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


It is not easy to effectively integrate and coordinate the operation of multiple health and human services programs that serve overlapping populations, but such efforts can yield significant gains. When one program determines eligibility based on the work already done by another program, public agencies can save administrative costs and streamline enrollment and retention for consumers. When programs jointly develop and operate shared eligibility infrastructure, they can achieve gains together that no single program could accomplish alone. And when programs collaborate in reaching out to a shared client population, more consumers can receive benefits for which they qualify.

This work has grown increasingly important following the 2010 enactment of the Patient Protection and Affordable Care Act (Affordable Care Act or ACA). In three basic categories, states and private-sector organizations have achieved notable success.

  1. Streamlining eligibility for one program based on data linkages with another program.
    • Louisiana renews children’s eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) through data from other public agencies, whenever possible. More than 3 in 4 of renewals (76 percent) are based on data matches, without any need to contact families for additional information. Nearly all children (95.4 percent) have eligibility continue at renewal, and fewer than 1 percent lose coverage for procedural reasons.
    • Louisiana and South Carolina have implemented Express Lane Eligibility (ELE) to provide children with Medicaid based on the income determinations of human services programs—especially the Supplemental Nutrition Assistance Program (SNAP). This initiative has covered more than 27,000 and 92,000 previously uninsured children in the two states, respectively. Mainly because of the many children who are automatically renewed based on their receipt of SNAP, each of these states achieved annual net savings of roughly $1 million and $1.6 million, respectively. Similar efforts are now beginning with adults as well, through targeted Medicaid enrollment strategies under the ACA.
    • In many states, Combined Application Project (CAP) demonstrations provide SNAP to recipients of Supplemental Security Income (SSI) based largely or entirely on information these seniors and people with disabilities already furnished when they sought SSI in a CAP demonstration state. From 2000 to 2008, CAP states experienced a 48% increase in SNAP participation levels among 1-person SSI households, at a time when such households’ enrollment in other states saw little change. To simplify SNAP procedures, CAP demonstrations use standardized rather than individualized SNAP benefit amounts, or individually determined benefits reflecting standardized shelter costs, either of which can result in slightly different amounts of aid than if beneficiaries had gone through the full SNAP eligibility assessment process. However, although SNAP programs provide notice, few CAP participants know they can obtain an individualized eligibility determination, and perhaps additional benefits, by submitting a regular SNAP application.
  2. Coordinating administration of multiple programs. Through efforts that spanned the better part of a decade, Utah built an integrated system of electronic case records, rules engine, external data matching, on-line applications, and benefit payment that serves multiple health and human services programs. From 2008 to the system’s full implementation in 2010, the caseload capable of being managed by a single worker increased 53 percent. From 2009- 2010, caseloads rose by 12.3 percent as total operating costs fell by 9.6 percent.
  3. Coordinating outreach and enrollment.
    • In implementing early Medicaid expansion under the Affordable Care Act, Minnesota enrolled eligible consumers through the “low-tech” strategies of (a) making a toll-free number available to hospital emergency rooms and (b) having state and local staff manually convert consumers from a prior state health program to Medicaid. The latter step was cumbersome and administratively costly, but these methods helped the state enroll 51,583 eligible consumers by the end of March 2011, the expansion’s first month. They represented 68% of all consumers who received coverage by the end of calendar year 2011.
    • Single Stop USA, a non-profit organization, helps community college students and their families enroll into health and human services programs, while providing financial and legal counseling. At 17 sites in seven states, 18,000 students were counseled in 2012, of whom 29% received health and human services benefits averaging $5,400 per student— roughly the maximum Pell Grant for a low-income college student. More than half also received financial or legal counseling. It took hard work to integrate this initiative into existing community college culture, but most school leaders have grown highly supportive, investing much of the funding needed for ongoing program operation.

On the other hand, several initially promising strategies have not yet achieved major gains. Another Single Stop effort involved connecting low-income consumers to health coverage when they filed tax returns at volunteer tax preparation sites. This effort faced serious challenges, including difficulty obtaining the necessary investment of time and staff from pre-ACA health application assisters, the unwillingness of many consumers to invest the additional time needed to apply for health coverage after completing the tax preparation process, and limitations of volunteer tax preparer health knowledge that forced a cumbersome “hand-off” from tax preparer to health application assister. The ACA strengthens the logical nexus between health coverage and tax preparation, which will provide increased motivation to overcome these challenges.

As another example, referring consumers to programs for which they apparently qualify, rather than actually signing them up for assistance, has achieved little success. One randomized, controlled experiment involved the tax preparation firm H&R Block. When the firm used tax return data and interviews to complete and file SNAP application forms on behalf of low-income customers, 80 percent more applications were filed than with a control group that received only basic SNAP information and a blank SNAP form. By contrast, no statistically significant effects were observed, compared to the control group, when H&R Block completed SNAP forms, handed them to families, and explained where and how to file them. A similar H&R Block experiment involving applications for college student aid reached similar results.

Efforts to integrate and coordinate enrollment, retention, and eligibility determination for health and human services programs typically require considerable effort, and not all such efforts have proven successful. That said, many states, localities, and private-sector groups have achieved significant positive outcomes using strategies that appear capable of replication elsewhere.

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