Opportunities under the Affordable Care Act for Human Services Programs to Modernize Eligibility Systems and Expedite Eligibility Determination. Addressing differences between program rules for health and human services programs


Health and human services programs may use different rules for determining eligibility, including:

  • Different definitions of the household members whose needs and resources are considered in determining eligibility;
  • Different methods for valuing or counting income or assets; and
  • Different deductions or disregards that are subtracted from “gross” income to determine the “net” income levels used to decide final eligibility or benefit levels.
Now that much of the ACA has gone into effect, most Medicaid consumers who are under age 65 and who do not have a disability will have their eligibility determined using Modified Adjusted Gross Income (MAGI), which is based on federal income tax law. For households consisting of parents, step-parents, and their minor children living together, Medicaid’s household definitions are now closer than in the past to those used by human services programs. Income disregards and income-counting rules, however, depart significantly from traditional public benefit principles.
Notwithstanding these differences, a range of strategies are available for using information from health programs to facilitate eligibility determination and verification by human services programs.28 For example:
  • Medicaid records could establish, verify, or confirm non-financial eligibility. When Medicaid uses definitions and verification procedures that are at least as stringent as those employed by the human services program, a finding of Medicaid eligibility should suffice to establish that the household meets the applicable requirement for purposes of the human services program. Examples of such non-financial factors include—
    • Citizenship or qualified alien status;
    • State residence; and
    • Non-incarceration.
  • The human services program could “deem” someone eligible based on their receipt of Medicaid, notwithstanding differences in the technical details of the two program’s eligibility rules. WIC already does this by granting so-called “adjunctive eligibility” whenever an applicant has already been found eligible for Medicaid. As another example, the National School Lunch Program is conducting pilot projects under which children automatically qualify for free school lunches, without any need to conduct separate income determinations, if Medicaid has already found that they have family income at or below 133 percent FPL.29 (Federal law is more likely to permit rule changes along these lines in a human services program that operates pursuant to a federal block grant than with uncapped funds, since block grant programs typically provide states with considerable flexibility in defining eligibility criteria.)
    • As one variant of the “deeming” approach, a human services program could deem eligibility only for limited purposes where the program finds it particularly warranted. For example, LIHEAP might grant automatic financial eligibility for crisis assistance, but not for other forms of aid, when households have been found eligible for Medicaid based on income at or below 138 percent FPL.
  • A human services program could change its rules to more closely resemble those applied by Medicaid under MAGI principles. Such a program could automatically grant eligibility and at least interim benefit levels based on Medicaid’s eligibility determinations.
    • A human services program may value, for policy reasons, income disregards that are not included in the MAGI income determination. Such a program could inform households that they may be able to obtain more generous benefits or a more favorable eligibility determination by providing information showing they qualify for such income disregards. As a result, if behavioral factors prevent a household from providing this information, at least the household will receive human services benefits based on the Medicaid eligibility determination. But a household that is willing and able to demonstrate qualification for an applicable income disregard can do so and obtain additional assistance.
    • A human services program could likewise prefer to retain its traditional household definitions, rather than move to those used for federal tax purposes. Among other reasons, that may avoid exposure to increased benefit costs, depending on the state and the benefit program. In such cases, officials could simply decide that they will incorporate MAGI income counting and income deduction rules. For households that are defined in the same way both by MAGI rules and by the human services program—which will often mean that they consist of parents, step-parents, adoptive or foster parents, and/or their minor children living together—the Medicaid eligibility determination will suffice to establish eligibility and benefit levels for the human services program. With other household types, additional work will be required to build on Medicaid’s findings and reach a determination of human services eligibility.
  • Medicaid’s records could provide specific information that is used to automatically pre-populate an application form for human services benefits. Examples of such information include address and social security number. Other information, such as that contained in payroll records, quarterly wage records, or state tax records already obtained by the Medicaid agency, could help verify eligibility for the human services program, sparing the latter program the need to seek out that same information.
  • Information in an applicant’s Medicaid records could either confirm attestations in a human services application or raise “red flags” suggesting a need for further verification—in either case, safeguarding program integrity for the human services program.

Which (if any) of these strategies is most useful will depend on the specific circumstances facing the human services program, including the state in which it operates.

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