Issues in Developing Programs for Uninsured Children: A Resource Book for States. C. Eligibility Verification Process

03/02/1998

The complexity of state eligibility verification processes is dependent upon the number of verification requirements and the resources available to program staff. Of the nine study states, seven had administrative staff employed by the program (or the state agency) to process enrollment and verify eligibility. New York and Pennsylvania were the two exceptions. Both New York and Pennsylvania require the health plans with which they contract to collect applications and determine the eligibility of applicants. Enrollment processing time is variable across states and programs. The time of application to actual program enrollment ranged from one day in Massachusetts and Tennessee to four months in Pennsylvania. The wait time in Minnesota is typically 30 days for processing and an additional 30 days, pending awaiting payment of the premium. There have been delays from time-to-time when program expansions create an influx of new applicants. Pennsylvania noted that the processing of an application requires approximately one month; however, as a result of their current waiting list, there may be a three to four month delay before coverage begins.

Some states utilized presumptive eligibility as a strategy to reduce the waiting time between the point of application and enrollment into the program. With presumptive eligibility, children are assumed eligible for a specific period of time until the documentation of their eligibility can be verified. Once complete, children are either officially enrolled or disenrolled in the program, depending on eligibility status. Currently, both Massachusetts' Children’s Medical Security Plan and New York's Child Health Plus Program use presumptive eligibility.

Table 3: Verification Methods

Program Verification Responsibility Presumptive Eligibility Average Time From Initial Application To Enrollment
CaliforniaKids Program Staff verify eligibility of applicants. No presumptive eligibility. Processing time is 2-6 weeks.
Colorado Children’s Health Plan (CCHP) Program Staff verify eligibility of applicants. Colorado also contracted with a foundation to help process applications. Yes-Children are considered "eligible" on the date that the application form is mailed to CCHP. "Presumptive eligibility" lasts until verification is complete and the child is placed into an HMO. During the time of presumptive eligibility, the child’s care is paid by CCHP on a fee-for-service basis. Processing time is 15-45 days.
Florida Healthy Kids Program Staff verify eligibility of applicants. School district and Medicaid Department provide enrollment databases for their programs to facilitate process. No-This has been considered, but there is not strong support from the public due to the chance that ineligible children would start to be subsidized by local funds. Processing time is 4-6 weeks. Enrollment begins the first of the month after verification.
Children’s Medical Security Plan (CMSP) Program Staff verify eligibility of applicants. Yes- Children can be presumptively enrolled for up to 45 days while family eligibility is verified. It takes approximately one week for enrollment to begin for families who mail in the application form. Coverage begins immediately for children who apply by phone due to presumptive eligibility rules.
Massachusetts Children’s Medical Security Plan (CMSP) Program Staff verify eligibility of applicants. Yes- Children can be presumptively enrolled for up to 45 days while family eligibility is verified. It takes approximately one week for enrollment to begin for families who mail in the application form. Coverage begins immediately for children who apply by phone due to presumptive eligibility rules.
MinnesotaCare Program Staff verify eligibility of applicants for both MinnesotaCare and Medicaid. No presumptive eligibility. It takes approximately 30 days to process the application. Families then must pre-pay for their first month’s coverage. Enrollment starts the first day of the following month. It usually takes 2-3 months from when the application is submitted until enrollment begins.
New York Child Health Plus Participating HMOs verify eligibility of applicants. Yes-Children can be presumptively enrolled for up to 60 days while family eligibility is verified. Enrollment under presumptive eligibility begins as soon as the application is received and is made permanent when the necessary documentation is submitted. The child is dropped from CHP if the family does not submit the necessary documentation by the end of the 60 day presumptive eligibility period.
Pennsylvania Children’s Health Insurance Program (CHIP) Participating HMOs verify eligibility of applicants. No presumptive eligibility. It takes approximately 1-2 months to process the application. Usually an additional 3-4 months on the waiting list before enrollment begins.
TennCare Program Staff verify eligibility of applicants. No presumptive eligibility for children. Pregnant women are allowed 45 days of presumptive eligibility. Applicants make an appointment with the county health department and are told what documentation to bring when they come. Appointments take about 15 minutes. Benefits for qualified applicants begin that day.
Washington Basic Health Plus The Department of Social and Health Services (DSHS) does the eligibility verification of applicants and enrollment for both Basic Health Plan and Basic Health Plus. The list of eligible names are then forwarded to both agencies. No presumptive eligibility. On average, it takes between 5-6 weeks for a child to be enrolled in Basic Health Plus. Families must enroll by a specific date the month before coverage begins, so it can sometimes take longer if children apply at the end of the month.