Opportunities under the Affordable Care Act for Human Services Programs to Modernize Eligibility Systems and Expedite Eligibility Determination. Streamlining human services programs’ eligibility determinations by accessing data from health programs


Once the ACA’s insurance affordability programs are fully phased in, Medicaid will be the country’s most widely-used need-based program—particularly in states that expand eligibility. If all states did so, the number of people eligible for help would be up to 60 percent higher for Medicaid than for the Supplemental Nutrition Assistance Program (SNAP), the need-based program with the second-largest number of people who qualify for help. Even among individuals with incomes below 138 percent FPL, expanded Medicaid eligibility would reach more than a third (36 percent) more people than SNAP.

Under nationwide Medicaid expansion, Medicaid and CHIP eligibility would reach 97 percent of SNAP recipients, 85 percent of families participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), 99 percent of recipients of Temporary Assistance to Needy Families (TANF), and 87 percent of participants in the Low Income Home Energy Assistance Program under age 65.1

Especially in states that expand Medicaid, health programs are likely, several years hence, to have considerable information about the vast majority of low-income households who apply for or receive human services benefits. Much of the data will be stored by marketplaces or subject to marketplace legal requirements. Under federal regulations revised in March 2014, human services programs can access most of this information (except for tax records) by taking several steps:

  • obtaining consent from the affected individuals;
  • showing that the health insurance marketplace would benefit; and
  • ensuring that the information will remain protected by confidentiality and data security safeguards no less stringent than those that apply within the marketplace.

TANF, SNAP, and certain other human services program can also access Medicaid information directly, outside the marketplace, under Social Security Act §1137.

Household definitions and other detailed eligibility rules differ between human services programs and Medicaid, which for most beneficiaries now follows Modified Adjusted Gross Income (MAGI) principles derived from federal income tax law. Nevertheless, eligibility information from Medicaid records could prove useful to human services programs, in several ways:

  • Medicaid records could confirm that particular individuals meet non-financial eligibility requirements for human services benefits, such as citizenship or status as a qualified alien.
  • The human services program could “deem” someone eligible based on Medicaid’s finding of financial eligibility, notwithstanding technical differences between program eligibility rules.
  • The human services program could change its eligibility rules so that, for some or all households, Medicaid and the human services program define income in the same way. A Medicaid income determination could then establish eligibility and benefit levels for the human services program.
  • Medicaid’s records could be used to pre-populate an application form for human services benefits—e.g., with an address or social security number—or provide the human services program with verification obtained by the health program, either confirming eligibility for human services or raising a “red flag” suggesting a need for further investigation.

Which (if any) of these strategies proves most useful will depend on the circumstances facing the human services program in the applicable state.

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