moving-Forward-2014/Targeted-Enrollment-Strategies/targeted-enrollment-strategies.html, downloaded 12/26/13;
Jocelyn Guyer, Tanya Schwartz and Samantha Artiga, Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion, Manatt Health Solutions and the Kaiser Commission on Medicaid and the Uninsured, November 19, 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/11/8517-fast-trac....

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