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


1  American Public Human Services Association (APHSA). A-87 Exception Toolkit for Human Service Agencies: Description of the Exception and Recommendations for Action. January 2014.

2  CMS. “FY 2011 Louisiana Medicaid: Payment Error Rate Measurement (PERM) Cycle 3 Summary Report.” November 31, 2012. Available at: http://ccf.georgetown.edu/wp-content/uploads/2013/01/LA.Error_.Rates_.Su....

3  These estimates applied before the state implemented ELE, which further increased the state’s automation of renewals. Georgetown University Health Policy Institute. “The Louisiana Experience: Successful Steps to Improve Retention in Medicaid and SCHIP” February 2009.

4  Georgetown University Health Policy Institute. “The Louisiana Experience: Successful Steps to Improve Retention in Medicaid and SCHIP” February 2009.

5  Benjamin D. Sommers. “From Medicaid to Uninsured: Drop-Out among Children in Public Insurance Programs.”
Health Services Research 40, no. 1 (2005): 59–78..

6  Sheila Hoag, et al. “Final Findings.” CHIPRA Mandated Evaluation of Express Lane Eligibility. Mathematica Policy Research, Inc. 2013.

7  Kaiser Family Foundation. “CHIPRA Performance Bonus Awards, FY2009-FY2012.” Statehealthfacts.org.
Available at: http://kff.org/other/state-indicator/chipra-performance-bonuses/.

8  Social Security Act §1902(e)(13)(D)(i) [42 USC §1396a(e)(13)(D)(i)].

9  Hoag, et al., op cit.

10  Goidel, Kirby, Stephen Barnes, and Dek Terrell. “Louisiana’s Uninsured Population: A Report from the 2011 Louisiana Health Insurance Survey.” Baton Rouge: Louisiana State University Division of Economic Development and Public Policy Research Lab, January 2012. Available at:

11  Dorn et al., 2012.

12  Dorn et al., 2012.

13  Colby, Maggie and Brenda Natzke. “Utilization of Services by ELE Enrollees.” CHIPRA Express Lane Eligibility Evaluation. Princeton, NJ: Mathematica Policy Research, 2013. To analyze the impact of ELE enrollment on utilization, researchers used a regression analysis to adjust the characteristics of ELE enrollees, in terms of age, gender, geography, and other factors, to fit the characteristics of Medicaid children enrolling through other methods.

14  Stan Dorn, Margaret Wilkinson, and Sarah Benatar. “Case Study of Louisiana’s Express Lane Eligibility: Final Report.” CHIPRA Express Lane Eligibility Evaluation. Washington, DC: Urban Institute 2013. August 2013.

15  Among children who did use services, average costs were slightly higher with the opt-in process: with the opt-in check box, ELE children who used services incurred costs that were 52 percent of average costs among non-ELE children who used services, compared to 48 percent of ELE children who enrolled under the earlier, opt-out, “consent through card use” process.

16  Edwards, Jennifer and Rebecca Kellenber. 2013. CHIPRA Express Lane Eligibility Evaluation: “Case Study of South Carolina’s Express Lane Eligibility Process.” Mathematica Policy Research; Hensley-Quinn, Mary Henderson, and Kimm Mooney. 2012. State Experiences with Express Lane Eligibility: Policy Considerations and Possibilities for the Future. State Health Reform Assistance Network. Robert Wood Johnson Foundation.

17  Supra, John. 2011. South Carolina’s Experience Implementing Express Lane Redeterminations. South Carolina Health and Human Services.; Iritani, Katherine. 2012. Medicaid and CHIP: Considerations for Express Lane Eligibility. Presentation to the U.S. Senate Committee on Finance. Presented December 5. GAO-13-178R. Government Accountability Office.

18  Edwards, op cit.

19  Edwards, op cit.

20  Hoag, et al., op cit.

21  Division of Policy and Research on Medicaid and Medicare at the University of South Carolina Institute for Families in Society, SC HealthViz, a project of the SC Department of Health and Human Services,
http://schealthviz.sc.edu/total-members-and-member-months#%7B%22path%22%..., downloaded 10/31/13.

22  Edwards, op cit.

23  Hoag, et al., op cit.

24  Hensley-Quinn, op cit.; National Academy for State Health Policy. 2012. South Carolina CHIP Fact Sheet.
http://nashp.org/system/files/CHIP/2012/NASHP-2012-South-Carolina... Insure Kids Now. N.D. CHIPRA Performance Bonuses: A History. http://nashp.org/system/files/CHIP/2012/NASHP-2012-South-Carolina-

25  Edwards, op cit.

26  Hoag, et al., op cit.

27  Edwards, op cit.

28  Hoag, op cit.

29  Esa Eslami, Joshua Leftin, and Mark Strayer. “Supplemental Nutrition Assistance Program Participation Rates: Fiscal Year 2010.” Mathematica Policy Research, Inc. December 2012.

