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

Publication Date
Dec 22, 2013

Prepared by:
Stan Dorn, Julia Isaacs, Sarah Minton, Erika Huber, Paul Johnson, Matthew Buettgens, and Laura Wheaton
The Urban Institute

Under Task Order: HHSP23337026T
Integrating Health and Human Services Programs and Reaching Eligible Individuals Under the Affordable Care Act

Prepared for:
Alana Landey and Carli Wulff
Office of the Assistant Secretary for Planning and Evaluation, DHHS

This report presents information on overlaps in eligible and participating populations in various health and human services programs, and identifies three main human services programs – the Supplemental Nutrition Assistance Program (SNAP), the Low Income Home Energy Assistance Program (LIHEAP), and the Earned Income Tax Credit (EITC) – as having considerable overlap with health insurance programs and high potential for possible integration and coordination efforts in states that implement the Medicaid expansion. The paper’s appendix presents an analytic framework for possible data usage strategies across programs.

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Introduction

The Patient Protection and Affordable Care Act (Affordable Care Act or ACA) extends health coverage to millions of uninsured Americans, primarily through newly created Health Insurance Marketplaces and expanded Medicaid eligibility. It also sets the stage for major changes to eligibility determination for both health and human services programs. This paper focuses on using data matches and the coordination and integration of enrollment and retention procedures to improve the efficiency and accuracy of eligibility determination and to increase participation by eligible individuals in health programs and uncapped human services programs.

Under the ACA, consumers can generally qualify for health coverage based on attestations made under penalty of perjury. However, when federal or state policy requires further verification, it must be based on data matches, if possible, including information in the records of human services programs. Only when data matches fail to verify eligibility can consumers be asked for documentation.

 Facing a potential surge in health coverage applications in 2013 and 2014, states that use data from human services programs to qualify multiple consumers for health coverage can trim their administrative workload while enrolling a large proportion of the newly eligible. At the same time, many people who have not previously received government assistance will seek health coverage. By connecting to this new stream of applicants for health coverage, programs that guarantee assistance to all eligible consumers, such as the Supplemental Nutrition Assistance Program (SNAP), Earned Income Tax Credit (EITC), and unemployment insurance (UI), could identify and enroll households who qualify but do not yet participate. In addition, information from health programs could simplify the work needed to qualify clients for human services programs that receive capped funding from the federal government and thus generally cannot serve all eligible people. For the latter programs, simplification efforts could reduce burdens for clients and lower the cost of eligibility determination, potentially letting some resources shift from administration to benefits. These programs include Temporary Assistance for Needy Families (TANF), the Child Care and Development Fund (CCDF), the Low Income Home Energy Assistance Program (LIHEAP), housing subsidies, and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).1

As a crucial step facilitating such data linkages, enhanced federal funding is available for information technology (IT) investments that improve eligibility determination for health programs. Full federal funding is available for state-run Marketplaces, and federal resources can pay 90 percent of the cost to modernize Medicaid eligibility systems. If such investments also benefit human services programs, normal cost-allocation rules are waived, so the latter programs are relieved of the need to share development expenses. This opportunity is time-limited, however. Federal funding for state Marketplace administration stops after December 31, 2014, and both the 90 percent Medicaid match and cost-allocation waiver end a year later.

To help state and federal officials who are working to realize the promise of the Affordable Care Act, this paper analyzes possible pairings of health and human services programs for data-based integration and coordination strategies. Researchers at the Urban Institute, working in consultation with federal project officers at the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services (HHS), with input from members of a Technical Working Group, have put together this analysis to identify the human services programs with beneficiary populations that will overlap most significantly with health programs when the Affordable Care Act is fully implemented.

We use the term, “human services,” to include a number of programs—EITC, housing subsidies, LIHEAP, and UI—that are sometimes classified outside the boundaries of “human services.” We seek to distinguish the programs that provide health coverage from the programs that meet other basic needs of vulnerable or low-income populations.

Rather than rely on administrative data limited to program recipients, our tabulations come from microsimulation techniques that can estimate both recipients and people who qualify for assistance under specified program rules. We use two large microsimulation models: the Transfer Income Model, Version 3 (TRIM3 or TRIM), which is developed and maintained by the Urban Institute, thanks to primary funding from ASPE; and the Health Insurance Policy Simulation Model (HIPSM), also developed and maintained by the Urban Institute with funding from multiple sources.2 We use the resulting combined information to estimate the overlap in (a) populations who will be eligible under the Affordable Care Act for Medicaid, the Children’s Health Insurance Program (CHIP), and subsidies for Marketplace coverage, which are sometimes referred to collectively as “insurance affordability programs;” and (b) people who receive or qualify for the following human services programs: SNAP, TANF, housing subsidies, CCDF, LIHEAP, WIC, UI, and EITC, as well as the noncustodial parents who are potentially reached by child support enforcement programs. We distinguish between recipients and eligibles for all human services programs except UI and EITC, for which we estimate eligibility only. Our analysis is limited to populations under 65, because the ACA’s coverage expansion affects health coverage only for the non-elderly.

Both models use the 2011 Current Population Survey-Annual Social and Economic Supplement (CPS-ASEC), which describes household circumstances during calendar year 2010. HIPSM identifies the respondents who have an offer of employer-sponsored insurance defined as “affordable” by the ACA and are thus disqualified from Marketplace subsidies, imputing such estimates based on statistical matches with other sources of information. We import this information into TRIM and combine it with TRIM’s extensive program, demographic, and income information to identify which individuals will qualify for Marketplace subsidies, Medicaid, and CHIP under the Affordable Care Act as well as to estimate human services program eligibility and receipt. Both models take into account current federal and state eligibility rules as well as the new rules for health programs that will apply beginning in 2014 under the ACA. The tabulations are restricted to individuals who are citizens or lawfully present immigrants under age 65. Our estimates show the number of people who will receive or qualify for various combinations of health and human services programs during the average month.

Our paper investigates the possibilities for program integration and coordination in states that implement the Medicaid expansion. Accordingly, our microsimulation, which is national in scope, assumes that all states implement the Medicaid expansion to 138 percent3 of the federal poverty level (FPL). In states that do not expand Medicaid, the analysis would be very different. Among other things, the overlaps would be greatly affected by each state's particular pre-ACA eligibility rules for Medicaid. We do not undertake that analysis here.

We begin the paper by analyzing data showing how human services programs could benefit from linkages with insurance affordability programs. We then provide results suggesting how health programs could also benefit from linkages with human services programs. Appendices set out a framework for analyzing strategies that link programs to facilitate eligibility determination, enrollment, and retention (Appendix I); a program-by-program comparison of eligibility requirements and methods (Appendix II); a detailed description of our microsimulation methodology (Appendix III); additional microsimulation results (Appendix IV); and a list of experts consulted in the preparation of this report (Appendix V). This paper is part of a larger study— Integrating Health and Human Services Programs and Reaching Eligible Individuals Under the Affordable Care Act—with later stages that will build on the analysis presented here.

Overlaps with health programs that could help human services programs function more effectively

Data from health programs could help establish eligibility for human services programs

Most human services programs are capped. This means that serving new people may require displacing current clients. The expansion in health coverage contemplated by the Affordable Care Act can nevertheless help these programs more effectively and efficiently determine eligibility. Several years after the ACA has been implemented, numerous human services applicants and recipients may have had their circumstances evaluated by health coverage programs. If so, human services programs could borrow from this work that health programs have already done, allowing human services eligibility to be determined more efficiently than in the past. Ultimately, this could help both capped and uncapped human services programs alike.

We find that the vast majority of human services program participants will qualify for health coverage. If all states implement the Affordable Care Act’s Medicaid expansion, Medicaid and CHIP eligibility will reach 97 percent of SNAP recipients, 85 percent of WIC families, 99 percent of TANF recipients, and 87 percent of LIHEAP recipients under age 65 (Figure 1). This suggests that, once the ACA’s expansions are fully implemented, human services programs may be able to expedite eligibility determination for numerous applicants and participants based on data from health programs.

Two limitations of this analysis are important to acknowledge. First, this information shows the potential reach of health programs. That is, we show the number of human services participants who will qualify for Medicaid, CHIP, and Marketplace subsidies if states expand Medicaid eligibility. Human services programs will not fully benefit from health programs until the latter have had time to ramp up enrollment among new eligibles.

Second, much of the verification that health programs will receive from a new federal data hub cannot be shared with human services programs.4 For the latter to benefit from health agencies’ findings, it will be important to confirm that health programs can share their final eligibility determinations—for example, that a particular person has been found to have income at a certain percentage of the FPL—even if they cannot provide human services programs with all the verification on which such determinations are sometimes based.

Figure 1. Among recipients of various human services benefits under age 65, the percentage who will qualify for health programs under the Affordable Care Act

Figure 1. Among recipients of various human services benefits under age 65, the percentage who will qualify for health programs under the Affordable Care Act

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes pre-ACA categories above 138 percent FPL and does not exclude ESI recipients. Estimates for children and adults include people with disabilities who receive Medicare. WIC and child care counts include spouses and dependents under age 19 who do not directly receive subsidies. Housing subsidies include public housing and rent vouchers. For more information about our methodology, see Appendix III.

