Even today, many who are eligible for Medicaid (or the Children’s Health Insurance Program) are not enrolled, for a variety of reasons, including:
- Not knowing or understanding eligibility requirements
- Negative perceptions or associations with enrollment in public programs
- Administrative, cultural, and/or language barriers to completing the application process
- State challenges in maintaining continuous enrollment for those who are eligible
Beginning January 1, 2014, the ACA requires states to make important changes to Medicaid, some of which will simplify the eligibility process and streamline enrollment. Specifically, the ACA eliminates the asset test requirement and establishes a new definition of income (modified adjusted gross income, or MAGI) for determining Medicaid eligibility. Furthermore, the law gives the states the option to use presumptive eligibility to enroll all individuals in Medicaid (which is only permitted for children and pregnant women today).
While we can be certain that Medicaid eligibility will expand greatly in 2014, actual Medicaid enrollment numbers will depend on the outreach and enrollment processes used by individual states. Michigan can learn from states that have successfully expanded eligibility in public insurance programs as it develops a comprehensive strategy for reaching and enrolling those who are currently eligible and the newly eligible population in 2014.
This paper examines the structure of the Medicaid program today, describes enrollment and outreach strategies used by other states, and identifies opportunities to increase Medicaid enrollment in Michigan.
Specifically, CMS sets standards for applications, documentation, income and asset verification, outstation workers, and recertification for the enrollment process in all states.
- Application: CMS requires the application to be in written form and signed by the applicant under penalty of perjury. States may design Medicaid application forms in any manner, and are allowed to create electronic applications and signatures if authorized by state law.
- Documentation: Applicants are required to document their citizenship and identity by providing proof, such as a birth certificate or passport. Certain applicants, such as those receiving SSI, Medicare, and/or SSDI benefits, are exempted from this requirement. Outside of citizenship and immigration status, federal law does not require documentation from applicants to verify any other information provided for determining eligibility, however, states may require applicants to provide paper documentation of their income and assets.
- Income and asset verification: Regardless of how a state collects an applicant’s income information, states must use the Income Eligibility Verification System (IEVS) to verify income. States have discretion to require their applicants to provide income and asset documentation, or allow them to self-declare their income and assets. States may also eliminate asset tests for families applying for Medicaid – a test which counts the resources that an applicant may have available beyond their income and other earnings, e.g. cars and savings accounts.
- Outstation workers: Eligibility workers must be out-stationed at disproportionate share hospitals and federally qualified health centers to accept and process Medicaid applications for children and pregnant women. States may use other outstation locations if they choose, and federal match dollars are available to fund these workers.
- Recertification: Eligibility must be re-determined at least once every 12 months, or whenever there is a change in circumstances that may impact eligibility. Face-to-face interviews and documentation for income and asset verification are not required for Medicaid coverage renewal.
Today, the Medicaid program in Michigan provides coverage for the following groups low-income groups:
- Children and pregnant women (Healthy Kids)
- Adults who are either aged, blind, or disabled
- Pregnant women whose income exceed the limit for Healthy Kids
- Caregivers of a dependent child
The program also provides limited basic coverage to a few other very low-income, childless adults who not eligible for Medicaid. The Child Health Insurance Program (CHIP) provides coverage to children up to 200 percent of poverty.
The Michigan Medicaid program has implemented the following policies, which are not required under federal law:
- Requires income tests for all Medicaid and CHIP applicants for both enrollment and renewal.
- Requires that individuals (with exception of Healthy Kids and pregnant women) provide income documentation when they apply for or renew enrollment in the program.
- Requires an asset test for all Medicaid applicants, except children under age 19 and pregnant women.
- Michigan verifies identity and citizenship through automated data exchanges with the Social Security Administration and state vital records.1 2
To increase enrollment of Medicaid and prepare for the newly eligible population in 2014, other states have pursued strategies to increase enrollment, including:
- Simplifying the eligibility process by creating online application systems, eliminating asset tests for all applicants, and automating the enrollment/re-enrollment and income verification processes.
- Strengthening current partnerships with presumptive agencies3 and building relationships with community-based organizations to help educate and enroll applicants.
