Overlapping Eligibility and Enrollment: Human Services and Health Programs Under the Affordable Care Act. Notes


1 If the Affordable Care Act increases the number of consumers who seek health coverage in local social services offices that also take applications for capped human services programs, the latter may need to devise approaches to prioritizing benefit receipt within a larger applicant pool. On the other hand, the ACA may shift some current Medicaid applications out of social service offices and into on-line and telephonic portals that serve as entryways into both Medicaid and subsidized coverage available in Health Insurance Marketplaces. If so, human services programs may face the challenge of maintaining vulnerable clients’ current access to benefits.

2 These sources include the Robert Wood Johnson Foundation, the Kaiser Commission on Medicaid and the Uninsured, and ASPE.
3 In determining Medicaid eligibility under the ACA, 5 FPL percentage points are subtracted from Modified Adjusted Gross Income, or MAGI. Accordingly, the gross income standard is 138 percent FPL but the net income standard is 133 percent FPL.
4 Some of the verification health programs will receive from the federal data hub, such as federal tax return information from the Internal Revenue Service and payroll information from private vendors, cannot be conveyed to human services programs because of data use restrictions imposed by the original data sources. More broadly, CMS announced on May 16, 2013, that “On Day 1 [i.e., October 1, 2013], States will not be able to use the data provided to the Federal Data Services Hub by other Federal agencies for making eligibility decisions for any program other than Medicaid, CHIP, or a State-based Marketplace. CMS will continue to explore this option for the future and will inform States if any of the data becomes available for additional programs.” CMS. May 16, 2013. “Can states use the federal data (e.g. SSA, DHS and IRS) verified through the Federal Data Services Hub for other programs, aside from Medicaid, CHIP, or a State-based Marketplace?” FAQ Medicaid and CHIP Affordable Care Act Implementation. http://www.medicaid.gov/State-Resource-Center/FAQ-Medicaid-and-CHIP-Affo....
5 US Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis, The Evolution of SNAP Modernization Initiatives in Five States by Lara Hulsey, Kevin Conway, Andrew Gothro, Rebecca Kleinman, Megan Reilly, Scott Cody, and Emily Sama-Miller. Project Officer, Rosemarie Downer. Alexandria, VA: March 2013.
6 Dorothy Rosenbaum. SNAP Is Effective and Efficient, Center on Budget and Policy Priorities, Updated March 11, 2013.
7 Karen E. Cunnyngham, “State Supplemental Nutrition Assistance Program Participation Rates in 2010,” December 2012, USDA FNS, prepared by Mathematica, Inc., http://www.fns.usda.gov/ora/menu/Published/snap/FILES/Participation/Reac....
8 Esa Eslami, Joshua Leftin, and Mark Strayer, “Supplemental Nutrition Assistance Program Participation Rates: Fiscal Year 2010: Final Report,” December 2012. Prepared by Mathematica, Inc. for the FNS Office of Research and Analysis, http://www.fns.usda.gov/ora/menu/Published/SNAP/FILES/Participation/Tren....
9 Dean Plueger. 2009. “The EITC Participation Rate for Tax Year 2005,” Internal Revenue Service Bulletin.
10 U.S. Department of the Treasury, Internal Revenue Service. “Earned Income Tax Credit: For Use in Preparing 2012 Returns.” Publication 596, http://www.irs.gov/pub/irs-pdf/p596.pdf.
11 Plueger op cit.
12 TRIM3 typically treats all persons eligible for EITC as receiving the credit and does not routinely identify UI participants. Generating estimates of EITC and UI participants was beyond the scope of this study.
13 42 C.F.R. § § 435.948(a).
14 42 C.F.R. § § 435.916(a)(2).
15 By contrast, with Marketplace subsidies, the amount of subsidy depends on the household’s income; the need for greater precision of income measurement makes it much harder to rely conclusively on the determinations of other programs in establishing financial eligibility and corresponding subsidy levels.
16 For sources and notes, see notes to Table 1.
17 That was the median level according to the most recent available information when the microsimulation was conducted. However, in January 2013, a new survey was released showing that the median threshold for working parents fell to 61 percent FPL.
18 In addition, the estimates in the previous sections include people with disabilities who receive Medicare. Those population counts are relevant to assessing the potential gains that human services programs could realize from linking to health coverage programs. The estimates in this section, which analyzes how health programs could benefit from such linkages in reaching the eligible uninsured, do not include Medicare recipients who also qualify for Medicaid.
