Opportunities under the Affordable Care Act for Human Services Programs to Modernize Eligibility Systems and Expedite Eligibility Determination. Opportunities presented by the ACA


If all states implemented the ACA’s Medicaid expansion, more people would qualify for Medicaid and CHIP than for SNAP, the need-based program with the second-highest number of eligible people. Assessing SNAP’s reach as of 2010, when the program’s eligibility for childless adults was at historically high levels, Medicaid- and CHIP-eligible nonelderly individuals under the ACA’s Medicaid expansion would exceed those who qualify for SNAP by—

  • 36 percent among such individuals with incomes at or below 138 percent FPL, mainly because Medicaid will cover more childless adults than did SNAP;
  • 47 percent if one also takes into account individuals (mainly children) above 138 percent FPL but does not include CHIP children enrolled in employer-sponsored coverage; and
  • 60 percent, if one also includes CHIP-eligible children in employer-sponsored coverage among those who could potentially qualify for Medicaid or CHIP, in which case the total number of Medicaid/CHIP eligibles would reach an estimated 91.9 million. 19

In addition to Medicaid, another 17.8 million individuals would qualify for subsidies in health insurance marketplaces.

Particularly in states with expanded Medicaid eligibility, health coverage programs will thus become a repository of information about a very large number of low-income households. If health programs have already evaluated the circumstances of someone applying for human services, the human services agency may be able to rely on the health program’s work, lowering the cost of eligibility determination and verification.

Those efficiencies could apply to a considerable fraction of human services agency caseloads. If all states implement the Affordable Care Act’s Medicaid expansion, Medicaid and CHIP eligibility will reach 97 percent of SNAP recipients, 85 percent of families participating in WIC, 99 percent of TANF recipients, and 87 percent of LIHEAP participants under age 65 (Figure 1). This suggests that, once the ACA’s expansions are fully implemented, human services programs may be able to expedite eligibility determination for numerous applicants and participants based on data from health programs.

Figure 1. Among recipients of various human services benefits under age 65, the percentage who will qualify for health programs under the Affordable Care Act

Figure 1. Among recipients of various human services benefits under age 65, the percentage who will qualify for health programs under the Affordable Care Act

Source: Dorn, Isaacs, et al., 2013. Notes: Based on the application of 2014 ACA health coverage rules to estimated average monthly participants in human services programs during calendar year 2010. Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes pre-ACA categories above 138 percent FPL and does not exclude recipients of employer-sponsored insurance. Estimates for children and adults include people with disabilities who receive Medicare. WIC and child care counts include spouses and dependents under age 19 who do not directly receive subsidies. Housing subsidies include public housing and rent vouchers.

Several limitations are important to acknowledge. First, this information shows the potential reach of health programs. That is, we show the number of human services participants who will qualify for Medicaid, CHIP, and marketplace subsidies if states expand Medicaid eligibility. Human services programs will not fully benefit from health programs until the latter have had time to ramp up enrollment among new eligibles.

Second, the information available from health programs may not be recent. Eligibility for health programs will typically be redetermined only once every 12 months, under the ACA’s new procedures. The human services program may thus need to consider the date on which the health program determined eligibility before deciding whether to rely on that determination.

Third, Medicaid programs that have expanded eligibility will often not make precise income determinations. The only fact relevant to financial eligibility is whether a consumer’s income is at or below 138 percent of the federal poverty level (FPL).20

For example, suppose that an applicant attests to income at 115 percent FPL and data matches with prior-year income tax records and recent quarterly wage records show income between 125 and 130 percent FPL. In that case, the Centers for Medicare and Medicaid Services (CMS) have made clear that available data are “reasonably compatible” with the applicant’s attestations and thus verify financial eligibility. The applicant is known to have income below 138 percent FPL and should not be asked for any financial documentation.21

A human services program will need more precise information to decide eligibility if its upper income limit is below 138 percent FPL. Moreover, many human services programs need precise income information to set benefit levels. Such programs may gain little from learning that a particular consumer qualified as financially eligible for Medicaid in a state that expanded eligibility.

It is important to note that neither of these timeliness and imprecision issues affect SNAP, which typically updates eligibility information every six months and attempts to ascertain income levels with great exactitude to determine benefits. It is true that SNAP does not offer Medicaid’s advantages in terms of the largest possible number of consumers potentially reached after full ACA implementation and the near-term benefits of accessing 90 percent federal funding to modernize eligibility systems. Nevertheless, SNAP is the country’s second-largest need-based program and a valuable information resource for other human services programs considering integration strategies for streamlining eligibility determination and verification. In addition, child support agencies are an important source of information that can help determine and verify eligibility for both health and human services programs. The latter agencies are likely to serve as useful partners given their experience in data matching, knowledge of confidentiality and data security issues, their regular practice of mandatory data exchange with numerous health and human services programs, and their access to a broad range of information sources potentially relevant to eligibility.

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