Many eligible nonparticipants in uncapped human services programs will qualify for health coverage

Health programs offer the potential to provide additional help to uncapped human services programs—that is, programs that serve all who qualify, without funding caps—by enabling them to reach eligible nonparticipants. SNAP is an uncapped program that has made extraordinary strides in recent years, modernizing program administration to improve program participation, lower error rates, and increase efficiency.5 From 2002 to 2010, the percentage of eligible individuals receiving benefits rose from 54 percent to 75 percent.6 Nevertheless, in some states and demographic groups, many eligible households remain unserved. California’s SNAP program, for example, reaches only 55 percent of eligible people;7 and among childless adults and working families, only 67 and 65 percent of eligible individuals, respectively, receive aid.8

If all states expand Medicaid eligibility, 88 percent of people who qualify for but do not receive SNAP will be eligible for insurance affordability programs, including 80 percent who will qualify for Medicaid or CHIP (Figure 2). Health programs may be particularly useful in helping SNAP reach two groups with below-average participation levels: childless adults and people with incomes above poverty. Among members of these two groups, 85 percent and 79 percent, respectively, will qualify for ACA health coverage (Figure 3).

EITC, another uncapped program, reaches an estimated 75 percent of eligible taxpayers.9 Among taxpayers with children who qualify, 81 percent claim the credit, but only 56 percent of eligible taxpayers without children receive it.

Insurance affordability programs may be able to help EITC outreach campaigns reach such eligible non-claimants. Altogether, 86 percent of people under age 65 who are eligible for EITC will qualify for health programs if all states expand Medicaid, including 84 percent of EITC-eligible childless adults (Figure 4).

It is worth noting, in this context, that a particularly underserved group of EITC-eligible taxpayers consists of childless adults with incomes too low to claim the full credit—that is, those with earned income between $1 and $6,200 a year, or 56 percent FPL for a one-person household in 2012.10 Not only does the low credit amount for which they qualify reduce these adults’ incentive to claim it, they are less likely than other taxpayers to file for other reasons, such as to obtain a refund or to meet legal requirements for filing tax returns; in 2012, for example, one-person households were not required to file unless their gross income was at least $9,750. As a result, it is not surprising that only 46 percent of such adults claim EITC.11 Almost all of this highly underserved group will qualify for Medicaid under expansion.

In terms of the final uncapped human services program that we examine in our microsimulation, unemployment insurance (UI), health programs will reach 62 percent of eligible individuals (Figure 5)—a smaller proportion than for the programs discussed earlier, but still representing more than three in five people who potentially qualify. As with EITC, it is worth emphasizing that we estimate the prevalence of consumers eligible for health programs only among people who are eligible for UI, regardless of whether they participate.12 It is also important to note that the estimates we present reflect UI eligibility during calendar year 2010, when the country was experiencing a severe economic downturn. The profile of UI-eligible consumers could be quite different under more favorable economic conditions.

More broadly, these estimates show the prevalence of insurance affordability program eligibility among people who qualify for SNAP, EITC, and unemployment insurance. They thus suggest the potential that health coverage could offer in reaching eligible populations not served by these uncapped human services programs. But we do not yet know, among consumers who will newly qualify for Medicaid or Marketplace subsidies, how many will enroll. In particular, we do not know the extent to which health programs will successfully enroll the very groups that SNAP, EITC, and unemployment insurance have had particular difficulty reaching. Human services program administrators and advocates will need to track carefully the progress of health programs in enrolling these populations over the next few years.

Figure 2. Health program eligibility among all people under age 65 who qualify for but do not receive SNAP

Figure 2. Health program eligibility among all people under age 65 who qualify for but do not receive SNAP

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes pre-ACA categories above 138 percent FPL and does not exclude ESI recipients. Estimates for children and adults include people with disabilities who receive Medicare. For more information about our methodology, see Appendix III.

Figure 3. Health program eligibility among two groups of people under age 65 who qualify for but do not receive SNAP

Figure 3. Health program eligibility among two groups of people under age 65 who qualify for but do not receive SNAP

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes pre-ACA categories above 138 percent FPL and does not exclude ESI recipients. Estimates for children and adults include people with disabilities who receive Medicare. For more information about our methodology, see Appendix III.

Figure 4. Health program eligibility among various groups of EITC-eligible people

Figure 4. Health program eligibility among various groups of EITC-eligible people

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes pre-ACA categories above 138 percent FPL and does not exclude ESI recipients. Estimates for children and adults include people with disabilities who receive Medicare. For more information about our methodology, see Appendix III.

Figure 5. Health program eligibility among people who potentially qualify for unemployment insurance

Figure 5. Health program eligibility among people who potentially qualify for unemployment insurance

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Children’s eligibility for Medicaid and CHIP includes children’s pre-ACA categories above 138 percent and does not exclude ESI recipients. Estimates for children and adults include people with disabilities who receive Medicare. For more information about our methodology, see Appendix III.

Overlaps with human services programs that could help health programs function more effectively

Participation in human services programs could help establish eligibility for Medicaid

As noted earlier, a Medicaid applicant’s attestation of financial eligibility can be verified by data that are reasonably compatible with those attestations, including data showing the receipt of human services benefits.13 Moreover, when a Medicaid beneficiary’s coverage period is coming to an end, if reliable data demonstrate continuing eligibility, the beneficiary’s eligibility is renewed administratively.14 Such data matches can play an important role in determining eligibility for Medicaid, since financial eligibility is established whenever income is at or below 138 percent FPL, which can frequently be verified based on determinations already made by human services programs.15

Table 1 shows, for children, parents, and childless adults, the probability of eligibility for Medicaid that is established by receipt of various human services benefits. This information could help states determine when data matches with human services programs eliminate the need for documentation from Medicaid applicants or from beneficiaries up for renewal. For example, a LIHEAP recipient who is a child or adult has a 94 percent or 78 percent likelihood of Medicaid eligibility, respectively. A state could thus verify a Medicaid applicant’s attestation of financial eligibility through a data match establishing receipt of LIHEAP, whether such applicant is a child or adult. Eliminating the need for consumers to present and for states to evaluate paper documentation is likely to increase eligible consumers’ Medicaid participation levels, reduce administrative costs, and lower the risk of manual error in determining eligibility.

Verification based on human services receipt could streamline enrollment and retention for numerous Medicaid-eligible consumers. Among people who will qualify for Medicaid if all states expand eligibility:16

  • 49 percent receive SNAP;
  • 18 percent receive LIHEAP;
  • 17 percent either receive WIC or have a sibling or spouse who receives WIC;
  • 9 percent receive housing subsidies;
  • 6 percent receive TANF; and
  • 3 percent either receive child care subsidies or have a sibling or spouse who receives such subsidies.

Table 1. Likelihood of Medicaid eligibility for various recipients of human services benefits under age 65

  Children Adults Total
SNAP 98% 94% 96%
WIC 90% 67% 81%
TANF 100% 95% 99%
LIHEAP 94% 78% 86%
Child care subsidies 92% 75% 86%
Housing subsidies 96% 86% 91%

Source: TRIM3, 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Medicaid eligibility categories are limited to MAGI-based eligibility up to 138 percent FPL, receipt of SSI, and children’s eligibility for Medicaid (whether funded through Title XIX or Title XXI of the Social Security Act) under their state’s pre-2014 rules. Estimates do not include people with disabilities who receive Medicare. Child care and WIC estimates include immediate family members of recipients. For more information about our methodology, see Appendix III.

Many consumers who will newly qualify for health coverage under the Affordable Care Act already participate in human services programs

A core objective of the Affordable Care Act’s health programs is maximizing enrollment of the eligible uninsured. To achieve this goal, the most important groups to reach are likely to be newly eligible consumers—Medicaid-eligible childless adults, Medicaid-eligible parents with incomes above their state’s pre-ACA thresholds, and people who qualify for newly created Marketplace subsidies.

Health programs could use human services programs to identify such consumers who have already been found to meet many requirements of Medicaid and Marketplace subsidies. Figure 6 indicates the relative size of these newly eligible populations among consumers who receive or qualify for various human services programs. To address variations among state pre-ACA eligibility limits, we use as a rough proxy for adults who will newly qualify for Medicaid the combination of: (a) childless adults, who are ineligible for Medicaid regardless of income in most states; and (b) parents with incomes above 63 percent FPL, the pre-ACA median income eligibility threshold for working parents.17

The estimates of Medicaid eligibility in this section thus differ from those in the previous section. The latter included, in addition to the childless adults and parents who are analyzed in this section, both children and the poorest eligible parents.18 Put differently, while the previous section encompassed all Medicaid-eligible consumers, this section focuses on those who are likely to be newly eligible in 2014.

Clearly, the most productive overall human services programs, in terms of their capacity to help enroll newly eligible populations, are EITC, SNAP, and LIHEAP. If all states expand Medicaid eligibility, these programs will reach 40 percent, 39 percent, and 15 percent of newly eligible Medicaid adults, respectively; they also serve 21 percent, 3 percent, and 5 percent of people who will qualify for Marketplace subsidies (Figure 6). SNAP could play a particularly significant role reaching newly eligible adults, since it serves substantially more such adults than any other human services program.

Of an estimated 26.9 million childless adults who would qualify for Medicaid under expansion, SNAP reaches 9.4 million, or 35 percent—significantly more than the 6.9 million who qualify for EITC, the human services program that reaches the second-highest number of childless adults eligible for expanded Medicaid coverage in 2014 (data not shown). That said, SNAP may soon serve many fewer childless adults. Typically, non-disabled adults who do not reside in a household that includes a child must work an average of 20 hours per week or be limited to 3 months of SNAP eligibility in each 36-month period that they are not working. However, states may apply to waive this requirement in areas where there is high unemployment or a lack of jobs. Forty-six states have approved waivers of this special work requirement through September 30, 2013, the end of federal fiscal year 2013.19 It is not clear how broadly this exemption will continue after then, because of changing economic conditions, state decisions to opt out of the exemption, and possible changes to the SNAP statute.

