Interim Evaluation Report: Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. B. Program and Policy Characteristics

02/26/2003

Eligibility Policies and Enrollment Processes

Simple Applications. The study states have adopted a variety of policies aimed at keeping the SCHIP application process simple (see Table 8). Specifically, every state has developed a joint application form for its SCHIP and Medicaid programs (ranging from one to eight pages), and none of them requires a face-to-face interview with an eligibility worker; families can apply for SCHIP by mail. In addition, to keep enrollment simple, five of the six states do not use an assets test in SCHIP. One of the states--New York--has adopted (but not yet implemented) presumptive eligibility for SCHIP applicants. 37

Another aspect of simple applications is minimal documentation requirements (see Table 9). Four study states do not require families to verify children's ages; four do not require them to document state residency; three do not require them to verify income the state has disregarded; three do not require families to verify their immigrant status; and none of the study states requires families to submit verification of their children's social security numbers. In the one state (Missouri) that applies an assets test for SCHIP, families do not have to submit documentation. All six study states, however, require that applicants submit verification of income (Missouri initially permitted families to self-declare their income).

Most states have simplified Medicaid application rules and procedures since the implementation of SCHIP. However, the Medicaid application process typically remains more difficult than the process for SCHIP (see Table 8). For example, Medicaid programs have been less likely than SCHIP programs in the same states to minimize verification requirements (Table 9). Medicaid programs in the study states often require applicants to submit verification of income deductions, assets, children's ages, residency, immigration status, and social security numbers--requirements they do not impose on SCHIP applicants. Further, only two of the six study states have eliminated assets tests for Medicaid, compared to five for SCHIP.

Continuous Eligibility and Retroactive Eligibility Policies. Four of the six study states extend 12-month continuous eligibility to children in their SCHIP programs. 38 Only three of the six states do so for children in their Medicaid programs (Texas extends 12-month continuous eligibility in its SCHIP program but 6-month continuous eligibility in its Medicaid program). Medicaid is required by law to make eligibility retroactive to 90 days prior to the date

TABLE 8: 
SCHIP AND MEDICAID SIMPLIFICATION STRATEGIES
State Simplification Strategies
Joint Application No Face-to-Face Interview Dropped Assets Test 12-Month Continuous Eligibility Presumptive Eligibility Retroactive Eligibility
  (Length) a SCHIP Medicaid b SCHIP Medicaidb SCHIP Medicaid b SCHIP Medicaid b SCHIP Medicaidb,c
California ✓(4)       d
Colorado ✓(8)         d
Louisiana ✓(2)     c
Missouri ✓(2)              
New York ✓(2)   e f  
Texas ✓(2) g   h      

Sources: 
Centers for Medicare & Medicaid Services (CMS), Framework For State Evaluation of Children's Health Insurance Plans Under Title XXI of the Social Security Act, 1999: California, March 2000. Web site http://cms.hhs.gov/schip/caeval98.pdf
Kaiser Commission on Medicaid and the Uninsured. Comparison of Medi-Cal and Healthy Families Programs in California, October 2000. 
Centers for Medicare & Medicaid Services (CMS), Annual Report of State Children's Health Insurance Plans Under Title XXI of the Social Security Act: Colorado, November 2000. 
Centers for Medicare & Medicaid Services (CMS), "Application and Enrollment Simplification Profiles: Medicaid for Children and SCHIP"; 
Centers for Medicare & Medicaid Services (CMS), Framework for Annual Report of State Children's Health Insurance Plans Under Title XXI of the Social Security Act: New York State, November 2000. CMS Web site [http://cms.hhs.gov/schip/charny99.pdf] 
Centers for Medicare & Medicaid Services (CMS), Framework For State Evaluation Of Children's Health Insurance Plans Under Title XXI of the Social Security Act, 1999: Texas, March 2000. Web site [http://cms.hhs.gov/schip/txeval98.pdf]

Notes: 
aThe numbers of pages in the application form are shown in the table. The application package includes instructions of varying length. 
bChildren's programs under Title XIX. 
cRetroactive to up to three months prior to date of application. 
dMedicaid policy requires retroactive coverage to date of application in many cases. 
eNew York has a 12-month redetermination cycle. 
fPresumptive eligibility for children was approved in the 1998 New York Health Care Reform Act, but it has not been implemented. 
gTexas has since taken action to allow children (but not adults) to apply for Medicaid without a face-to-face interview. 
hContinuous eligibility under Medicaid in Texas is for 6 months, not 12.


