States have been hard at work building and debuting new enrollment systems and processes to meet the Affordable Care Act’s (ACA) requirements for streamlined access to coverage. To help states as they adopt major changes in their eligibility and enrollment processes, CMS issued aletter to state Medicaid directors outlining options for efficiently targeting and enrolling low-income individuals.
One of these optional strategies is using income data from the Supplemental Nutrition Assistance Program (SNAP) to identify Medicaid-eligible individuals, many of whom are newly eligible for coverage in 2014. So far, targeted enrollment letters have been sent to SNAP recipients in five states opting to implement this strategy—Arkansas, Illinois, New Jersey, Oregon, and West Virginia. Most of these states are using this option to focus on enrolling eligible adults, but Arkansas and West Virginia have leveraged it to also target eligible but unenrolled children.
In Arkansas, as in most states, the eligibility level for SNAP is 130 percent of the federal poverty level (FPL). This eligibility level falls just below that of Arkansas’ Private Option Medicaid program for newly eligible adults with incomes under 138 percent FPL, and also below the state’s ARKids First Medicaid program eligibility of 216 percent FPL for low-income children. The alignment of eligibility makes SNAP an opportune source of information for states looking to enroll families living near or below the poverty line in health coverage.
As part of this targeted enrollment strategy, Arkansas mailed letters to 132,662 SNAP households, representing 145,370 adults and 9,050 children. These letters clearly listed all Medicaid-eligible individuals in the household based on information already provided to the Department of Human Services (DHS), which administers both SNAP and Medicaid. To enroll in coverage, letter recipients simply opted in on behalf of all eligible household members by signing and returning the letter to DHS.
Upon receiving the signed letters, the state automatically enrolled children in ARKids First and mailed an ID card for each child. For adults, the state mailed a second letter giving adults up to 12 days to select a Private Option plan through the state’s web portal. Adults who did not select a plan within this timeframe were automatically enrolled in one. Coverage for children began immediately while coverage for adults is effective January 1, 2014. As of November, 43 percent of the households that received letters signed and returned them to DHS, resulting in about 3,000 children gaining Medicaid coverage in Arkansas.
West Virginia has been successful in enrolling more than 58,000 children and adults with the help of this strategy and has recently announced a second push of this and other targeted enrollment efforts. While West Virginia sends individual letters to children and parents, Arkansas explicitly includes whole households in its SNAP letter and clearly notifies parents of the options that exist for themselves as well as their children. Arkansas state officials and stakeholders outlined why including children in their efforts was efficient and valuable:
- SNAP is a current and reliable source of financial information on low-income children. To qualify for SNAP, households generally are under 130 percent of FPL, and most SNAP recipients fall well below state Medicaid eligibility levels. In fact, half of all SNAP households with children have income below 50 percent of the poverty line and a recentreport found that 98 percent of children receiving SNAP benefits nationally qualify for Medicaid under the ACA. In addition, many states including Arkansas, employ stringent processes for verifying income eligibility, such as requiring families to verify their income every six months.
- Children must have coverage before parents can enroll in Medicaid. Federal regulations require parents to enroll their dependent children in Medicaid, the Children’s Health Insurance Program (CHIP), or other coverage that meets minimum requirements, before they themselves can enroll in Medicaid as part of the expansion group. In Arkansas as of 2011, 93.6 percent of eligible children in the state already participated in Medicaid or CHIP. Thus this enrollment strategy was used to target a relatively small group of remaining uninsured children, and in particular targeted children whose parents will become newly eligible for coverage in January 2014.
While states can draw a variety of lessons from the efforts in all five states, Arkansas demonstrates one way of focusing on children’s coverage even when implementing enrollment simplification strategies primarily designed to enroll newly eligible adults.
Is your state considering implementing this or another enrollment simplification strategy to facilitate the enrollment of children? Let us know in the eligibility simplification discussion or in a comment below.
This blog post was written in conjunction with Children in the Vanguard—a NASHP initiative, supported by the Atlantic Philanthropies, that brings together state officials and advocates from 14 states to focus on children’s coverage during health care reform implementation. New Jersey, Oregon, and West Virginia have all participated in the Children in the Vanguard network. For more information and tools relevant to the ACA and children’s coverage please visit the initiative’sChildren’s Coverage Toolbox.