In addition, child support enforcement programs work with noncustodial parents, many of whom will qualify for health coverage under the Affordable Care Act. If all states expand eligibility, noncustodial parents will include an estimated 8 percent of adults who will be newly eligible for Medicaid (measured using the proxy measure described above) and 6 percent of people who will qualify for Marketplace subsidies (Figure 6). Child support enforcement programs could thus make an important contribution to reaching the newly eligible uninsured.20

HHS’ Centers for Medicare & Medicaid Services (CMS) have authorized states to use SNAP records to enroll Medicaid-eligible consumers into coverage.21 In states that take such steps, Figure 7 shows the extent to which other human services programs could reach the remaining groups who will be newly eligible for health coverage. Not surprisingly, the most useful programs in reaching non-SNAP recipients who will be newly eligible Medicaid adults or who will qualify for Marketplace subsidies are likely to be EITC and LIHEAP, followed by programs that serve noncustodial parents.

Figures 6 and 7 suggest that unemployment insurance may also be helpful in reaching these populations. However, that may be a result of the time period from which the modeling results were taken. As explained earlier, our estimates are based on the 2011 CPS-ASEC, which reflects conditions during the 2010 economic downturn. It is not clear whether, under more favorable economic conditions, unemployment insurance will continue to reach as many people who will qualify for Medicaid, CHIP, or Marketplace subsidies.

Figure 6. Among consumers under age 65 who will be newly eligible for health programs under the Affordable Care Act, the percentage who receive or qualify for various human services programs

Figure 6. Among consumers under age 65 who will be newly eligible for health programs under the Affordable Care Act, the percentage who receive or qualify for various human services programs

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Eligibility for Medicaid and CHIP includes children’s pre-ACA categories above 138 percent FPL. Proxy measure for newly eligible adults includes childless adults up to 138 percent FPL and parents with incomes between 63 percent FPL, the income-eligibility threshold for working adults in the median pre-ACA state, and 138 percent FPL. Estimates do not include people with disabilities who receive Medicare. Child care and WIC estimates include immediate family members of recipients. Unemployment insurance and EITC estimates are for potential eligibility and eligibility, respectively; other human services program estimates are for receipt. For more information about our methodology, see Appendix III.

Figure 7. Among consumers under age 65 who will be newly eligible for health programs under the Affordable Care Act and who do not receive SNAP, the percentage who receive or qualify for various other human services programs

Figure 7. Among consumers under age 65 who will be newly eligible for health programs under the Affordable Care Act and who do not receive SNAP, the percentage who receive or qualify for various other human services programs

Source: TRIM3, HIPSM 2012. Notes: See notes to figure 6.

Conclusion

Human services programs serve many of the same people who will qualify for health programs under the Affordable Care Act. The resulting overlap, along with new federal resources for IT development, may create promising opportunities to use one program’s data to qualify low-income consumers for other programs. This offers the possibility of improving participation levels in uncapped programs, lowering administrative costs, lifting burdens from consumers, and increasing the accuracy of eligibility determinations by reducing the potential for manual error.

Appendix I. Analytic Framework

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

MethodConcept
(A is the sending program; B is the receiving program)
Examples that illustrate the conceptComments about the method
Program pairing and directionStrategy
Purpose: Using data from one program to establish eligibility and determine benefit levels for another program
1. Entailed eligibilityIf 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 subsidiesIf 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 MedicaidIn 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 eligibilityWhether 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 MedicaidAnyone who qualifies for SNAP is automatically deemed income-eligible for Medicaid, notwithstanding different eligibility methodologies used by the two programs.22If 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 subsidiesAt 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 eligibilityB 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 TANFTANF 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 agenciesUsing 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 TANFTANF 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 eligibilityIf 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 MedicaidIf 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 eligibilityIf A has found that someone meets a particular eligibility requirement, B treats that finding as sufficient verification of an attestation of eligibility.SNAP to MedicaidIf 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 rateReceipt of A is used as a factor in distinguishing between B enrollees who qualify for various federal matching rates.TANF to MedicaidTANF 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 consumersIf 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 SNAPMedicaid 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 subsidiesAddress, 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 enrollmentSome or all recipients or other people “touched” by A are targeted for facilitated enrollment into B.Medicaid to SNAPPeople 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 subsidiesOn 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 enrollmentIf A is conducting an outreach campaign with facilitated enrollment, the campaign also helps people sign up for B.EITC to Medicaid and HIM subsidiesAnnual 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.

Appendix II. Overview of Programs

This appendix provides an overview of the various government programs discussed in the body of the paper. The following tables describe the eligibility rules and methods of each program, including rules on income limits, asset limits, reporting requirements, immigration and citizenship status, documentation requirements, enrollment priorities, and more. This appendix also gives information on benefits, redetermination periods, and whether or not programs are capped. The rules described reflect federal policies and regulations, with notations for when a policy varies by state. Specific details and caveats are excluded from the tables in order to maintain a broad overview.

The programs are grouped into four tables: insurance affordability programs, or “IAPs” (Medicaid, CHIP, and subsidies for coverage in health insurance marketplaces); assistance programs for low-income families that do not involve housing (TANF, SNAP, and WIC); housing-related programs (LIHEAP, Section 8 housing vouchers, and public housing); and programs with comparatively high financial eligibility limits (CCDF and EITC). The general focus in the following tables is on people under age 65 whose eligibility is not based on disability.

Table A2. Health Programs

 Medicaid (ACA rules)CHIP (generally limited to children)Health Insurance Marketplace (HIM) Subsidies
Do benefits vary by income, once someone qualifies?
No, except that newly eligible adults can get a “benchmark” package of benefits, which can be less generous than standard Medicaid.
For higher income adults, premiums and cost sharing may vary by state.
Premiums and co-pays vary by state.Yes. Tax credit amounts and cost-sharing reductions vary by income.
Eligibility Overview:Non-elderly adults and children qualify with income at or below 138 percent of poverty, using MAGI definition of income. Pre-ACA non-MAGI eligibility continues for the elderly, disabled, and others.Varies by state – in most states, those with income up to 250 percent of the federal poverty level (FPL) are eligible.Income must be between 100 and 400 percent of poverty level, using MAGI definition of income. Must be ineligible for Medicaid and CHIP and not offered affordable employer-sponsored insurance (ESI).
If vary by state, give eligibility in lowest, median and highest stateNA (assuming that states implement expansion), except that states with higher pre-ACA eligibility for children must maintain it until 2019
Maximum monthly income for initial eligibility varies by state, ranging from:
  • Lowest: 160% FPL
  • Median: 250% FPL
  • Highest: 400% FPL.24
NA
Eligibility based on current monthly income, projected annual income, past annual income, or some other budgeted period?Monthly. At state option, eligibility at renewal can be based on projected annual income. Children can receive 12-months continuous eligibility.Varies by state.Projected annual income.
Reporting requirementsMust report changes that may affect eligibility. Which changes must be reported may vary across states.Must report changes that may affect eligibility.Must report changes, but advance payment of tax credits (APTC) are reconciled to actual year-end income.
Redetermination periodsAnnual for MAGI-based Medicaid.Annual.Annual.
Additional Details: (Whether or not asset limits, income disregards, etc.)
  • No assets test or disregard, except 5% income disregard, which is applied in determining whether net income is below 133 percent of poverty.
  • MAGI incorporates federal tax Adjusted Gross Income (AGI) plus tax exempt interest, foreign income, and the nontaxable portion of social security.
  • No assets test or disregard
  • MAGI incorporates AGI plus tax exempt interest, foreign income, and the nontaxable portion of social security.
  • No assets test or disregard.
  • MAGI incorporates AGI plus tax exempt interest, foreign income, and the nontaxable portion of social security.
  • Persons legally present in the U.S. who are ineligible for Medicaid due to immigration status are eligible for HIM subsidies if income is otherwise too low.
Is program capped?No. All who qualify are enrolled.No. All who qualify are enrolled.No. All who qualify are enrolled.
Are there priority policies?No. All who qualify are enrolled.No. All who qualify are enrolled.No. All who qualify are enrolled.
Restrictions on immigrants? If so, what are they?
  • Qualified aliens as defined by PRWORAStates have the option to cover other lawfully present children and pregnant women. are eligible
  • States have the option to cover other lawfully present children and pregnant women.
  • Qualified aliens as defined by PRWORA.
  • States have the option to cover other lawfully present children and pregnant women.
Individuals who are “lawfully present” in the U.S. will be eligible. This includes LPRs, refugee/asylees, conditional entrants, deportation withheld, other humanitarian entrants, temporary protected status, special immigrant juveniles, deferred action, battered immigrants, victims of trafficking, U visa holders, etc.
What are the documentation requirements to verify for citizenship if any?For citizenship, states can opt for SSN verification with SSA or require original documentation and match with state databases.For citizenship, states can opt for SSN verification with SSA or require original documentation and match with state databases.SSN verification with SSA for citizenship.
What are the documentation requirements to verify immigration status, if any?SAVE for immigration status.SAVE for immigration status.SAVE for immigration status.
What are the requirements for state residency and documentation of residency?State residency required. State residence in Medicaid is defined as living in a state and having the intent to remain for an indefinite period.State residency required. State residence is defined as living in a state and having the intent to remain for an indefinite period.State residency required; Center for Medicare and Medicaid Services is coordinating definition with Medicaid.
Are there rules pertaining to non-incarceration?Medicaid does not cover services to the involuntarily incarcerated, except for inpatient and institutional care.NAIncarcerated people are ineligible, except for people in custody pending disposition of charges.
Are data housed at federal, state or local level?State and local.State.State and federal.