TABLE 9: 
VERIFICATION REQUIRED FROM APPLICANTS TO SCHIP AND MEDICAID
  Verification Requirements

State

Income Deductions Assets Age State Residency Immigration SSNe
  SCHIP Medicaidc SCHIP Medicaidc SCHIP Medicaidc SCHIP Medicaidc SCHIP Medicaidc SCHIP Medicaidc

California

Net Net NA        

Colorado

Net Net   NA            

Louisiana

Net Net NA NA a a     b b    

Missouri

Gross Net NA     a a b b a a

New York

Grossd Net NA NA NA     NA

Texas

Net Net NA          

Notes: SSN = social security number. 
Blank indicates that self-declaration is sufficient. 
NA = not applicable. 
aVerified using state databases. 
bFor applicants who are noncitizens. 
cChildren's programs under Title XIX. 
dSelf-declaration of income is permitted as a last resort, when no income verification can be provided. 
eNote that this refers to the verification of the SSN. NA indicates that the SSN is not required.

Sources: Donna Cohen Ross and Laura Cox, Making It Simple: CHIP Income Eligibility Guidelines and Enrollment procedures: Findings from a 50-State Survey.Kaiser Commission on Medicaid & the Uninsured, October 2000. 
Centers for Medicare & Medicaid Services (CMS), Framework For State Evaluation Of Children's Health Insurance Plans Under Title XXI of the Social Security Act, 1999: California. March 2000. Web site [http://www.hcfa.gov/init/caeval98.pdf] 
Kaiser Commission on Medicaid and the Uninsured. Comparison of Medi-Cal and Healthy Families Programs in California, October 2000. 
Annual Report of State Children's Health Insurance Plans Under Title XXI of the Social Security Act: Colorado November 2000. 
Centers for Medicare & Medicaid Services (CMS), Application and Enrollment Simplification Profiles: Medicaid for Children and SCHIP. 
Centers for Medicare & Medicaid Services (CMS), Framework for Annual Report of State Children's Health Insurance Plans Under Title XXI of the Social Security Act: New York State, November 2000. CMS Web site http://www.hcfa.gov/init/charny99.pdf ] 
Centers for Medicare & Medicaid Services (CMS), Framework For State Evaluation Of Children's Health Insurance Plans Under Title XXI of the Social Security Act, 1999: Texas, March 2000.Web site [http://www.hcfa.gov/init/txeval98.pdf]


TABLE 10: 
AVENUES FOR SUBMITTING SCHIP AND MEDICAID APPLICATIONS
  Avenue of Submission
State Mail-In Applicationa Community-Based Enrollment Phone Applicationb Internet Applicationb County Social Services
  SCHIP Medicaid c SCHIP Medicaid c SCHIP Medicaid c SCHIP Medicaid c SCHIP Medicaid c
California     d  
Colorado     e  
Missouri     f  f    
Louisiana        
New York g          
Texas h    

Notes: 
aTherefore, no face-to-face interview is required. 
bSignature required either electronically or as a hard copy. 
cChildren's programs under Title XIX. 
dCurrently in a pilot phase. Soon to be introduced on a county-by-county basis. 
eCurrently under development. 
fPhone center staff fill out the application during the phone call, but then mail it to the family for a signature. The family then mails the signed application back to the phone center for final processing. 
gA face-to-face interview is required for children referred to Medicaid, but it can be conducted by a facilitated enroller rather than a social services worker. 
hTexas now allows mail in applications to Medicaid for children (but not adults).