30  See general discussion in Karen Cunnyngham, “Final Report.” State Trends in Supplemental Nutrition Assistance Program Eligibility and Participation Among Elderly Individuals. Sept. 28, 2010. Mathematica Policy Research, Inc. September 28, 2010. http://www.mathematica-mpr.com/publications/PDFs/nutrition/SNAP_elderly.pdf.

31  Food and Nutrition Service (FNS). “Combined Application Projects Guidance for States Developing Projects.”
March 2005. http://www.fns.usda.gov/snap/government/promising-practices/CAPsDevelopm...

32  Social Security Administration, Office of Retirement and Disability Policy. “The Food Stamp Program and Supplemental Security Income.” Social Security Bulletin Vol. 67 No. 4. 2007.

33  FNS. “Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2011.” November 2012. http://www.fns.usda.gov/system/files/2011Characteristics.pdf

34  FNS, 2013 Program Access Toolkit. March 2013.

35  Barbara Murphy. Combined Application Projects: An Analysis of their Impact on the Supplemental Nutrition Assistance Program. USDA Food and Nutrition Service, Sept. 2010 draft (Contract # AG‐3198‐D‐08‐0111).

36  FNS, March 2005.

37  Food Research and Action Center (FRAC). A Guide to the Supplemental Security Income/Food Stamp Program Combined Application Projects. January 2004.

38  Cunnyngham, Karen. “State Trends in Supplemental Nutrition Assistance Program Eligibility and Participation Among Elderly Individuals.” Mathematica Policy Research, Inc. September 28, 2010. http://www.mathematica-mpr.com/publications/PDFs/nutrition/SNAP_elderly.pdf

39  CAP states’ increase in participation levels among SSI recipients was apparently not a function of more general changes to their overall SNAP programs. Unlike in non-CAP programs, where the average participation level of SSI-recipient households, as a percentage of the total SNAP participation rate among all households, declined slightly from 2000 to 2008, it rose in CAP states by almost a third, from 45 to 58 percent. Murphy, op cit.

40  Murphy, op cit.

41  Murphy, op cit.

42  APHSA. Interoperable IT for Health and Human Service Programs. September 14, 2012.

43  FRAC, op cit.

44  FRAC, op cit.

45  APHSA 2014, op cit.

46  NASCIO Awards. 2011. Utah EREP: Enterprise Eligibility.

47  Governing. 2010. Utah eREP: An Innovative and Cost-Effective Approach to Transform Social Services Delivery.
Webinar presented April 6. http://www.governing.com/events/webinars/Utah-eREP.html.

48  Erickson, Casey. 2012. Utah’s Eligibility System: Rebooting from the Ground Up. Presentation for the NASHP Annual State Health Policy Conference. Presented October 17. http://www.nashpconference.org/wp-content/uploads/2012/presentations/eri....

49  NASCIO, op cit.; Governing, op cit.; Erickson, op cit.

50  Governing, op cit.

51  Governing, op cit.; NASCIO, op cit.

52  Governing, op cit.; NASCIO, op cit.

53  Governing, op cit.

54  Governing, op cit.

55  Governing, op cit.; NASCIO, op cit.

56  Erickson, op cit.

57  Governing, op cit.

58  Governing, op cit.

59  Governing, op cit.

60  Manatt Health Solutions. Income Verification Product Evaluation. Memorandum to New York State Exchange Team, October 2011; Utah Department of Workforce Services. eFind. (undated)

61  Governing, op cit.

62  Governing, op cit.

63  Governing, op cit.

64  Erickson, op cit.

65  Megan Lape, APHSA, personal communication, 2013.

66  Governing, op cit.

67  Office of Governor Mark Dayton, “Governor Dayton Signs Executive Orders Implementing Medicaid Opt-In In First Act As Governor,” January 05, 2011, http://mn.gov/governor/newsroom/pressreleasedetail.jsp?id=102-9259.

68  Gibson, Karen. “Minnesota’s Early Medicaid Adult Expansion.” April 14, 2011.
http://www.shadac.org/files/shadac/publications/GibsonSlides_EarlyMedica.... The previous Legislature had authorized the Governor to take this action.

69  Kaiser Commission on Medicaid and the Uninsured, States Getting a Jump Start on Health Reform’s Medicaid Expansion, Apr 02, 2012, http://kff.org/health-reform/issue-brief/states-getting-a-jump-start-on-....