 

Table A3. Assistance programs for low-income families that do not primarily involve housing

 TANF25SNAPWIC
Do benefits vary by income, once someone qualifies?Yes, with exceptions (i.e., child-only cases with caregiver relatives).Yes.No.
Eligibility Overview:Varies by state and within state.Gross income must be less than 130% of poverty for households that do not contain an elderly or disabled member. Net income must be less than 100% of poverty.Gross monthly income must be less than 185 percent of poverty. Recipients must be pregnant, post-partum, breastfeeding, or under age five.
If vary by state, give eligibility in lowest, median and highest state

Maximum monthly income for initial eligibility for 3-person family26:

  • Lowest: $269 = 17% of FPL (AL)
  • Median: $753= 49% of FPL (MT)
  • Highest: $1740= 98% of FPL (HI).
Federal requirement does not vary by state. States have the option for higher eligibility limits under broad based categorical eligibility rules.States may set income limits between 100 and 185 percent of poverty (all states use 185 percent).
Categorical eligibilityNAHouseholds in which all members receive or have been authorized to receive benefits from TANF, SSI, or state-funded general assistance are categorically eligible for SNAP. Forty-three states use broad-based categorical eligibility, including 41where any household that gets any TANF benefit (including non-cash assistance) are eligible; income limits can be raised to 200% of poverty with categorical eligibility, and net income and asset limits may be waived. Categorically eligible households will only be eligible for non-zero benefit if they have sufficiently low income, except 1- and 2-person households, which are eligible for $16 minimum benefit.Those enrolled in TANF, SNAP, or Medicaid are automatically income eligible.
Eligibility based on current monthly income, projected annual income, past annual income, or some other budgeted period?Varies by state.Monthly; Income received during the past 30 days is used as an indicator of the income available to the household for the certification period. Also, "prospective budgeting” allows the agency to project an average monthly income over the certification period based on the best estimate from previous earnings.WIC agencies may consider the income of the family during the past 12 months and the current rate of income to determine which indicator more accurately reflects the family’s status. In addition, if unemployment is recent, income during the period of unemployment is used to determine eligibility.
Reporting requirementsVaries by state.Simplified reporting household must be certified for a minimum of four months. Periodic report periods vary in length from 4-6 months. States do not need to require households certified for six months or less to complete a periodic report. The household must report if income exceeds the gross income limit for the applicable household size. Households must also report work hours for certain household members subject to work requirements.Income may change during certification periods, but WIC agencies do not update the income data on files until the next certification period.
Redetermination periodsVaries by state.Certification periods vary by state and household type from six to 24 months. Only households that are all elderly or disabled can have a 24-month certification. Most other households have a12- month certification.27WIC certification periods extend for a fixed period – up to one year, six months, the duration of pregnancy, or until a child’s next birthday. There is an optional 12-month certification for infants (which all states currently use). The program is phasing to 12-month verification period for children, also at state option. Local WIC agencies are required to reassess eligibility during certification periods if they are made aware of a change in the participant’s economic circumstances.28
Additional Details: (Whether or not asset limits, income disregards, etc.)
  • Asset limits vary by state, ranging from none to $6,000. There are also asset exemptions, such as value of vehicle.
  • Income disregards vary by state.
  • In all states, there are requirements (and exemptions) regarding satisfactory participation in work activities for parents, but details vary.
  • $2,000 asset limit, or $3,250 if at least one person is age 60+ or disabled, with vehicle exemptions varying by state.
  • 20% earned income deduction.
  • Standard deduction of $149 for household size 1-3, $160, $187, $214 for 4,5,6+. (These amounts are higher in AK, HI, and GU, and lower in VI.)
  • Deduction for dependent care, medical expenses greater than $35/month, child support, shelter costs greater than 50% of income after other deductions (not to exceed $469 unless elderly/disabled, and higher in AK/HI). The deduction for shelter costs includes a utility expense deduction, which is a standard allowance in many states (SUA).
 
  • No assets limits.
  • No disregards.
  • Income eligibility for WIC is “family” based. Family income in WIC regulations is “a group of related or nonrelated individuals who are living together as one economic unit.”
Is program capped?Yes, capped entitlement to states.No.Yes.
Are there priority policies?Varies by state.No, everyone eligible receives benefits.Yes, based on factors such as medical condition and age. Priority is not income based.
Restrictions on immigrants? If so, what are they?
Arrived pre-PRWORA (8/22/96): “Nonqualified” (illegal immigrants, nonimmigrants, and first-year parolees) are not eligible for federal funding, but a state may use its own funding. “Qualified” immigrants (permanent residents, refugees, asylees, those with deportation withheld, parolees admitted more than one year, and battered aliens) are eligible for federal funds, states choose.
Arrived post-PRWORA: During their first five years, “nonqualified” and “qualified” immigrants are not eligible for federal funds but states can fund them separately. After five years, “nonqualified” immigrants are still not eligible for federal funding (a state may use its own funding) but “qualified” are eligible for federal funds (state still choose who qualifies).
Certain legal immigrants that have lived in the country for at least five years are eligible. Immigrants that are children or receive disability-related assistance are eligible regardless of entry date. Certain non-citizens, such as those admitted for humanitarian reasons are also eligible. Eligible household members can get SNAP benefits even if there are other members of the household that are not eligible.State agencies may choose to restrict eligibility to citizens and qualified immigrants.
What are the documentation requirements to verify for citizenship if any?If citizenship or immigration status is a condition of eligibility for the TANF benefit, citizenship is verified through methods that vary by state.SNAP regulations require State application forms to provide a statement allowing applicants to attest, under penalties of perjury, to the citizenship status of the members applying for benefits. Citizenship is verified when questionable.Varies by state.
What are the documentation requirements to verify immigration status, if any?If citizenship or immigration status is a condition of eligibility for the TANF benefit, information must be verified through SAVE.
Applicants are required to provide proof of eligible immigrant status for household members applying for SNAP. If applying on behalf of only children in the household, only the child’s immigrant status needs verification.
Non-citizens who are lawfully present typically have documents issued by DHS containing information about their immigration status and the date that individual entered the country or adjusted to the status shown on the card. Some eligible applicants may not have documents issued by DHS. Acceptable documentation may also be issued by other Federal agencies, such as ORR, the Bureau of Indian Affairs, or a court. Most State agencies can verify the validity of immigration documents through the SAVE system. States that have opted to participate in SAVE must use SAVE.
Varies by state.
What are the requirements for state residency and documentation of residency?State residency is required; some states require longer history in state.A household must live in the State where it applies for SNAP benefits. Residency must be verified except in unusual cases. Verification of residency should be accomplished to the extent possible in conjunction with other verification, such as, but not limited to, rent and mortgage payments, utility expenses, and identity.Proof of state residency is required. Applicants served in areas where WIC is administered by an Indian Tribal Organization (ITO) must meet residency requirements established by the ITO. At State agency option, applicants may be required to live in a local service area and apply at a WIC clinic that serves that area. Applicants are not required to live in the State or local service area for a certain amount of time in order to meet the WIC residency requirement.
Are there rules pertaining to non-incarceration?PRWORA imposes a lifetime limit on benefits for people with felony drug convictions after August 22, 1996, unless the state opts out. Thirteen states enacted laws that allow people with drug felony convictions to receive TANF.29PRWORA prohibits states from providing SNAP to convicted drug felons unless the state decides to extend benefits to these individuals. Thirteen states have kept the ban, 21 have eliminated the ban, and 19 have amended the ban.Not specified.
Other special rules
  • Many states have diversion programs (an up-front lump sum payment), most of which are voluntary for applicants, but some are required.
  • There is a 60-month federal time limit. (less in some states) All states include sanctions and time limits, but specifics vary.
  • Special rules on child-only cases also vary by state.
  • Able-bodied adults without dependents (ABAWDS) are limited to 3 months of benefits in an 36 month period.
  • Restrictions on ABAWDs can be waived in areas of high unemployment.
  • Most students and strikers are barred from benefits.
Must be nutritionally at risk.
Where are data housed?State agency (except California).State agency.State agency.

Table A4. Housing-related programs

 LIHEAP30Section 8 Housing Vouchers31Public Housing30
Do benefits vary by income, once someone qualifies?Yes. Each state generates an award amount based on household size, income, and energy need/cost. Some states include an option of an additional payment for households with extra-high fuel costs or a high ratio of fuel costs to income. For the LIHEAP crisis payment in some states, awards are only given if they can cover the full amount needed to avert the crisis (for example, to pay for reconnection of service that has been cut off for nonpayment).Yes, the amount a household pays for rent based on income.Yes, the amount a household pays for rent based on income.
Eligibility Overview:States establish their own eligibility criteria within federal parameters. Maximum federal income eligibility is the greater of 150 percent of the federal poverty guidelines or 60 percent of state median income. States may not set eligibility lower than 110% of the federal poverty guidelines.Eligible families must have incomes no higher than 50 percent of area median income. Forty percent of units that become available each year must be given to families that are extremely low-income (incomes no higher than 30 percent of area median income). In some limited circumstances, families may be low-income with incomes as high as 80 percent of area median income.HUD sets the lower income limits at 80 percent and very low income limits at 50 percent of the median income for the county or metropolitan area.
If vary by state or area, give eligibility in lowest, median and highest state

The income limits vary by state. Within states, limits can vary by the type of assistance provided. In, FY 2012 income limits range from32:

  • Lowest: $20,383 = 110% of FPL
    (MI, NV, OK)
  • Median $27,795= 150% of FPL (across all states)
  • Highest: $50,429 = 272% of FPL, 60% State Median Income (SMI) (MA).

