Overlapping Eligibility and Enrollment: Human Services and Health Programs Under the Affordable Care Act. Appendix I. Analytic Framework

12/23/2013

This appendix describes a systematic approach to developing and categorizing specific data usage strategies that involve pairing a health program with a human services program for integration or coordination of eligibility determination, enrollment, or retention. Here, our goal is to identify analytic strategies (including a typology of approaches) that policymakers may find useful in many different contexts.

The specific human services programs analyzed here include SNAP, WIC, TANF, CCDF, LIHEAP, EITC, Section 8 housing vouchers, public housing, Unemployment Insurance (UI), and child support enforcement. The specific health programs include Medicaid, CHIP and subsidies in Health Insurance Marketplaces (HIM). With each pairing, one can define multiple options that vary based on the following factors:

  • The purpose of the data use. Such purposes can include (1) establishing eligibility and determining benefit levels, (2) simplifying eligibility determination, or (3) structuring facilitated enrollment campaigns. The table below provides more specificity about particular data use methods in each of these three categories.
  • Data flows in both directions—that is, (1) using health program data to help with human services program eligibility determination and (2) using human services data to help with health program eligibility determination.
  • The nature of the data that are sent from the “originating” program, including (1) the simple fact of eligibility, (2) a program’s determination of a specific fact (e.g., a certain net household income), or (3) verification gathered by the program to establish that fact (e.g., quarterly wage records that show a particular individual receiving a certain wage level during a specific quarter).
  • Caseload selectivity—that is, whether data from the originating program are gathered from (1) all participants in a particular program or (2) only participants with certain characteristics (e.g., those whose income was found to fall below a certain level, or those with a household configuration that fits a certain definition).
  • The specific eligibility requirements involved when data are used to establish eligibility, determine benefit levels, or simplify eligibility determination. Such requirements include (1) income, (2) citizenship, (3) immigration status, (4) state residence, and (5) non-incarceration.
  • Using data for (1) initial enrollment and (2) retention.

Feasible and productive data uses will vary across states (and sometimes localities) because of different eligibility rules (such as in TANF, CCDF, and LIHEAP); procedures for outreach, application and enrollment; administrative data systems; and agency and departmental organization.

Table A1. Purposes and methods of using data from one program to strengthen another program’s eligibility determination