19 USDA Food and Nutrition Service. Supplemental Nutrition Assistance Program (SNAP)—Able Bodied Adults Without Dependents Waivers for FY 2013, March 21, 2012.
20 The noncustodial parent estimates presented here include noncustodial parents who are not in contact with child support enforcement programs, and so the potential effect for noncustodial parents may be overstated. However, child support enforcement programs also work with custodial parents who could benefit from higher Medicaid eligibility limits in many states and from Marketplace subsidies. Further analysis is required to ascertain the full extent of the child support enforcement program’s potential reach.
21 CMS. “Facilitating Medicaid and CHIP Enrollment and Renewal in 2014,” SHO #13-003, ACA #26, May 17, 2013. http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-003.pdf.
22 This is an example of Express Lane Eligibility.
23 For example, in 2002 the Social Security Administration sent 16.4 million letters to low-income Medicare beneficiaries who were probably eligible, according to federal income data, for Medicare Savings Programs (MSP). The letters provided information about MSP, which pays some or all Medicare cost-sharing, depending on income. The letters also listed a phone number that could be called to enroll. Only 74,000 people—0.5 percent of letter recipients—enrolled in MSP as a result. While sending notices increased the volume of phone calls, few consumers actually enrolled. Government Accountability Office, Medicare Savings Programs: Results of Social Security Administration’s 2002 Outreach to Low-Income Beneficiaries, GAO-04-363, March 2004.
More recently, Iowa and New Jersey have required taxpayers to indicate on state income tax returns whether their children have insurance coverage. In 2009, when parents in these states said that their children were uninsured, they were mailed application forms for health coverage, along with information about how to enroll. In Iowa, roughly 1 percent of parents filed application forms and sought coverage. Brenda Freshour Johnston, Reaching Uninsured Children: Iowa’s Income Tax Return and CHIP Project, prepared by the Iowa Department of Human Services for the State Health Access Reform Evaluation project of the Robert Wood Johnson Foundation, with the State Health Access Data Assistance Center serving as national program office, August 2010. New Jersey streamlined its already simple child health application, based on the availability of tax data, and mailed out approximately 172,000 simplified forms to parents who indicated that their children were uninsured; roughly 750 children enrolled—less than 0.5 percent of the children in these families. John Guhl and Eliot Fishman, New Jersey Family Care: Express Lane Eligibility, State Coverage Initiatives Program National Conference, July 2009.
25 Much of the information on TANF comes from CRS report R41625: Federal Benefits and Services for People with Low Income: Programs, Policy, and Spending, FY2008-FY2009.
26 Welfare Rules Database, July 2011.
28 Code of Federal Regulations 7 CFR 246.7(h)(1): http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&SID=6e22e5365c88729939d261e4....
30 LIHEAP information comes from the following sources: http://www.acf.hhs.gov/programs/ocs/resource/liheap-eligibility-criteria, http://www.acf.hhs.gov/programs/ocs/resource/statute, http://www.acf.hhs.gov/programs/ocs/resource/fact-sheet-0, Interpretation of "Federal Public Benefits" Under the Welfare Reform Law - http://www.acf.hhs.gov/programs/ocs/resource/interpretation-of-federal-b... and Spar, Karen. 2011. Federal Benefits and Services for People with Low Income: Programs, Policy, and Spending, FY2008-FY2009. Congressional Research Service. CRS Report R41625.
36 Spar, Karen. 2011. Federal Benefits and Services for People with Low Income: Programs, Policy, and Spending, FY2008-FY2009. Congressional Research Service. CRS Report R41625.
Giannarelli, Linda, Sarah Minton, and Christin Durham. Child Care and Development Fund (CCDF) Policies Database, 2011. ICPSR34390-v1. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2012-10-23. doi:10.3886/ICPSR34390.v1. CCDF regulations (Code of Federal Regulations 45 CFR Parts 98 and 99: Child Care and Development Fund: Final Rule) may be accessed via the U.S. Government Printing Office website (http://www.gpo.gov/fdsys/pkg/CFR-2011-title45-vol1/pdf/CFR-2011-title45-...).
37 Spar, Karen. 2011. Federal Benefits and Services for People with Low Income: Programs, Policy, and Spending, FY2008-FY2009. Congressional Research Service. CRS Report R41625. Internal Revenue Service (IRS). 2012. Publication 596. Earned Income Credit (EIC). Cat. No. 15173A. Department of the Treasury Internal Revenue Service (IRS). http://www.irs.gov/Individuals/EITC-Income-Limits,-Maximum-Credit--Amoun....