Income limits vary by county and metropolitan area. In 2012, annual income limits for a family of four at 50 percent of area income vary from :

  • Low: $21,100 = 91% of FPL, to
  • High: $64,200 = 278% of FPL.

Income limits vary by county and metropolitan area. In 2012, annual income limits for a family of four at 50 percent of area income vary from :

  • Low: $21,100 = 91% of FPL, to
  • High: $64,200 = 278% of FPL.
Eligibility based on current monthly income, projected annual income, past annual income, or some other budgeted period?The guidelines used for eligibility are generally based on annual income.Based on annual income.Based on annual income.
Reporting requirementsAll federal reporting in connection with LIHEAP is done annually around the time of application; there is no follow up between applications.Families may be required to inform the Public Housing Authority (PHA) of changes in income or family composition in between annual recertification.33Families may be required to inform the Public Housing Authority (PHA) of changes in income or family composition in between annual recertification.12
Redetermination periods

Annual for regular LIHEAP benefit.

The program year varies from state to state and may be shorter than 12 months. Most states permit households to qualify for a second benefit within a given program year, to address a crisis such as a shutoff notice or disconnection of utility service for nonpayment. This second benefit requires re-application. Some states might receive a total of four applications from a particular household if they are eligible for each assistance type and if each type is offered by that state: heating, cooling, crisis, and weatherization.

Annual.Annual.
Additional Details: (Whether or not asset limits, income disregards, etc.)
States may grant categorical eligibility to households in which at least one member receives TANF, SSI, SNAP, or certain veterans’ programs.
States may choose to serve only income eligible households that meet additional LIHEAP eligibility criteria, such as passing an assets test, residence in non-subsidized housing, or receipt of a utility disconnection notice.
Federal regulations list a series of disregards child support, non-cash benefits, student loans).
Both gross and net income factor into the calculation of a household’s rental payment. Net income includes deductions for dependents, child care expenses, certain disability related expenses, an elderly or disabled family allowance, and medical expenses for households with an elderly or disabled head or spouse.Both gross and net income factor into the calculation of a household’s rental payment. Net income includes deductions for dependents, child care expenses, certain disability related expenses, an elderly or disabled family allowance, and medical expenses for households with an elderly or disabled head or spouse.
Is program capped?Yes.Yes.Yes.
Are there priority policies?Priority can be given to homes with the highest energy needs, taking into consideration the energy burden of the household and the situations of households with vulnerable populations. Vulnerable populations include very young children, individuals with disabilities, and frail older individuals. Young children are usually considered to be five years or younger. Elderly are typically viewed as 60 years or older.Each PHA may establish local preferences for selecting applicants from its waiting list. PHAs may give a preference to a family who is homeless or living in substandard housing, paying more than 50% of its income for rent, or involuntarily displaced.Each PHA may establish local preferences for selecting applicants from its waiting list. PHAs may give a preference to a family who is homeless or living in substandard housing, paying more than 50% of its income for rent, or involuntarily displaced.
Restrictions on immigrants? If so, what are they?Must be citizen or qualified alien (immigrant). Victims of trafficking are eligible.Eligibility is given to immigrants who are lawful permanent resident, refugees, asylees, have their deportation withheld, parolees, granted amnesty. Some immigrants who are paroled into the United States could be ineligible depending on local policies.
All family members must either be citizens, nationals of the U.S., or eligible immigrants. Eligible immigrants include:
lawful permanent residents, refugees, asylees, those with deportation withheld, parolees, and those with amnesty.
What are the documentation requirements to verify for citizenship if any?Varies by state. General interim DOJ guidance is published in the Federal Register at 62 FR 61344At the federal level, citizens are not required to provide documentation of their citizenship status. Every applicant must declare in writing under threat of perjury that he or she is a citizen. Local PHAs may adopt a policy requiring documentation, such as a passport.At the federal level, citizens are not required to provide documentation of their citizenship status. Every applicant must declare in writing under threat of perjury that he or she is a citizen. Local PHAs may adopt a policy requiring documentation, such as a passport.
What are the documentation requirements to verify immigration status, if any?Varies by state.
Eligible noncitizens and qualified aliens must provide a signed declaration under threat of perjury of their eligible immigration status, documentation from the Department of Homeland Security, and a signed verification consent form relating to communications between DHS and HUD. The PHA or property owner must verify the documents using the SAVE system.34
Immigration status does not need to be verified for those over 62 years old.
Eligible noncitizens and qualified aliens must provide a signed declaration under threat of perjury of their eligible immigration status, documentation from the Department of Homeland Security, and a signed verification consent form relating to communications between DHS and HUD. The PHA or property owner must verify the documents using the SAVE system.33
Immigration status does not need to be verified for those over 62 years old.
What are the requirements for state residency and documentation of residency?Varies by state, but usually involves proof of present address (e.g., rent receipt, lease or deed, property tax bill).Applicants need not be a resident to get on a local housing authority waiting list. Some localities give preference to local residents, but PHA rules vary widely.Applicants need not be a resident to get on a local housing authority waiting list. Some localities give preference to local residents, but PHA rules vary widely.
Are there rules pertaining to non-incarceration?Varies by state, but generally ineligible if incarcerated because they are not living at home and therefore do not have home energy need. Other eligible members of the household could be served though.Federal regulation bans those on lifetime sex offender list or convicted of producing methamphetamine in federally assisted housing. PHAs have discretion in determining otherwise.35Federal regulation bans those on lifetime sex offender list or convicted of producing methamphetamine in federally assisted housing. PHAs have discretion in determining otherwise.34
Other special rulesLIHEAP benefits are usually paid directly to utilities or fuel vendors.None.Applicants can qualify due to elderly or disability status.
Where are data housed?State agency; local agencies and subgrantees in some states.Local housing authorities report their 50058/50059 eligibility data to HUD quarterly. HUD maintains these data in the PIC system.Local public housing authority.

Table A5. Programs with higher income eligibility thresholds

 CCDF (subsidized child care)36EITC37
Do benefits vary by income, once someone qualifies?
Yes, copayment varies based on income.
Some copayments are based on cost of care, but amount may still be based on income.
Yes, based on earned income and number of children. Income eligibility limits are lower for childless adults.
Eligibility Overview:
  • Children must be under age 13, or under 18 if disabled or under court supervision.
  • Parent must be working or attending job training, unless the child is receiving protective services.
  • Family income must be no greater than 85 percent of state median income or lower depending on state policy.
Families with qualifying children (i.e., under age 19 or 24 if a full-time student, or permanently or totally disabled) and childless adults (aged 25-64) who have earned income below specified levels are eligible.
Earned Income and AGI must each be less than:
  • $45,060 ($50,270 married filing jointly) with three or more qualifying children
  • $41,952 ($47,162 married filing jointly) with two qualifying children
  • $36,920 ($42,130 married filing jointly) with one qualifying child
  • $13,980 ($19,190 married filing jointly) with no qualifying children.
If vary by state, give eligibility in lowest, median and highest state

Initial eligibility thresholds range, as a percent of poverty, from 120 percent in Nebraska to 250 percent in New Hampshire.

  • Lowest: $1,854 in Nebraska
  • Median $2,856 in Kansas
  • Highest: $4,524 in Alaska.
As of 2012, 25 states and the Districts of Columbia had state EITCs that generally follow the eligibility rules of the federal EITC, although at lower benefit levels..
Eligibility based on current monthly income, projected annual income, past annual income, or some other budgeted period?Varies by state. Income may also be defined differently by state.Annual.
Reporting requirementsEach state sets its own policies for what must be reported and when changes must be reported.NA (information reported when filing taxes).
Redetermination periods
Varies by state.
Over half of states set periods of 12 months, with almost all other states setting periods of 6 months. Caseworkers may set shorter periods (due to discretion, policies for different groups, etc). Some states allow different redetermination periods for different groups (i.e. Head Start kids have longer period).
NA (based on annual information).
Additional Details: (Whether or not asset limits, income disregards, etc.)

Additional details vary by state.

