Simulation of Medicaid and SCHIP Eligibility: Implications of Findings From 10 States. Final Report.. A. Data Requirements for Eligibility Simulations


While simulation models take different forms, a model that seeks to capture all aspects of the eligibility determination process must include each of the following steps, which are applied, in turn, to every household in the database:

  • Determine state of residence. This will determine the specific set of eligibility rules to be applied.
  • Identify the members of each family unit. Using the reported relationships between household members, their ages, and their receipt of particular benefits, the members of one or more families are identified for the purpose of determining their joint eligibility or, for child-specific eligibility, who should be counted in determining family income and the applicable poverty thresholds. Note, for example, that a family member who receives SSI generally will be eligible for Medicaid (and ineligible for SCHIP), and that both the family member and the amount of the SSI payment will often (but not always, particularly among S-SCHIP programs) be excluded in determining the Medicaid or SCHIP eligibility of other family members.
  • Determine categorical eligibility. Determine if the child or family meets any categorical eligibility criteria that may confer automatic or at least conditional eligibility.
  • Calculate gross income. Sum all sources of income that are counted under program rules for all members of the family. A state may define what is counted in gross income differently across programs, requiring multiple totals.
  • Identify the components of income to which disregards may apply. Calculate total earnings and calculate or impute the totals for other sources of income that are partially or totally disregarded by one or more programs within the state.
  • Identify the expenditures to which disregards may apply. Using the amounts reported for child care and other expenditures for which applicants are allowed to disregard part of their income, calculate or impute the amount of each expenditure.
  • Calculate net income. Apply the disregard rules to the corresponding income or expenditure amounts and calculate net income as gross income minus the disregards. A state may define net income differently across programs, requiring multiple totals.
  • Calculate the family poverty level. Divide gross or net income, as appropriate, by the applicable poverty threshold (which depends on family size) to obtain the family poverty level for the family unit or units identified above. If a state defines income differently across programs that use poverty levels as income thresholds, it will be necessary to calculate multiple poverty levels.
  • Determine eligibility based on income. Compare the poverty level or net or gross income, as appropriate, to the applicable threshold for each state program to determine income eligibility.
  • Calculate countable assets and apply asset test. Using reported or imputed assets, determine whether countable assets exceed the asset limit. Within a state, different programs may or may not require an asset test, or they may define the test differently, thus, possibly requiring multiple tests.
  • Determine insurance coverage. A child who is insured under an employer-sponsored plan or whose family has declined such coverage recently may be ineligible for a S-SCHIP program despite being eligible by all other criteria. Similarly, an uninsured child who did not lose coverage until relatively recently may be ineligible until the spell reaches a specified length (for example, six months). To simulate this program feature requires information on both "current" coverage (that is, contemporaneous with the measure of eligibility) and, for the uninsured, a measure of the duration of the current spell.
  • Determine eligibility by program. Using the results of the categorical eligibility, income, and asset tests, along with reported insurance coverage, determine whether the family or child is eligible for any of the programs offered within the state. If the state has a medically needy program and the family is not otherwise eligible, determine if the family's medical expenditures would allow the family to spend down to the applicable income limit.