The states of Massachusetts and Wisconsin passed state health reform legislation that expands coverage to low-income residents and employs innovative outreach and enrollment strategies to increase coverage among the eligible. The experiences these two states can be applied across the nation, both for enrolling individuals in Medicaid and CHIP today, and in the expanded program in 2014.
In April 2006, Massachusetts’ comprehensive health care reform legislation was signed into law. The legislation extended Medicaid coverage for children up to 300 percent of poverty and created a new subsidy program – Commonwealth Care (CommCare) – for low-income adults up to 300 percent of poverty who were ineligible for Medicaid. Along with expanding coverage, the legislation mandated that all adults in the state enroll in health insurance; however, this mandate did not extend to children or adults with incomes at or below 150 percent of the federal poverty level.
A number of state agencies, programs, and community leaders came together and developed – then executed – a comprehensive outreach and enrollment strategy that included simplifying eligibility, collaborating with health care providers and community-based organizations, and carrying out an extensive, multi-faceted public education campaign. Two years after the law was enacted, more than 97 percent of the state’s residents were enrolled in coverage during at least some portion of the year.
Prior to the passage of reform legislation, the state ran an uncompensated care pool (UCP), which reimbursed disproportionate share hospitals and community health centers for care provided to the low-income uninsured who were ineligible for subsidized coverage. The pool was funded through a mix of mandated payer contributions, hospital contributions, and a state legislative appropriation. For patients whose care was reimbursed by the UCP, the pool contained eligibility records with income and Medicaid ineligibility data. Post reform legislation, the state Medicaid agency used this data to identify eligible patients and automatically converted them to CommCare in two different waves.
In 2004, Massachusetts created an online portal – the Virtual Gateway – to serve as an Internet-based application system. This application was a single form that fed into one eligibility system for Medicaid, CHIP, the UCP, and other public health subsidies-based programs. Post-reform in 2006, this system integrated new subsidy programs, including CommCare. Through a computer software program, the Medicaid office determines eligibility for all subsidized programs by applying one set of income methodologies.
Partnerships with Safety Net Providers and Community-Based Organizations
Massachusetts’ Medicaid agency enlisted many safety net providers and community-based organizations (CBOs) to conduct outreach, public education, and enrollment. Massachusetts Medicaid will not fully reimburse safety net providers when a patient’s application for health coverage is not completed in full. This rule incentivized providers to commit staff to assist patients when completing applications through the Virtual Gateway.
CBOs also had another incentive to enroll people. For years prior to reform, and in partnership with the Blue Cross Blue Shield of Massachusetts Foundation, the state provided mini-grants to CBOs to be “application assisters” for residents – this practice continues today. CBO staff built on existing relationships in their communities to educate and complete applications for those who may be eligible. CBO and safety net provider’s staffs are regularly trained (every quarter) by the state in enrollment practices and updated on all components of developing state health care programs. Moreover, these sessions allow the state to systematically solicit input from CBOs and advocates when making program and policy decisions.
Marketing and Outreach
To educate the public about health reform legislation and available coverage options, the state worked with leaders in pro sports, health plans, community organizations, and major corporations on a statewide education campaign. The following are examples of Massachusetts’ multidimensional outreach campaign:
- Running advertisements on the television, radio, and during game time in partnership with the Boston Red Sox baseball team.
- Purchasing ad-space on public transportation.
- Enlisting hospitals, health centers, and CBOs to conduct their own campaigns using different outreach venues.
- Mailing postcards to residents and employers.
In addition to educating the public about their new available coverage options, the campaign informed residents about the individual mandate to enroll in coverage.
Challenges to the Outreach and Enrollment Strategy
Although Massachusetts was very successful in enrolling its uninsured population after the enactment of reform legislation, the state also encountered a number of challenges, some similar to those Michigan will face in 2014.
- The state underestimated the number of uninsured residents that would be eligible for subsidized coverage. This resulted in a greater need for assistance in enrollment and initial subsidy costs than the state originally expected for the first year of enrollment.
- All of the state’s health coverage programs were not included in the state’s eligibility system, which made it difficult to have a fully integrated, data-driven system.