  • States establish a number of rules, including assistance unit composition, countable income, asset limits, and approved activities for eligibility.
  • States may establish eligibility limits and age limits lower than the federal guidelines.
  • States also have discretion to define core elements such as defining the unit, countable income, allowable activities, etc.
  • Earned income includes wages and other compensation, or net income from self-employment (without deduction for self-employment taxes).
  • Tax filers are ineligible for the EITC if investment income exceeds $3,200 for 2012 tax returns.
Is program capped?Yes.No.
Are there priority policies?
States are required to give priority to very low-income children and target a certain amount of funds to welfare families working toward self-sufficiency or families at risk of welfare dependency. States may define very low income differently.
States may choose whether or not to establish additional priority policies and which families receive priority.
NA
Restrictions on immigrants? If so, what are they?
Under federal policy, the child is considered the primary beneficiary of child care services; therefore, only the citizenship and immigration status of the child is relevant when determining eligibility. Children can be citizens or qualified immigrants.
Qualified immigrants include: lawful permanent residents (persons with green cards); refugees, persons granted asylum or withholding of deportation/removal, and conditional entrants; persons granted parole by the Department of Homeland Security (DHS) for a period of at least one year; Cuban and Haitian entrants; certain abused immigrants, their children, and/or their parents; and certain victims of trafficking.
To qualify, the individual must be a U.S. Citizen or resident alien all year. The taxpayer, taxpayer’s spouse, and any qualifying child for the credit must also have a Social Security number (SSN) valid for work in the United States. If the claimant or his or her spouse (if married) were a nonresident alien for any part of the year, they cannot claim the earned income tax credit unless their filing status is “married filing jointly.” They can use that filing status only if one spouse is a U.S. citizen or resident alien and the other chooses to treat the nonresident spouse as a U.S. resident. If they choose this status, they are taxed on their worldwide income.
What are the documentation requirements to verify for citizenship if any?States determine what information must be verified and the form of documentation required.Must have valid SSN entered on tax form.
What are the documentation requirements to verify immigration status, if any?States determine what information must be verified and the form of documentation required.Must have valid SSN entered on tax form.
What are the requirements for state residency and documentation of residency?Applicants must be state residents, and some states may establish county residency requirements. States determine what information must be verified and the form of documentation required.NA for federal EITC, although some states have their own state EITC.
Are there rules pertaining to non-incarceration?Some states allow a single parent or caretaker to apply for subsidies when one of the parents is incarcerated.Amounts received for work performed while an inmate in a penal institution are not earned income when figuring the earned income credit. This includes amounts for work performed while in a work release program or while in a halfway house.
Other special rulesMost rules are determined at the state level, including recertification periods, categorical eligibility, waiting lists, etc.
  • Claimants cannot file forms 2555 or 2555-EZ for foreign earned income.
  • Taxpayers must meet the rules for qualifying children.
Where are data housed?
State agencies.
In some states, data may be housed in local agencies - for example, TX, CO, and NY set local policies.
Federal (IRS).

Appendix III. Microsimulation Methodology

This appendix describes the microsimulation methodology used to estimate health and human services eligibility and receipt. The tabulations for this report are drawn from information from two large microsimulation models, the Transfer Income Model, Version 3 (TRIM3), which is developed and maintained by the Urban Institute under primary funding from ASPE, and the Health Insurance Policy Simulation Model (HIPSM), also developed and maintained by the Urban Institute with funding from multiple sources, including ASPE, the Robert Wood Johnson Foundation, and the Kaiser Commission on Medicaid and the Uninsured.

HIPSM was used to estimate whether or not individuals were offered affordable employer-sponsored insurance, and then this information was imported into TRIM and combined with TRIM estimates of Modified Adjusted Gross Income (MAGI) to determine whether individuals qualify for HIM subsidies. Medicaid eligibility was estimated in TRIM using program rules simulated for 2014 (e.g., MAGI less than 138 percent of poverty or otherwise eligible). In addition, TRIM was used to estimate human services program eligibility and receipt. The following information provides a more detailed description of the methodologies used by each model.

Hipsm

Our results are based on HIPSM’s simulation of the ACA as if it were fully implemented, including an expansion of Medicaid eligibility to 138 percent FPL. HIPSM augments the underlying Current Population Survey (CPS) data with imputations of health care costs, premiums, Employer Sponsored Insurance (ESI) offers, immigration status, and detailed Medicaid eligibility type.38 For purposes of this analysis, HIPSM’s imputation of ESI offers was exported to TRIM for purposes of determining eligibility for HIM subsidies.

Trim3

TRIM provides the estimates of ACA Medicaid and HIM eligibility, using HIPSM’s imputation of the availability of an affordable ESI offer. Additional details of the TRIM simulation of Medicaid, HIM, and human services program eligibility and receipt is provided below.

Data year and population

The tabulations use the spring 2011 CPS-ASEC file, with demographic data as of the month of the survey and income data for CY 2010. The data were not “aged” in any way to capture changes in demographics, employment/unemployment, or income since 2010. In particular, note that because the modeling uses 2010 as the base year, it does not reflect growth in the number of recipients receiving SNAP benefits between 2010 and 2013, and so the estimates of overlap between SNAP recipients and other programs are conservative. The exception is the imputation of whether a worker has an offer of affordable insurance, which is based on estimates of what employers will offer post-ACA. However, estimated post-ACA offer rates do not differ radically from pre-ACA offer rates. Persons 65 and older as well as non-citizens imputed to be undocumented were excluded from the tabulations. Medicare recipients with disabilities are excluded from certain figures and tables, as indicated in the figure and table notes.

Determination of MAGI

Determining eligibility for both Medicaid and HIM subsidies requires knowing the modified adjusted gross income (MAGI) of a person’s family.

For purposes of HIM subsidies, the family is always defined as a taxpayer, his/her spouse, and his/her dependents. The income that is counted is the income of the taxpayer/spouse, plus the income of any dependent who is required to file a tax return. TRIM3’s Federal Tax simulation determines dependency relationships and filing requirements. For HIM purposes, MAGI is computed on an annual basis, and compared to the annual poverty guideline for a particular family size.

For purposes of Medicaid eligibility under ACA, the final regulations 39 describe alternate family definitions covering individuals in certain circumstances, such as children living with unmarried parents or claimed as a dependent by a noncustodial parent, and individuals (any age) who do not expect to file a tax return and do not expect to be claimed as a dependent, or who are claimed as a dependent by someone other than a spouse or parent. The simulation models these alternate family definitions as described in the final regulations. However, due to data limitations, dependency relationships involving persons living outside the household are not captured in the analysis.

The final regulations also clarify that Medicaid eligibility is based on current or projected income rather than the prior year’s income. To capture this fact, the simulation computes MAGI as a percentage of the poverty guideline on a month-by-month basis, using the monthly income amounts developed for use in all TRIM simulations of benefit programs.40

On either an annual or monthly basis, MAGI includes all the types of income that are counted in AGI for tax purposes—earnings, pensions, asset income, interest, dividends, rents and royalties, Social Security benefits, Unemployment Insurance, alimony, and capital gains. MAGI includes tax exempt interest not included in AGI and also the non-taxable portion of Social Security. To capture capital gain/loss amounts, TRIM uses amounts that have been statistically matched to the TRIM3 file for purposes of TRIM3’s standard federal tax simulation, using the IRS Statistics of Income Public Use File (PUF), which contains de-identified data from a representative sample of taxpayers’ 1040 forms. For purposes of allocating this amount to specific months, the annual amount is divided evenly over all months. (In reality, many capital gains/losses would be lump-sum amounts, which could be treated differently for purposes of monthly eligibility.) MAGI includes AGI adjustments to income—three of which are captured in this analysis (the deductions for half of the self-employment tax, and deductible IRA contributions and payments to Keogh plans obtained through the statistical match with the PUF).

Determination of Medicaid eligibility under the ACA

The TRIM3 model is used to simulate Medicaid and CHIP eligibility assuming that the ACA has been fully implemented, and that all states have expanded Medicaid eligibility to 138 percent of poverty. Eligibility is assessed on a month-by-month basis.

Eligibility is simulated as follows:

  1. Adults qualify for Medicaid if they have MAGI at or below 138 percent of the poverty guidelines, or if they have mandatory coverage as SSI recipients.41 Other pathways are assumed to no longer be available. The simulation assumes no continuous coverage for adults.
  2. Children ages 0-18, inclusive, qualify for Medicaid if they have MAGI at or below 138 percent of the poverty guidelines. States that currently (2010) apply continuous enrollment to children were assumed to apply continuous enrollment to children newly-eligible under the ACA.
  3. Children above 138 percent of FPL qualify for Medicaid and CHIP if they qualify under their state’s pre-ACA rules. The modeling of eligibility for CHIP, including for separate state programs, does not exclude from eligibility children who are reported in the survey as covered by employer-sponsored insurance (ESI). Although by federal statute receipt of ESI is incompatible with eligibility for separate CHIP programs,42 children in many states can move from ESI into CHIP.43 Except for our EITC results (as shown in Figure 4),44 using a different assumption would cause only minor changes to the results we report in the body of the paper.

More details are provided below on the assumptions regarding pre-ACA pathways and the modeling of continuous coverage.

Assumptions regarding pre-ACA pathways

The simulation assumes that individuals age 19 and older would only have two pathways to Medicaid eligibility—having MAGI under 138 percent of poverty, or having mandatory coverage via SSI receipt.

However, children are modeled as eligible for Medicaid if they are eligible either under the ACA rules or through any prior pathway other than the Medically Needy pathway. This is an approximation of the “maintenance of effort” (MOE) requirements, but not a simulation of those requirements since it is not yet known exactly how states will convert their current pathways to use MAGI income. In other words, the simulation of MOE eligibility for children above 138 percent of poverty uses current (2010) measures of income, not the MAGI-equivalent measure that will actually be used under the ACA.

Note that when determining who among the population with income greater than 138 percent of poverty is covered by the child MOE requirement, we treated all persons under 19 who are eligible in 2010 as MOE-eligible under the ACA. This was done even if the 2010 pathway is an “adult” pathway (e.g. a pregnancy pathway, the 1931 parent pathway, and some waiver pathways). Also, persons over 138 percent of poverty who are age 19-20 may be eligible as Ribicoff children, or eligible though their state’s option percent-of-poverty coverage of children (even though they are classified as adults in the tables).

The Medically Needy pathway is assumed to no longer be needed since individuals previously covered through Medically Needy could generally be eligible under ACA rules without the need for spend-down, and since the ACA is assumed to result in universal coverage where no citizen or legal resident has high medical bills.45

Procedurally, the different treatment of the pre-ACA pathways for adults vs. children was modeled by performing two TRIM3 Medicaid simulations. The primary simulation simulated eligibility under the ACA (including MOE for children) but turned off all pathways through which adults could become eligible except for the 138-percent-poverty and SSI receipt pathways. In a second simulation, all pathways were set to their 2010 levels. If a child was ineligible in the first simulation but eligible in this second simulation through any pathway other than Medically Needy, he or she was considered to be eligible under the ACA (via the ACA’s MOE requirement for children). In effect, this second simulation captures those children above 138 percent of poverty who would be eligible under the MOE requirement but only via a pathway that can also be used by adults (primarily the 1931 pathway, but also some state optional coverage of people with disabilities) – child-only pathways have the MOE requirement simulated in the primary simulation.