Source: Information obtained during each site visit.


of application. SCHIP programs, like private insurance, for the most part begin coverage after an application has been approved, or as of the application date. 39

Enrollment Procedures. Children in the study states can enroll in SCHIP and Medicaid in many ways. These methods, displayed in Table 10, are summarized below:

  • Mail. All six study states accept mailed-in SCHIP applications. They adopted this policy to make it easier for parents to apply and to avoid any resistance that might arise from requirements to meet with an eligibility worker in a social services agency. Although five states permit mail-in applications to be used for both SCHIP and Medicaid, New York requires a face-to-face interview for those children who apply for, or are referred to, Medicaid. 40
  • Community-Based Application Assistance. Five states have introduced community-based help for families completing program applications, as discussed extensively in Chapter VI, which describes states' outreach activities.
  • Telephone Assistance. Two states can take applications by telephone. Missouri has established seven regional telephone application assistance centers. The state's outreach materials display a toll-free hotline number. Phone center staff can take an applicant's personal information over the phone, make a preliminary eligibility determination based on that information, and then mail the application to the parent for a signature. Alternatively, phone center staff can just mail parents a blank application. Texas has a similar system; however, its hotline staff typically mail applications to families, rather than completing applications over the phone, due to a high volume of calls.
  • Internet. Three states are exploring using the Internet to facilitate SCHIP and Medicaid enrollment. California and Texas have pilot-tested Internet-based applications and are introducing their systems in selected counties. California's Certified Application Assistors and Outreach Contractors initially will use the Health-E Application to help families apply. Texas' "E-Z App" will be directly available to consumers for them to complete their applications online. Although Colorado has been designing a similar program since the program began, it is not yet in use.
  • County Departments of Social Services. Finally, in all six study states, families can apply for SCHIP coverage at county welfare offices or with eligibility staff outstationed at public clinic and hospital sites. In states with separate programs, families applying in this way typically complete the longer Medicaid (or multiprogram) application and eligibility is reviewed for the entire family. This process can lead to referrals to SCHIP for children in families with incomes or assets above Medicaid limits. The county staff we interviewed stated that they infrequently help families complete SCHIP application forms; instead, they refer families to SCHIP but also may give them a SCHIP application form. In states with Medicaid expansions, of course, county social services agencies review applications for both SCHIP and Medicaid eligibility.

Screen-and-Enroll Procedures. To ensure that children eligible for Medicaid are enrolled in Medicaid rather than SCHIP, states must review every SCHIP application for Medicaid eligibility before covering any child under SCHIP. In the two study states with Medicaid expansion programs, Louisiana and Missouri, screen-and-enroll is relatively simple; social services staff in county offices, phone centers, and application centers review all applications and determine which program each child is eligible for.

In the four states with separate programs, screen-and-enroll procedures have proven complex. This occurs primarily because county social services agencies retain responsibility for Medicaid, while a different entity is responsible for determining SCHIP eligibility. Thus, states needed to develop mechanisms for transferring applications back and forth between these entities. In California, Colorado, and Texas, vendors act as "single points of entry" into SCHIP and Medicaid; all applications in these states are mailed to the vendors, who then conduct screen-and-enroll reviews. The vendors process SCHIP-eligible applications but transfer to county social services offices in the child's county of residence applications for those children who appear to be Medicaid-eligible. In New York, no single point of entry exists; instead, "Facilitated Enrollers" and their "lead agencies" conduct screen-and-enroll and make referrals to county social services offices.


37. Presumptive eligibility policies permit designated local agencies and providers to deem someone "presumptively eligible," based on information provided by the applicant. Services may then be provided (and will be paid for) for these applicants during the time period, until the state completes its official eligibility determination.

38. Neither Missouri nor New York guarantees continuous coverage for 12 months in the SCHIP program, although both states redetermine eligibility every 12 months. During that period, families must notify the state of any changes in income or family structure that could affect their eligibility status.

39. Of the two Medicaid expansion programs in the study, Missouri, under its Section 1115 Medicaid demonstration, provides no retroactive coverage to Title XXI enrollees.

40. In New York, a qualified "Facilitated Enroller" can conduct the face-to-face interview, rather than a county social services worker.

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