Method Concept
(A is the sending program; B is the receiving program)
Examples that illustrate the concept Comments about the method
Program pairing and direction Strategy
Purpose: Using data from one program to establish eligibility and determine benefit levels for another program
1. Entailed eligibility If A uses the same or a more restrictive approach to a particular eligibility requirement as B, and A has found that someone meets that requirement, then B automatically finds that the person meets the requirement. Medicaid and health insurance marketplace subsidies to TANF, SNAP, LIHEAP, and child care subsidies If Medicaid and HIM subsidies define state residence and current non-incarceration no more broadly than do TANF, SNAP, LIHEAP, and child care subsidies, then the latter programs automatically find state residence and non-incarceration for consumers who had those findings made by Medicaid or the HIM. Usually involves eligibility alone, not benefit levels.
SNAP to Medicaid In cases where SNAP’s determination of citizenship uses the same verification methods applied by Medicaid, then Medicaid citizenship requirements are satisfied by the SNAP determination.
2. Deemed eligibility Whether or not A’s approach to a particular eligibility requirement is sometimes more expansive than B’s, if A has found that someone meets that requirement, then B automatically finds that the person meets the requirement. SNAP to Medicaid Anyone who qualifies for SNAP is automatically deemed income-eligible for Medicaid, notwithstanding different eligibility methodologies used by the two programs.22 If B is CHIP or HIM subsidies, must define the approach to Medicaid “screen and enroll.” In some cases, may need to change or waive certain federal or state policies.
Medicaid to child care subsidies At renewal of eligibility for child care subsidies, a family receiving MAGI-based Medicaid is automatically found financially eligible for child care subsidies.
3. Changing policy to align eligibility B changes an eligibility requirement to align with A’s rules for that requirement. Accordingly, if A finds that someone meets the requirement, B automatically makes the same finding. Medicaid to TANF TANF changes its income rules to be consistent with MAGI-based Medicaid, establishing eligibility and benefit levels accordingly. As a result, Medicaid recipients seeking TANF need not provide income information. Requires state to change program B’s eligibility requirements. In some cases, may need to change or waive federal requirements.
4. Incorporating and modifying eligibility determinations of other agencies Using any of methods 1-3, after A has made a finding about an eligibility requirement, B uses additional information to make a final determination about that requirement. Medicaid to TANF TANF begins with income findings from MAGI-based Medicaid, then applies additional income disregards to determine final net income for TANF, establishing eligibility and benefit levels accordingly. Usually involves income, not other eligibility requirements. In some cases, may need to change or waive federal requirements.
5. Presumptive eligibility If A has found that someone meets specified eligibility requirements, B provides temporary benefits until the consumer obtains a standard eligibility determination for B. WIC to Medicaid If WIC determined a household’s income level while establishing eligibility, and that level is below 138 percent FPL, Medicaid provides temporary eligibility. Typically involves initial enrollment, not renewal. Typically based on A’s income determination.
Purpose: Using data from one program to simplify eligibility determination for another program
6. Verification of eligibility If A has found that someone meets a particular eligibility requirement, B treats that finding as sufficient verification of an attestation of eligibility. SNAP to Medicaid If a Medicaid applicant attests to financial eligibility, receipt of SNAP verifies income-eligibility, and the applicant is not asked to provide further income documentation. May involve eligibility alone, not benefit levels.
7. Determining federal matching rate Receipt of A is used as a factor in distinguishing between B enrollees who qualify for various federal matching rates. TANF to Medicaid TANF receipt is one factor in an algorithm that distinguishes newly eligible adults from other adults. Not the standard method under final regulations, which uses MAGI to determine FMAP.
8. Reducing information or document requests from consumers If case files for A show household information (e.g., address or SSN) or facts relevant to eligibility for B, then B uses such facts to prepopulate forms, dynamically structure questions to lessen consumer burdens, or present profile to consumers for confirmation. Medicaid to SNAP Medicaid income verification, including pay stubs presented by applicant, is incorporated into SNAP eligibility files. SNAP determines eligibility without asking applicant to provide that information again. Data could go directly from A to B, or data from both programs could be shared in a common electronic case record or data warehouse.
WIC to HIM subsidies Address, name, and household composition information from WIC records are shared with HIM. When consumer applies for subsidies, HIM includes this information in the profile it presents to the applicant for confirmation.
Purpose: Using data from one program to structure facilitated enrollment into another program
9. Using data to target facilitated enrollment Some or all recipients or other people “touched” by A are targeted for facilitated enrollment into B. Medicaid to SNAP People who receive Medicaid but not SNAP receive phone calls to help them sign up for SNAP. This method is limited to facilitated enrollment. It does not include referral and mailing strategies that have often been ineffective in the past.23
Unemployment Insurance (UI) to Medicaid and HIM subsidies On UI forms, applicants are asked if they want help paying for health coverage; and if so, how the state health agency should contact them. The HIM then follows up to help them apply for health coverage.
10. Joint campaigns for facilitated enrollment If A is conducting an outreach campaign with facilitated enrollment, the campaign also helps people sign up for B. EITC to Medicaid and HIM subsidies Annual EITC outreach campaigns are expanded to include efforts to help consumers sign up for health coverage. Typically used for initial application, not renewal.

A single initiative can incorporate multiple methods listed in this table. Here is an example that combines deemed eligibility (Medicaid to LIHEAP); reducing requests from consumers (Medicaid/HIM subsidies to LIHEAP and SNAP); and using data to target facilitated enrollment (Medicaid to SNAP and HIM to LIHEAP):

  • When a consumer finishes a web application for health coverage, the consumer is asked if he or she wants to have information from the health application shared with the state’s SNAP and LIHEAP agencies to see if the person qualifies for help with food and utility costs.
  • People who say yes are asked how best to reach them (phone, text, email, mail, etc.) if additional information is needed.
  • If the applicant consents, data gathered by the health coverage eligibility system (including information provided by the consumer and, to the extent they can be shared, verifications obtained from external data sources) are transferred to populate eligibility records for SNAP and LIHEAP.
  • SNAP follows up to obtain any additional information needed to determine eligibility and benefit levels, either as part of the same on-line session in which the consumer applied for health coverage or (using the communication method requested by the consumer) through a later phone call, text message, email, etc.
  • LIHEAP automatically grants eligibility for consumers who qualify for MAGI-based Medicaid, notwithstanding the different eligibility methodologies normally applied by the two programs.
  • LIHEAP follows up to obtain any additional information needed to determine LIHEAP eligibility for consumers who qualify for HIM subsidies based on the HIM’s determination of MAGI below a specified level (e.g., 150 percent of the federal poverty level).

This typology, as well as the overall analytic framework, are offered as tools to help analyze strategies for data-based integration and coordination between health and human services programs.

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