Louisiana applies ELE to both initial enrollment of previously uninsured children and to renewing coverage for Medicaid beneficiaries. SNAP findings about income, state residence, identity, and Social Security Number (SSN) are used to satisfy Medicaid eligibility requirements. The state matches records between the programs, based on identifying information such as name, SSN, and address. However, the SNAP program’s verification of a child’s citizenship or satisfactory immigration status is used to establish Medicaid eligibility only if the evidence meets standard Medicaid requirements. Otherwise, these non-financial requirements are verified through typical Medicaid procedures.
Much of the initial funding for development and implementation of this practice came from the above-described “MaxEnroll” program, which proved particularly important in funding necessary information technology (IT) improvements. Implementation of ELE also required coordination between two separate agencies: DHH (the agency responsible for Medicaid) and DCFS (the agency responsible for SNAP). State health officials met twice per week, spending months to plan implementation. Once the program was underway, DHH drafted and paid for all mailings to SNAP recipients, which reduced the cost and effort required of DCFS. DCFS supported ELE as helping meet the needs of the agencies’ shared low-income clientele while generating administrative savings for taxpayers.
Louisiana’s ELE implementation began in late 2009. DHH matched SNAP and Medicaid records to identify children who received SNAP but not Medicaid. To prevent duplicate enrollment, the state began by covering SNAP-recipient children who previously received Medicaid or CHIP but no longer participated. With other children, the state delayed enrollment until conducting further investigation to ensure that they weren’t actually receiving Medicaid but described differently in SNAP records—for example, with a nickname rather than a formal first name, or with an SSN or address that had several digits reversed.
The state sent letters to families whose children were in the group slated for initial enrollment. The letters explained that, if families did not “opt out,” their children could be enrolled in Medicaid, based on their receipt of SNAP. Less than one percent of the letters’ recipients opted out, and the state prepared to enroll the remainder into Medicaid.
Before the state could do so, however, clarification from CMS forced a change in direction. “Opting out” is sufficient to authorize data matching between SNAP records and Medicaid records, explained CMS officials, but enrolling children into Medicaid coverage requires 8affirmative consent from their parents, under the federal ELE statute. To meet this requirement, the state informed parents that it would send them Medicaid cards, and that using the cards to access care would signify affirmative consent to enrollment. CMS accepted this as meeting statutory requirements. In February 2010, Louisiana mailed Medicaid cards to more than 10,000 children who had qualified for Medicaid in December 2009 because of SNAP receipt.
The state also enrolled children into Medicaid based on monthly SNAP applications, starting in January 2010. For this ongoing, monthly process, parents could “opt-out” of data sharing on the SNAP application form. When those who did not opt out qualified for SNAP, their children’s identity was compared to records of current Medicaid enrollees. Children not participating in Medicaid were sent Medicaid cards, and their parents could complete the enrollment process by providing affirmative consent through using the cards to access care.
In November 2010, Louisiana began using ELE to renew coverage for all families whose Medicaid households consisted entirely of children with SNAP cases, regardless of how or when those children originally joined Medicaid. However, when it came time to renew the first group of automatically enrolled ELE children, the state experienced problems because of its IT system. Different renewal procedures applied to (a) ELE enrollees who had consented through card use and (b) those who had not yet used their cards. However, children’s utilization of services could be analyzed only by accessing the state’s claims payment system, which could not communicate with the state’s eligibility system. As a result, the expensive manual involvement of state staff was required for renewal.
To prevent this problem from recurring, state officials changed to a new consent policy that would permit renewal without any need to access data outside DHH’s eligibility system. Starting in January 2011, affirmative consent to enrollment was provided, not by using Medicaid cards to access care, but by checking a box on the SNAP form requesting Medicaid coverage. The check box was bolded, prominently placed at the top of the second page, and written in plain language, to maximize the chances that it would be read and understood.