- Differing eligibility rules for the two Medicaid-run programs, Medicaid and CommCare, made it difficult for enrollees to transition from one program to the other and resulted in gaps in coverage.
- Instead of completing eligibility/enrollment applications on behalf their uninsured patients, some hospitals (non-safety net) billed uninsured patients directly for provided services.
Unlike Massachusetts, Wisconsin did not undergo comprehensive system reform for public health programs. Instead, Wisconsin built on its existing public health insurance programs and expanded eligibility to achieve near-universal coverage. This resulted in BadgerCare Plus – launched on February 1, 2008 – a combination of CHIP, Medicaid, and Healthy Start programs and funding. The following January, the program extended coverage to low-income childless adults.
To understand the population in need of coverage, Wisconsin conducted a statewide survey in 2007 (called the Family Health Survey) and identified that 78,000 low-income adults in the state were uninsured and had very complex health conditions, no relationships with primary care, and received a lot of treatment in the emergency department. This data was the driving force behind Wisconsin’s expansion of BadgerCare Plus to cover these childless adults. To get these adults and other eligible Wisconsin residents covered, BadgerCare Plus relies on simplified eligibility and enrollment processes as well as partnerships with the community.
Wisconsin relies heavily on information technology to simplify the enrollment process. The state created a centralized and paperless electronic application system, which combines Wisconsin eligibility and Medicaid management information systems. An online tool called ACCESS allows individuals and families to determine their eligibility for various public programs, apply for benefits, and check their application statuses. State residents are able to apply for health coverage electronically and much of their income and lack of access to employer coverage information is automatically verified.
The state uses three systems to support the operations and administration of the program: Client Assistance for Re-Employments & Economic Support (CARES) is the enrollment/eligibility system; ACCESS is the application tool used by the public; and the state’s Medicaid Management Information System (MMIS) supports the business functions for program administration.4
Partnerships with CBOs – Marketing and Outreach
Relationships with community-based organizations are a cornerstone of outreach for BadgerCare Plus. In order to facilitate and simplify enrollment and renewal in the program, the Department of Health Services partnered with over 200 community-based organizations and health care providers to identify and enroll eligible children and families. Partners assist families in enrollment by logging into ACCESS. To incentivize partner organizations to enroll eligible persons, the Department of Health Services implemented a one-time grant program where they paid 31 organizations a fifty-dollar “finder’s fee” for each approved BadgerCare Plus application.
These relationships were very useful as the public insurance-eligible population expanded, and MDHS will continue to rely on these organizations under full Medicaid expansion in 2014. State health programs in Wisconsin, like Medicaid, had never worked with community organizations to help find and enroll eligible children, their families, and other adults prior to BadgerCare Plus. These partnerships had and continue to have a large impact in increasing enrollment.
Using these various strategies, Wisconsin has successfully expanded coverage to all children, more parents and caregivers, more pregnant women, and adults without dependent children. In doing so, BadgerCare Plus has reduced the state’s administrative costs by significantly simplifying the application process and developing partnerships with more than 200 community-based organizations that assist with outreach and enrollment. Currently the state uses a mix of funding to finance the program, including: Medicaid, CHIP, Healthy Start, state general revenue funds, re-directed dollars from federal disproportionate share hospital payments, and a federal grant. Like Michigan, Wisconsin is facing critical budget problems; however, the commitment to the program by the state’s governor is vital to its long-term existence.
Other states have used a variety of approaches to enroll people into Medicaid and CHIP, which are summarized in Attachment A.
Michigan has already taken steps to increase enrollment in public health insurance programs:
- Late in the summer of 2010 the two state departments that handle enrollment in Medicaid and CHIP – the Michigan Department of Human Services (MDHS) and the Michigan Department for Community Health (MDCH) – have begun integrating their eligibility data systems. However, MDHS workers have to input most eligibility data by hand into the current enrollment system (BRIDGES), making full integration impossible and creating other challenges.
- In the early fall of 2010, MDHS began using Social Security numbers to verify an applicant’s citizenship and identity, no longer requiring that applicants provide proof through documentation.