The results shown in Table 1 and the bullets that immediately precede Table 1 differ from other results in that these particular results are limited to Medicaid. They include neither eligibility for separate CHIP programs nor eligibility for HIM subsidies. To exclude from our Medicaid eligibility estimates children who will qualify for coverage under separate CHIP programs, we applied the FPL thresholds listed for children’s Medicaid coverage under both Title XIX and Title XXI programs as listed by the Kaiser Family Foundation’s statehealthfacts.org46 to reflect the findings of the Georgetown Center for Children and Families and the Kaiser Commission on Medicaid and the Uninsured concerning financial eligibility rules in effect in January 2013.47 Children with incomes above those thresholds, defined using each state’s pre-ACA income disregards and other income methodologies, were excluded from our estimates of Medicaid-eligible children.48 We then consulted statehealthfacts.org to determine that California is the only additional state that has passed legislation that, before 2014, will shift children above 133 percent FPL from a separate CHIP program into a Medicaid program funded through Title XXI.49 As a result, for California children, we assumed that, in 2014 and later years, children with incomes at or below the FPL threshold of the state’s previous separate CHIP program will qualify for Medicaid. Children with incomes above that threshold, determined using the state’s pre-ACA CHIP income disregards and other methodologies, were excluded from these estimates of Medicaid eligibility.

Modeling continuous coverage

As mentioned above, it is assumed that if a state previously allowed continuous coverage for children, that the policy would continue. For example, in states with 12 months of continuous coverage, if there is one month when a child passes the eligibility tests, he or she is counted as eligible for the remainder of the year. In reality, the child would only be covered in these months if he or she actually chose to enroll in Medicaid.50

The current policy of extending “continuous eligibility” to pregnant women for the duration of their pregnancy is assumed to not be continued under the ACA (even if the women initially became eligible as a child).51

Determination of eligibility for HIM subsidies

People qualify for subsidies in the marketplace (HIM) if—

  • They are not offered affordable ESI;
  • They are citizens or lawfully present in the U.S.;
  • They are ineligible for Medicaid or CHIP
  • They are not covered by Medicare52; and
  • They either –
    • Have annual MAGI between 100 and 400 percent of the poverty guideline; or
    • Have MAGI low enough to qualify for Medicaid (and below 100 percent of poverty) but are ineligible due to immigrant-related restrictions

Although the MAGI assessment for HIM purposes is annual, Medicaid/CHIP eligibility is assessed monthly and can change during the year. Thus, a person can be simulated as eligible for HIM in some months of the year, but eligible for Medicaid in other months of the year. The simulation captures the final regulations’ “safe harbor” that allows persons who are ineligible for HIM subsidies because annual MAGI is under 100 percent FPL to qualify for Medicaid in months where monthly MAGI exceeds 138 percent FPL.

Data from HIPSM was imported into TRIM and used to determine which workers were offered affordable ESI by their employer. If a worker had an affordable offer, the following household members were assumed to have access to that coverage as well:

  • Spouse
  • Children under 26 (even if married or a parent)53
  • Any person under 19 claimed as a dependent by the worker, or the worker’s spouse.

A worker with an affordable offer was not considered to have that offer in months where he or she was not working (i.e. months where he or she had no earnings). Likewise, spouses and dependents do not have access to that worker’s offer in months where the worker has no earnings.

While undocumented noncitizens are never eligible for subsidies, legal noncitizens face no special restrictions. Furthermore, if a legal noncitizen has MAGI under 100 percent of poverty but is not eligible for Medicaid solely because of Medicaid’s restrictions on noncitizens, he or she is eligible for subsidies.

Note that we assumed all persons eligible for a subsidy would enroll in a HIM plan, regardless of whether they were subject to the mandate. This also assumes that no eligible person would choose to pay the penalty for non-compliance.

Determination of eligibility and receipt of human services

Eligibility and receipt of human services were based on TRIM-simulated 2010 eligibility and participation in those benefit programs. With the exception of Unemployment Insurance (which is based on the characteristics and income of an individual), eligibility is determined based on the income and characteristics of a group of people within a household, referred to as the filing unit. TRIM simulates the nuances of whose income is counted and which persons in the unit are eligible for benefits. For example, in SNAP, most lawfully present non-citizens aged 18 or older are generally ineligible for assistance in their first five years in the United States, but their lawful permanent resident or citizen children are eligible. Following SNAP rules, TRIM counts a prorated share of a non-citizen’s income in determining eligibility for his or her children. Whereas the child is counted as eligible for SNAP, the parent is not.

In general, the tables for this report categorize a person as eligible for assistance if he or she is personally eligible (not simply in a unit where someone is eligible). However for three programs, a broader definition of eligibility was used:

  • EITC: If a taxpayer is simulated to be eligible for the EITC, that eligibility is considered to include not just the taxpayer, but also his or her spouse and all children in the household who meet the criteria for an “EITC qualifying child”.
  • Child Care Subsidies: If any children are eligible for subsidies, that eligibility is considered to include the head and spouse of the children’s family, any unmarried parents outside the family (but in the household), and any other family members under 19. Subfamilies are treated as separate families.
  • WIC: If any child (or pregnant woman) is eligible for WIC, that eligibility is considered to include the head and spouse of the family, any unmarried parents outside the family (but in the household), and any other family members under 19. Subfamilies are treated as separate families.

Note the following about TRIM’s simulation of the following human services programs:

  1. The Unemployment Insurance data for this analysis does not adjust for the under-reporting of UI income in the CPS-ASEC data.
  2. WIC adjunctive eligibility via Medicaid does not include persons who are simulated to be newly-eligible for Medicaid under the ACA. Only persons who report Medicaid on the CPS and TRIM finds eligible for Medicaid in 2010 are considered adjunctively eligible.
  3. The count of individuals who are eligible for WIC includes only people who would be eligible based on that month’s characteristics and family income; it does not include people who would be eligible through continuous enrollment based on enrollment in a prior month.

Determination of whether a person should be categorized as a child, parent, or non-parent in the tables

This categorization attempted to follow the categorization that applies to most Medicaid eligibility pathways. A “child” was defined strictly in terms of age – anyone under 19 was categorized as a child, regardless of whether that person was married and/or was a parent. Persons 19 and older were categorized as “parents” if they were the head or spouse of a family and that family contained at least one person under 19 who was the “own child” of the family head (thus, as in most states’ Medicaid programs, in cases where all children are being cared for by relatives, the caretaker relatives were not categorized as “parents”). Note that unmarried parents living in the same household were considered to be members of the same family and were each counted as a parent. However, if a parent is a step-parent, he or she was not categorized as a parent. Related subfamilies were treated as separate families. All persons 19 and older who did not meet the definition of “parent” were categorized as “non-parents.”

Average monthly eligibility vs. annual eligibility

Since TRIM determines eligibility on a monthly basis, aggregate eligibility estimates can be calculated on either an average monthly or annual basis. Annual estimates consider a person to be eligible for a particular program if he or she is eligible for that program in a least one month of the year, and no consideration is given to the actual number of months he or she is eligible (e.g. a person eligible for 12 months is treated the same as a person eligible for only 1 month). On the other hand, average monthly eligibility estimates adjust for months of eligibility by “pro-rating” each person by the number of months he or she is eligible (e.g. in the aggregate eligibility estimate, a person eligible for all 12 months will count 12 times as much as a person eligible for just 1 month).

The eligibility estimates presented in this report are all average monthly estimates, and reflect the overlap in monthly program eligibility. For example, a person who was eligible for UI for the first half of the year and Medicaid for the last half of the year would not be counted in table cells showing overlap in Medicaid and UI eligibility. However, if eligibility for these programs overlapped in one month, then 1/12 of the person’s weight would be counted in the table, and if eligibility overlapped in all months, then the person’s full weight would be counted. Note that eligibility for the EITC and LIHEAP is calculated based on annual income, so individuals eligible for those programs are counted as eligible for the entire year. Similarly, non-resident parent status is determined on an annual basis, so persons classified as non-resident parents are counted as such for the entire year.

Appendix IV. Additional Microsimulation Results

This appendix provides additional detailed microsimulation results. As previously noted, the tabulations are drawn from information from two large microsimulation models, the Transfer Income Model, Version 3 (TRIM3), which is developed and maintained by the Urban Institute under primary funding from ASPE, and the Health Insurance Policy Simulation Model (HIPSM), also developed and maintained by the Urban Institute.

