Examples of Promising Practices for Integrating and Coordinating Eligibility, Enrollment and Retention: Human Services and Health Programs Under the Affordable Care Act. Pairing volunteer tax preparers with health application assisters


Single Stop’s work connecting individuals to services and benefits is not limited to helping students at community colleges. Another initiative focuses on volunteer tax preparation sites in New York City. Single Stop funds nonprofit tax preparers so that, when their low-income clients file federal income tax returns to claim Earned Income Tax Credits (EITC), child tax credits, or other tax refunds, the clients can also obtain additional benefits or services for which they qualify. One such service is health coverage. As a small part of its overall program, Single Stop has encouraged some volunteer tax preparers to link their low-income clients with health application assisters, who enroll them into Medicaid or CHIP. In the past, “Facilitated Enrollers” (FE) in New York’s Medicaid and CHIP programs have most often been employed by health plans but sometimes consisted of the staff of community-based organizations.

While the practice varies by site, the consumer typically goes through the intake process and provides information that is entered into BEN, Single Stop’s screening tool, described above.78 The tax preparer helps the person with his or her taxes and then takes the person to the on-site facilitated enroller. The FE then helps the consumer apply for health coverage. In order to avoid potential criminal liability for sharing confidential tax information with FEs, the FE does not receive any tax information for the individual. Instead, the FE uses the BEN intake form as the basis for the health application. The FE asks additional questions of the individual as needed, then files an application for Medicaid and CHIP.

Many sites do not include a facilitated enroller, and even those with FEs have them available only at certain hours. If the FE is not present, the consumer can have his or her contact information shared, letting the FE reach out to the consumer after the tax preparation visit and enroll the consumer into health coverage.

This effort has been, in the words of one key informant, “great in theory, but a heavy lift” in practice. Only a minority of tax filers have been helped to apply for health coverage.

One challenge involves the temporary nature of tax preparation services. Tax preparers are often short-term volunteers without the expertise to do more than tax preparation. Also, tax preparation services are heavily concentrated in a relative short amount of time. More than 78 percent of returns that claim EITCs are filed before March 31.79 Linking tax preparers to organizations that already have health knowledge—that is, FEs—eliminates the need for tax preparers themselves to acquire that knowledge. However, shuttling clients from tax preparers to FEs in crowded quarters can create challenges, and it is easy for information to get lost in the process or for clients to get discouraged and leave.

A second challenge involves potential criminal liability for sharing tax information. As explained earlier, that issue was circumvented by using intake information, rather than tax information, to complete applications for health coverage. However, that “work around” makes the process much less efficient than the more automated procedures normally employed by Single Stop in other contexts.

A third challenge involves the “push back” Single Stop received when it first started encouraging tax preparers to help their clients qualify for non-tax benefits. Over the years, the organization’s tax preparers have grown increasingly receptive to providing more comprehensive services. Single Stop staff note that while there was a desire to help people, tax preparers were sometimes hesitant to take on additional tasks due to organizational issues related to the nature of tax preparation services, including the limited expertise and time of volunteer tax preparers.

Fourth, as indicated above, most FEs serving the state’s Medicaid and CHIP programs were health plan staff. When a community organization served as an FE, significantly above-average results were typically obtained, according to Single Stop officials. Such improved results could become more common under the ACA since New York’s Navigators and other health application assisters will mainly consist of mission-driven, community-based organizations.

Fifth, low-income people filing tax returns tend to be very focused on completing the tax filing process and obtaining refunds. Given the hectic atmosphere of nonprofit or volunteer tax preparation sites, consumers may be forced to wait before seeing the tax preparer, with whom consumers often have no prior relationship. Linking low-income tax filers to public benefits of any sort is not easy, and health coverage is no exception. After finally meeting with a tax specialist and obtaining a tax refund, many low-income people are not willing to spend the additional time needed to meet with a FE and enroll into health coverage.

Sixth, as indicated earlier, FEs did not have the staff needed to be present at tax filing sites whenever low-income consumers were seeking aid. In the majority of tax filing sites, FEs were never present on site. Even in sites where FEs were sometimes present, they would generally be available only part-time—typically between 10 am and 2 pm, and just two days per week.

FEs face a fundamental trade-off. To help the largest number of consumers, they need to be present when tax preparation sites are at their busiest. But it is at precisely such times when low-income consumers have the least willingness to wait the additional period of time that is often required to apply for health coverage.

The model of using “the tax filing moment” to jump-start enrollment into health coverage has substantial appeal. Many low- and moderate-income people who will qualify for health coverage in 2014 and beyond are motivated to file federal income tax returns, both to claim refunds and, in some cases, to comply with their legal duty to file. Further, filing tax returns is less stigmatized than applying for public benefits. On the other hand, successful partnerships between tax preparers and health application assisters are not always easy to develop.

National conversations among organizations providing nonprofit tax preparation services to low- and moderate-income consumers are increasingly exploring the nexus between health coverage and tax filing, according to Single Stop staff who are part of those discussions. The combination of tax-enforced penalties for failing to obtain coverage, tax credits to subsidize premiums in health insurance marketplaces, and the risks of tax reconciliation obligations if advance payment of such credits turn out to be excessive, all create a natural link between tax filing and applications for health coverage. The nonprofit tax preparation community has been expressing increased interest in helping low-income taxpayers obtain health coverage as part of tax filing.

Single Stop is now transitioning to the direct provision of tax preparation and health enrollment services on-site. Instead of the past bifurcated service delivery model, with volunteers furnishing tax preparation services and a FE helping consumers enroll into health coverage, Single Stop plans to provide both sets of services, with health application assistance supported through New York’s “Navigator” program. Notwithstanding past challenges, Single Stop’s leaders believe that combining free tax-preparation services with enrollment into health coverage offers enormous potential to provide health coverage for numerous low- and moderate-income uninsured. They are optimistic that additional resources will make it possible to surmount the obstacles this strategy has experienced to date.

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