In South Carolina, children in low-income families with incomes up to 200 percent of the Federal Poverty Level (FPL) have long qualified for Medicaid. As of 2011, 19 percent of children in this income band were uninsured; only five states had a higher percentage of low-income children without coverage.16
“Churning” was also a common problem, with close to 140,000 children (roughly half of all enrolled children) losing coverage annually, and almost 90,000 of them returning to the program within the year, according to estimates from South Carolina’s Department of Health and Human Services (DHHS). Most children reapplied and rejoined the program within 2 months or less of termination. This churning raised administrative costs as staff members had to complete new eligibility determinations for children who, despite ongoing eligibility, exited and reentered the program. In addition to coverage rates and churning, the state’s program also faced challenges in paper processing and administrative burdens on staff and families.17
With a new governor taking office in 2011 and a new Medicaid director arriving from Louisiana, these problems received a fresh review. To address the administrative costs of churning, among other issues involving children’s health coverage, the state began planning to implement Express Lane Eligibility. As part of this process and before seeking approval from CMS, DHHS staff consulted with officials in Alabama, Louisiana, and Oregon, states that had previously adopted ELE, to learn more about the process and to identify the best strategies for South Carolina.18
In June 2011, South Carolina received CMS approval to implement ELE by qualifying children as financially eligible for Medicaid based on the income determinations of SNAP and TANF. South Carolina began using ELE to renew children’s coverage starting in July 2011. Data matches with the Department of Social Services (DSS) determine if children enrolled in Medicaid are part of an open TANF or SNAP case. If so, DHHS sends a letter to the family explaining that Medicaid has been automatically renewed. The family is not required to submit any additional information.19
Starting in September 2012, the state extended ELE to enroll children who had not previously received Medicaid. South Carolina compares TANF/SNAP records and Medicaid records to identify children who receive TANF or SNAP but not Medicaid. The state enrolls these children in Medicaid and sends their families a letter encouraging them to select a managed care plan. The letter lists a toll-free number that parents can call if they want to opt out of Medicaid coverage. The letter explains that those who neither opt out nor select a plan can use their Medicaid coverage to access fee-for-service care for their children, which constitutes consent to enrollment. Accessing care also triggers a new round of managed care selection, with a plan chosen by default if a family fails to select a plan within 90 days of seeking fee-for-service care.