- Michigan uses presumptive eligibility for children, which is an option that allows states to allow designated qualified entities, like schools and hospitals, to determine a child’s temporary eligibility for Medicaid or CHIP if the child appears to be eligible. Enrollment in coverage by the qualified entity is temporary, while the state completes application process within sixty days. Michigan currently has approximately 400 presumptive agencies, which are mostly hospitals, doctor’s offices and local health departments. The state trains staff at these agencies, mostly through online webinars, but does not fund them to provide enrollment.
- MDHS is currently researching ACCESS, the online eligibility and application tool used by Wisconsin, as a method for enrolling residents into the Medicaid program in Michigan.
- States must eliminate asset tests for most Medicaid applicants.
- States must coordinate Medicaid, CHIP, and the exchanges and use a single online application. Specifically, state Medicaid and CHIP programs must accept pre-screened applicant referrals from the exchanges without further review of eligibility. Additionally, state Medicaid programs must ensure that ineligible applicants are screened for eligibility for subsidies in the exchanges and enrolled if eligible.
- States must operate a streamlined enrollment process, foster administrative simplification using uniform rules and forms, and use data matching arrangements to establish, verify and update eligibility in all three programs (Medicaid, CHIP and the exchanges).
- States will no longer be able to maintain their current income disregards and deductions to determine those newly eligible based on modified adjusted gross income.
These provisions will help streamline eligibility and enrollment processes in each state; however, they do not take effect until 2014. It would be best for Michigan take steps to ensure an efficient and effective Medicaid eligibility and enrollment process in time for federal changes to take effect.
Michigan has taken some steps to simplify and streamline Medicaid and CHIP enrollment processes, but there is more work to do. The following are specific actions Michigan can investigate to address its current system:
- Simplify the eligibility process by:
- Exploring avenues to establish an integrated and automated eligibility system that serves multiple health programs (i.e. the use of ACCESS) so all applicants use a single online system, instead of just children and pregnant women. Michigan can begin now to develop the information technology infrastructure needed to meet federal requirements in 2014 and create web-based application and eligibility portals.
- Eliminating the asset test for all Medicaid applicants prior to the required 2014 deadline. States that have eliminated the asset test have found that it enabled them to streamline the eligibility determination process; more easily adopt automated eligibility systems; and reduce Medicaid administrative costs. Although Medicaid officials in these states could not assess the direct impact of eliminating the asset test on enrollment separate from other outreach programs, they did not think dropping the requirement made a significant contribution to increased enrollment. For example, after New Mexico dropped the asset test, the direct additional cost due to increased enrollment was estimated at $23,000 per year in state general funds.12
- Eliminating the income verification requirement and use data from other sources, i.e. income tax data, to verify an applicant’s income.
- Assessing the use of “express lane eligibility,” a method of using eligibility data from other public programs, like food stamps or Head Start, to identify and enroll children with parental or guardian consent.
- Strengthen current partnerships with presumptive agencies and build relationships with community-based organizations to help educate and enroll applicants.
- Currently, presumptive agencies are mostly trained utilizing webinars and have no interaction with other agencies qualified to perform presumptive eligibility. Michigan should consider coordinating regular face-to-face training sessions (i.e. semi-annually or quarterly) where staff at the various agencies can share enrollment strategies and provide feedback to state Medicaid staff. Furthermore, when the program is expanded in 2014, presumptive eligibility should be extended to the newly eligible population.
- Although most CBOs cannot be qualified presumptive agencies, they can still help identify and enroll individuals and families acting as application assistors. Many CBOs in the state already perform outreach, educate, and assist those in their community with Medicaid enrollment. The state should consider partnering with these organizations by either providing mini-grants for each application that results in enrollment and/or providing them with technical assistance training (along with presumptive agencies).
- Use specific state and regional data when adopting certain enrollment policies and creating tailored and targeted outreach programs. Outreach begins with understanding the target populations.