Table A6. Average monthly eligibility/receipt of human services benefits, by eligibility for insurance affordability programs (IAPs) under the ACA for people under age 65 (thousands) (part 1)

  All Eligible for Medicaid or CHIP Eligible for HIX subsidies
Children Parents Non-parents Total Children Parents Non-parents Total
All persons 256,874 45,555 15,206 31,146 91,906 1,163 3,777 12,896 17,836
Receives SNAP 43,118 20,677 9,844 11,123 41,644 61 256 286 602
Eligible for but does not receive SNAP 14,450 4,309 1,857 5,451 11,617 25 142 966 1,133
Family receives WIC 16,813 10,180 4,054 125 14,359 77 607 19 704
Family eligible for but does not receive WIC 12,216 7,386 2,860 87 10,334 49 325 15 389
Receives TANF 4,719 3,550 1,084 22 4,656 0 24 0 24
Eligible for but does not receive TANF 9,483 6,508 2,698 73 9,279 1 76 0 77
Receives LIHEAP 17,812 7,437 3,285 4,829 15,551 32 312 552 896
Eligible for but does not receive LIHEAP 50,981 20,370 8,720 13,968 43,058 132 1,068 2,038 3,239
Family receives child care subsidies 2,851 1,846 700 23 2,570 5 57 5 67
Family eligible for but does not receive child care subsidies 13,613 8,497 2,806 111 11,414 63 428 15 506
Receives housing subsidies 8,729 3,963 1,712 2,345 8,021 3 73 139 216
Potentially eligible for UI 8,083 13 1,314 2,261 3,588 2 273 1,134 1,409
Eligible for EITC 53,481 24,014 10,599 7,655 42,268 361 2,087 1,146 3,594

 

Table A6. Average monthly eligibility/receipt of human services benefits, by eligibility for insurance affordability programs (IAPs) under the ACA for people under age 65 (thousands) (part 2)

  Medicare enrollees not eligible for insurance affordability programs Other persons not eligible for insurance affordability programs
Children Parents Non-parents Total Children Parents Non-parents Total
All persons 56 323 2,883 3,262 31,587 42,062 70,220 143,869
Receives SNAP 1 62 140 204 53 419 196 668
Eligible for but does not receive SNAP 1 6 332 339 93 459 809 1,361
Family receives WIC 1 24 3 29 298 1,369 54 1,721
Family eligible for but does not receive WIC 2 26 6 34 229 1,183 46 1,459
Receives TANF 0 1 0 1 0 38 0 38
Eligible for but does not receive TANF 0 4 0 4 0 122 1 123
Receives LIHEAP 1 30 158 189 59 564 553 1,176
Eligible for but does not receive LIHEAP 1 65 371 437 227 1,969 2,052 4,247
Family receives child care subsidies 0 1 2 2 29 168 15 212
Family eligible for but does not receive child care subsidies 1 5 0 6 254 1,276 158 1,688
Receives housing subsidies 1 18 100 119 15 166 193 374
Potentially eligible for UI 0 10 52 62 8 1,138 1,879 3,025
Eligible for EITC 3 100 247 349 889 4,954 1,428 7,271

Source: TRIM3, HIPSM 2012. Notes: Assumes that all states expand Medicaid eligibility for adults to 138 percent FPL. Eligibility for children’s Medicaid and CHIP includes pre-ACA categories above 138 percent and does not exclude ESI recipients. WIC and child care subsidy counts include spouses and dependents under age 19 who do not directly receive WIC or child care subsidies. Housing subsidies include public housing and rent vouchers. UI and EITC estimates are for potential eligibles and eligibles, respectively. Other human services estimates are for aid recipients. Human services estimates are based on eligibility and participation levels in calendar year 2010 as reflected in the 2011 CPS-ASEC.

Table A7. IAP eligibility, by eligibility/receipt of human services, for people under age 65 (thousands) (part 1)

  All Receives SNAP Eligible for, does not receive SNAP Non-custodial parent Family receives WIC Receives TANF
Eligible for Medicaid or CHIP, 0-50% FPL Children 14,429 14,429 879 19 4,071 3,143
Parents 5,991 4,813 317 500 1,803 913
Non-parents 15,300 6,744 1,698 1,253 52 22
Total 35,721 22,062 2,894 1,772 5,926 4,079
Eligible for Medicaid or CHIP, 51-100% FPL Children 8,124 5,802 1,131 11 2,311 282
Parents 4,468 2,989 664 337 1,101 120
Non-parents 5,890 1,779 1,358 399 27 0
Total 18,482 10,570 3,152 747 3,439 402
Eligible for Medicaid or CHIP, 101-138% Children 6,471 2,963 1,273 14 1,740 33
Parents 4,089 1,669 840 291 1,011 32
Non-parents 5,742 904 1,671 404 31 0
Total 16,302 5,535 3,783 709 2,782 65
Eligible for Medicaid or CHIP, > 138% FPL Children 15,956 1,069 978 33 1,922 27
Parents 177 49 9 22 50 1
Non-parents 755 47 65 79 3 0
Total 16,888 1,165 1,052 134 1,975 28
Eligible for HIM subsidies under ACA Children 1,163 61 25 3 77 0
Parents 3,777 256 142 288 607 24
Non-parents 12,896 286 966 817 19 0
Total 17,836 602 1,133 1,108 704 24
Medicare recipients Children 631 339 50 0 137 64
Parents 804 386 33 67 113 19
Non-parents 6,341 1,789 991 274 16 0
Total 7,775 2,516 1,074 340 267 84
Not IAP eligible (Other) Children 31,587 53 93 31 298 0
Parents 42,062 419 459 2,234 1,369 38
Non-parents 70,220 196 809 3,788 54 0
Total 143,869 668 1,361 6,053 1,721 38

Table A7. IAP eligibility, by eligibility/receipt of human services, for people under age 65 (thousands) ( part 2)

  Receives LIHEAP Family receives CCDF Receives housing subsidies Potentially eligible for UI Eligible for EITC
Eligible for Medicaid or CHIP, 0-50% FPL Children 3,430 662 2,419 6 5,661
Parents 1,492 219 1,022 530 2,720
Non-parents 2,380 4 1,182 976 2,442
Total 7,303 884 4,623 1,512 10,823
Eligible for Medicaid or CHIP, 51-100% FPL Children 1,839 606 803 2 6,076
Parents 985 294 382 460 3,930
Non-parents 860 5 337 608 2,323
Total 3,684 904 1,523 1,070 12,328
Eligible for Medicaid or CHIP, 101-138% Children 1,063 304 380 0 5,102
Parents 634 179 225 295 3,645
Non-parents 726 14 215 604 2,125
Total 2,424 497 819 899 10,871
Eligible for Medicaid or CHIP, > 138% FPL Children 995 268 285 3 6,926
Parents 37 5 10 21 147
Non-parents 70 0 14 46 334
Total 1,102 273 309 70 7,407
Eligible for Medicaid or CHIP, > 138% FPL Children 32 5 3 2 361
Parents 312 57 73 273 2,087
Non-parents 552 5 139 1,134 1,146
Total 896 67 216 1,409 3,594
Medicare recipients Children 111 7 78 1 253
Parents 167 3 91 18 257
Non-parents 952 3 697 80 679
Total 1,227 14 865 98 1,189
Not IAP eligible (Other) Children 59 29 15 8 889
Parents 564 168 166 1,138 4,954
Non-parents 553 15 193 1,879 1,428
Total 1,176 212 374 3,025 7,271

Source: TRIM3, HIPSM 2012. Notes: See notes to table A6. Eligibility for Medicaid and CHIP is limited to people not receiving Medicare.

Appendix V: Experts Consulted

Work on this report was made possible by the invaluable feedback provided by experts listed below. However, the views expressed in this report are solely those of the authors and may not reflect the views of the experts listed below or their affiliated organizations. The authors would like to thank the following people, including members of our Technical Working Group and others, for their input at various stages in the process, in addition to our project officers, Alana Landey and Carli Wulff in ASPE’s Office of Human Services Policy.

Technical Working Group

Federal Officials

HHS 

Susan Golonka, ACF/OFA

Vicki Turetsky (along with Jennifer Burnszynski), ACF/OCSE
Mark Fucello, ACF/OPRE
Rochelle Rollins, advisor to the Chief Medical Officer, ACF
Jeannie Chaffin, ACF/OCS
Suma Nair, HRSA/Bureau of Primary Care
Ben O’Dell and Lisa Carr, Center for Partnerships
Gregorio Hunt, OIEA
Elizabeth Hadley and Christie Peters, ASPE/Office of Health Policy
Donna Cohen Ross, CMS/CMCS

USDA/FNS 

Kathryn Law, Office of Policy Support

SSA

Craig Streett, Office of Income Security Programs

State Officials

Louisiana

Ruth Kennedy, Medicaid director

Nongovernmental Members

Anita Light and Megan Lape, American Public Human Services Association

Catherine Hess, National Academy for State Health Policy
Helen Neuborne, Ford Foundation
Andy Hyman, Robert Wood Johnson Foundation
Elisabeth Mason, SingleStop USA (representing the Coalition for Access and Opportunity)
Krista Drobak (health) and Meghan Wills (human services), National Governors Association
Rachel Klein, Enroll America
Steve Taylor, United Way
 
Other Experts
 
Gina Adams, Urban Institute
Robert Adams, HHS/CMS/Office of Communications
Lauren Christopher, HHS/ACF
Stacy Dean, Center on Budget and Policy Priorities
Lisa Dubay, Urban Institute
Linda Giannarelli, Urban Institute
Olivia Golden, Urban Institute
Heather Hahn, Urban Institute
Jesse Jannetta, Urban Institute
Kay Joslin, the National Center for Appropriate Technology
Alicia Kone
Pamela Loprest, Urban Institute
Elaine Maag, Urban Institute
Barbara Ormand, Urban Institute
Claudia Page, Social Interest Solutions
Lynne Page Snyder, Housing Health L.L.C.
Elizabeth Peters, Urban Institute
Susan Popkin, Urban Institute
Andrew Stettner, Single Stop USA
John Wancheck, Center on Budget and Policy Priorities
Stephen Wandner, Urban Institute
Matt Winters, Single Stop USA
Sheila Zedlewski, Urban Institute

 

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.