38 Matthew Buettgens, “HIPSM Methodology,” (Washington, DC: The Urban Institute, 2011) http://www.urban.org/UploadedPDF/412471-Health-Insurance-Policy-Simulati...
39 The final regulations are posted at http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/html/2012-6560.htm (“Final Rule 42 CFR Parts 431, 433, 435, and 457 “Medicaid Program: Eligibility Changes under the Affordable Care Act of 2010.”). Section 435.603, “Application of modified adjusted gross income (MAGI),” (which begins on page 17,206 of the regulations) describes the alternative family definitions.
40 See the discussion “Modifications to the Underlying Surveys” on the TRIM3 documentation page, http://trim.urban.org/T3Technical.php.
41 SSI recipients are identified by TRIM3’s baseline SSI simulation for 2010, which augments the survey-reported data to correct for under-reporting. Details on TRIM3’s SSI model are available on the TRIM3 website’s documentation page, http://trim.urban.org/T3Technical.php.
42 CMS. Answers to Frequently Asked Questions: Telephonic Applications, Medicaid and CHIP Eligibility Policy and 75/25 Federal Matching Rate. August 9, 2013.
43 For an example of a state that has ended waiting periods between the end of ESI and the start of eligibility for a separate CHIP program, see, e.g., Cathy Hope, “Colorado Puts an End to CHIP Waiting Period – Let’s End the Wait for All Kids,” Say Ahh! A Children’s Health Policy Blog, April 08, 2013, http://ccf.georgetown.edu/all/colorado-ends-chip-waiting-period/. For a state that has a two-month waiting period but makes many exceptions, including for children with serious health problems and families experiencing domestic violence or employment changes, see Oregon Department of Human Services, Medical Assistance Programs - H. Healthy KidsConnect (HKC), Release 70B: August 1, 2013, http://apps.state.or.us/caf/fsm/08ma-h.htm. For examples of states that waive waiting periods under specified income levels and of several states other than Colorado that have eliminated waiting periods altogether, see Martha Heberlein, Tricia Brooks, Joan Alker. Samantha Artiga and Jessica Stephens. Getting into Gear for 2014:Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012–2013, Georgetown Center for Children and Families and Kaiser Commission on Medicaid and the Uninsured, January 2013, http://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf.
44 If separate CHIP programs are modeled to exclude ESI recipients, then the percentage of EITC-eligible children who qualify for Medicaid and HIM subsidies, respectively, falls to 87 percent and 3 percent; and among all EITC-eligible people, 75 percent and 7 percent qualify for Medicaid/CHIP and HIM subsidies, respectively. If all CHIP programs are modeled to exclude ESI, including Medicaid expansion programs as well as separate state programs, those percentages are as follows: for children, 85 percent and 3 percent; and for all people, 74 percent and 7 percent. In Figure 4, counting all otherwise eligible ESI recipients as qualifying for both separate state programs and Medicaid/CHIP programs, those percentages are 95 percent and 1 percent for children; and 79 percent and 7 percent for all people. Results for childless adults and parents are unaffected.
45 Note that in standard TRIM3 Medicaid simulations, individuals who report Medicaid in the survey but who do not appear eligible through any other pathway are assumed to be eligible for Medicaid due to high medical bills. Since this pathway is not used, some children with survey-reported Medicaid will not be simulated as eligible for Medicaid under the ACA if they are not eligible under either ACA rules or another pre-ACA pathway.
47 Martha Heberlein, et al., 2013, op cit.
48 Where Title XIX Medicaid and Title XXI Medicaid were listed with different FPL thresholds for children of a particular age, we used the higher threshold.
50 To facilitate the analysis, the TRIM simulation was run assuming 100 percent enrollment.
51 This assumption was incorporated into TRIM’s Medicaid simulation via a special (and temporary) version of the simulation code (version 99.73).
52 Among children, a substantial portion of the Medicare enrollment according to the public-use data was imputed by the Census Bureau.
53 The government’s ACA website, http://www.healthcare.gov/law/features/choices/young-adult-coverage/inde..., further states that a child can be covered even if not living with the parents; however, because the CPS does not provide information on persons outside the household, an adult child living away from the parents would never be identified as having an affordable offer through that parent.


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