Information Technology – New Mexico and Louisiana
Some states are taking advantage of technology to share data between various state social service agencies. This enables the Medicaid program to obtain information needed to determine or renew Medicaid eligibility from other assistance programs, with similar eligibility rules, in which applicants or enrollees may already participate. For example, almost half of all Medicaid programs are now establishing citizenship by matching eligibility data with the Social Security Agency, instead of requiring applicants to submit original birth certificates or passports.13
The following section presents specific examples of ways that New Mexico and Louisiana are using information technology to increase enrollment in their various public health insurance programs.
New Mexico has found a way not only to make the application and renewal process fully electronic, but also to increase enrollment for target child populations (identified through the use of eligibility and enrollment data). Using grant funding from the Child Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the New Mexico Human Services Department is installing standalone enrollment kiosks at community centers and schools that can be used by individuals to apply for Medicaid and CHIP electronically, eliminating the need to visit enrollment offices. Applicants can enter basic information to determine whether or not they are eligible, and assistance is available from trained individuals who already working at the kiosk locations. If eligible, individuals can complete an application that will be sent directly to the Human Service Department.14
Express Lane Eligibility (ELE) was authorized by CHIPRA and allows state Medicaid and CHIP agencies to use eligibility findings from other public programs like food stamps or Head Start, and/or on tax return data to identify, enroll, and recertify children, with family consent. This program is meant to streamline eligibility renewal and prevent children from losing coverage due to paper work. As of February, Louisiana is one of three states to receive approval to use ELE in their Medicaid programs. A month after ELE was launched in Louisiana, Medicaid enrolled more than 10,000 children using the new process, and four months later, that number reached 14,000. To better implement express lane eligibility, Louisiana’s Department of Health and Hospitals found that the department needed additional staff time to develop ELE and work out data-matching problems.15
Currently, the authority to implement ELE for Medicaid enrollment does not extend to adults. However, it is likely that a large portion of the newly eligible Medicaid population in 2014 will be enrolled in food stamps, and the use of Supplemental Nutrition Assistance Program (SNAP) data could be very effective in determining eligibility and reaching newly eligible adults.
Using information technology to coordinate programs and share data can reduce administrative burdens. Technology can also enhance eligibility determination and enrollment through online applications and submission. Online applications may also promote the enrollment of younger, healthier populations in the Medicaid program.
Partnerships with Community-Based Organizations – Colorado
State funding is limited, which creates difficulty in implementing wide range outreach and enrollment initiatives without partners. Many states maintain diverse enrollment options by developing partnerships with community-based organizations. These organizations play a key role in outreach and enrollment because they can leverage their existing relationships with individuals and families in the community, regardless of the initiative.
Colorado has used strategic partnerships in different ways to increase enrollment and awareness of different public insurance programs. The Colorado Health Foundation,16 created as a result of a joint venture of a for-profit and a non-profit health system, is a grant making organization with the goal to make Colorado the healthiest state in the nation.
created as a result of a joint venture of a for-profit and a non-profit health system, is a grant making organization with the goal to make Colorado the healthiest state in the nation.
The Foundation funds community-based organizations to provide community outreach and create ways to simplify the enrollment and renewal processes for public health insurance. Grants provided by the Foundation have been used in a variety of ways, specific to the needs of the community-based organization and its target population. Some use the funding to hire staff providing application assistance to families and others develop more innovative projects. For example, in 2007, about 72 percent of Colorado children eligible for Medicaid and CHIP were Latino. To best target this population, the Encrucijada Project – a coalition of various community groups – received Foundation funding and produced a Spanish-language soap opera that includes information on applying for and using public health insurance, as well as messages around health promotion and disease prevention.
Foundation grant dollars have also been used to drive the passage of several pieces of state legislation aimed at simplifying enrollment and eligibility for Medicaid and CHIP. Another grant paid for a technological update to the state’s computerized eligibility system, making it possible to verify an applicant’s income by accessing the Department of Labor and Employment’s databases and simplifying the approval process.
Collaboration is a key factor in all enrollment strategies – both collaborating across various social service and other departments at the state level and partnering with community-based organizations. These organizations provide a vital link to Medicaid and CHIP for those who face cultural, language or literacy barriers to enrollment, live in rural areas, need extra assistance, or will not initiate enrollment on their own. States often develop innovative ways to collaborate with nongovernmental social service agencies to conduct outreach and even submit eligibility applications.