70  Goldrick-Rab, Sara, Katharine Broton, Christin Gates. 2013. Clearing the Path to a Brighter Future: Addressing Barriers to Community College Access and Success. University of Wisconsin. Prepared for the Association of Community College Trustees and Single Stop USA.

71  Kauff, Jacqueline, Emily Sama-Miller, Gretchen Rowe, Cicely Thomas, and Libby Makowsky. 2011. Promoting Public Benefits Access Through Web-Based Tools and Outreach. Final Report. Mathematica Policy Research.

72  Goldrick-Rab et al., op cit.

73  Kauff et al., op cit.; Goldrick-Rab et al., op cit.

74  U.S. Department of Education. Federal Pell Grant Program. http://www2.ed.gov/programs/fpg/index.html.

75  Goldrick-Rab et al., op cit.

76  Goldrick-Rab et al., op cit.

77  Goldrick-Rab et al., op cit.

78  Kauff, Jacqueline, Emily Sama-Miller, Gretchen Rowe, Cicely Thomas, and Libby Makowsky. 2011. Promoting Public Benefits Access Through Web-Based Tools and Outreach. Final Report. Mathematica Policy Research.

79  . During the average year in 2009-2011, 78.2 of all returns claiming EITC were filed by the end of the first calendar quarter. Authors’ calculation, IRS, Taxpayer Filing Attribute Report, op cit.

80  Diane Whitmore Schanzenbach. “Experimental Estimates of the Barriers to Food Stamp Enrollment.” Institute for Research on Poverty, Discussion Paper no. 1367-09. Sept. 2009.

81  Eric P. Bettinger, Bridget Terry Long, Philip Oreopoulos, and Lisa Sanbonmatsu, “The Role Of Simplification And Information In College Decisions: Results From The H&R Block FAFSA Experiment,” National Bureau of Economic Research Working Paper 15361 (September 2009). Bettinger and colleagues found that, among dependents, completing the form on behalf of the family raised the proportion submitting applications from 40.2 percent to 55.9 percent—a 40 percent relative increase. Among independent adults, the form completion intervention nearly tripled the likelihood of filing for student aid, raising the form submission rate from 13.8 percent to 39.5 percent.

82  Government Accountability Office, Medicare Savings Programs: Results of Social Security Administration’s 2002 Outreach to Low-Income Beneficiaries, GAO-04-363, March 2004. In the case of MSPs, sending notices increased the volume of phone calls, but few consumers managed to complete the enrollment process.

83  Brenda Freshour Johnston, Reaching Uninsured Children: Iowa’s Income Tax Return and CHIP Project, prepared by the Iowa Department of Human Services for the State Health Access Reform Evaluation project of the Robert Wood Johnson Foundation, with the State Health Access Data Assistance Center serving as national program office, August 2010.

84  John Guhl and Eliot Fishman, New Jersey Family Care: Express Lane Eligibility, State Coverage Initiatives Program National Conference, July 2009.

85  Hoag, et al., op cit.

86  Under the state’s prior approach, a family would check a box on the SNAP form to “opt out” of data sharing. The greatly reduced level of participation that resulted when the state changed from an “opt out” to an “opt in” approach is consistent with considerable behavioral research. See, e.g., Johnson, E.J., and D.G. Goldstein. “Defaults and Donation Decisions.” Transplantation. 78 (12): 1713-1716. December 27, 2004; Sunstein, C.R., and R. H. Thaler.
“Libertarian Paternalism is Not an Oxymoron.” The University of Chicago Law Review. 70 (4): 1159-1202. Fall 2003. Based on such research, the Centers for Disease Control and Prevention now recommend that, in almost all clinical settings, patients should be tested for HIV using “opt-out” regimens, through which they are tested unless they object. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. “Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.” MMWR Recomm Rep. 2006;55(RR-14):1–17. See also Ari Bitnun, Susan M. King, Cheryl Arneson, Stanley E. Read. “Research Letter: Failure to prevent perinatal HIV infection.” CMAJ. 2002 April; 166(7): 904–905. Gayatri C.
Jayaraman, Jutta K. Preiksaitis, Bryce Larke. “Mandatory reporting of HIV infection and opt-out prenatal screening for HIV infection: effect on testing rates.” CMAJ. 2003 March; 168(6):679-82.

87  David Laibson, “Impatience and Savings,” National Bureau of Economic Research Reporter, Fall 2005, pp. 6-8.

88  James J. Choi, David Laibson, and Brigitte C. Madrian. $100 Bills on the Sidewalk: Suboptimal Investment in 401(K) Plans. NBER Working Paper 11554. August. 2005.

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