Using Behavioral Economics to Inform the Integration of Human Services and Health Programs under the Affordable Care Act . SNAP check-boxes


Louisiana’s experience illustrates the impact of requiring families to check a simple opt-in box before their children can obtain expedited Medicaid coverage based on SNAP receipt. Since February 2010, Louisiana has implemented Express Lane Eligibility (ELE) to qualify children as financially eligible for Medicaid using findings already made by the SNAP program. Children who received SNAP but not Medicaid were mailed Medicaid cards they could use to obtain care. To meet ELE’s statutory requirement for parental consent, the state informed families that using the Medicaid cards would also provide consent to enrollment.

According to the congressionally mandated evaluation of ELE, approximately 18,000 previously uninsured children joined Medicaid through ELE in 2010. This represented a 3 percent increase in total children’s Medicaid and CHIP coverage, with ELE accounting for 28 percent of all new enrollees between February and July.38 However, information technology problems led Louisiana to change its approach to enrollment. Starting in January 2011, children could not receive Medicaid through ELE unless their parents first consented by checking a box on the SNAP application form.39 Even though the check-box was highlighted, bolded, prominently placed on the second page of the SNAP form, and written in very clear language, the average number of children enrolled via ELE as a result of monthly SNAP applications fell by 62 percent after this change was made.40

38 Hoag, et al., op cit.
39 Children’s use of Medicaid cards to access fee-for-service care could be tracked only through the state’s claims payment system, which could not communicate with the state’s eligibility system. When it came time to redetermine eligibility for the first group of ELE children, the state used different procedures for those who had used their cards to access care, thereby consenting to enrollment, and those who had not. The latter group needed to receive a final opportunity to consent to enrollment before termination. Accordingly, state workers had to go into the state’s claims payment system to identify which ELE children had used services and which had not. They then needed to go into the eligibility system to carry out the various renewal procedures that applied to the two different groups of ELE children. The cost of that manual intervention made this system unsustainable, causing the state’s change to using an opt-in box on the SNAP form, rather than continue using the state’s prior “consent through card use” approach.
40 Stan Dorn, Margaret Wilkinson, and Sarah Benatar. “Case Study of Louisiana’s Express Lane Eligibility: Final Report.” CHIPRA Express Lane Eligibility Evaluation. Washington, DC: Urban Institute, January 2012.

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