Integrating Tax Code Information – Maryland and Iowa
Several states have begun to use adjusted gross income and other data from tax forms as an innovative way to build upon more traditional outreach efforts by enacting legislation that asks parents to identify uninsured children on state income tax forms.17
National research has shown that 89.4 percent of uninsured children who qualify for Medicaid or CHIP live in households that file federal income tax returns. An important caveat is that using annual income tax information may not capture monthly or seasonal income fluctuations. Furthermore, income reported on state income tax forms often contain errors and do not always correctly identify the financial status of some individuals. Both Maryland and Iowa have passed legislation that modified state tax forms to reflect insurance coverage, which is used to determine Medicaid and CHIP eligibility.
Signed by the governor in May of 2008, the Maryland Kids First Act mandated that the state health department use the state’s personal income tax system to target outreach efforts to children who might be eligible for Medicaid or CHIP. To achieve this, a question was added to the tax form asking taxpayers to report the health care coverage status for each dependent child. The Comptroller is required to send Medicaid/CHIP applications and enrollment instructions to families who appear to meet income eligibility standards and indicate that one or more of their children were uninsured. Maryland learned an important lesson in implementing the Kids First Act – that collaboration between state revenue and health agencies, and eliminating data-sharing barriers are key strategies in using the tax system to increase Medicaid outreach.18
In 2008 Iowa passed comprehensive health reform legislation that established a number of innovative strategies to reduce the number of uninsured in the state. In particular, one strategy involved collaboration between the Department of Human Services and the Iowa Department of Revenue and the use of state tax information to spur enrollment in Iowa’s CHIP and Medicaid programs. Iowa modified tax forms to include a question about health care coverage for an individual’s dependents. Based on tax data, potentially CHIP eligible residents were sent brochures with CHIP enrollment information. In 2009, this system resulted in health coverage for 471 previously uninsured children.19
State tax forms are a potential tool for state-level health coverage data and opportunity for catalyzing enrollment.
Promote Enrollment through Marketing – Vermont
Large-scale and targeted marketing can help increase awareness of Medicaid and CHIP programs. In fact, marketing initiatives around expanding Medicaid or CHIP eligibility to higher income individuals have proven effective in enrolling newly eligible uninsured children.20
Marketing strategies are diverse and can include a range of approaches, from advertising through the media (e.g. radio, television, newspapers) to distributing promotional materials in community centers. In the last few years, Vermont has effectively used a comprehensive marketing strategy to increase awareness and enrollment for new public health insurance programs.
The Health Care Affordability Acts in 2006 created two public health insurance programs to provide coverage for Vermont’s uninsured population. In order to spread knowledge about these programs, Vermont implemented an aggressive outreach campaign, which also may have led to an increase in enrollment into the existing Medicaid programs. Vermont used a strategic communications research firm to devise a multi-pronged marketing approach for outreach. For one, Vermont rebranded all of its state-funded programs to be called Green Mountain Care in order to de-stigmatize and simplify the administration of publicly funded health care programs in the state. Vermont also developed a series of television and print ads based on feedback from focus groups that guided residents to a Green Mountain Care website to find more information on the various health insurance programs. (The website guides potential applicants through the application process.)
State funding for outreach was limited, and Vermont only funded one position to roll out this approach, the Director of Outreach & Enrollment. In addition to the director, a steering committee was formed with representatives from various departments within the state government, insurance providers, the Vermont Campaign for Health Care Security, AARP, Bi-State Primary care Association, provider associations, the business community and others. These organizations leveraged their own resources to reach their constituents.
Enrollment training was provided to over 200 health care providers, outreach workers, human resource professionals and others involved in eligibility and enrollment. Vermont also used targeted outreach efforts to reach the 18 to 24 age group through sponsoring concerts, emailing college seniors, letter writing campaigns to parents and faculty, and hiring young Green Mountain Care ambassadors to do outreach within their communities.21
A large number of individuals in 2014 will need to be introduced to the Medicaid program. Vermont’s experience shows that campaigns to market Medicaid to this group can not only increase enrollment, but also remove stigma and improve perceptions of the program.