How States Can Align Benefit Renewals Across Programs Options For Simplifying And Aligning Eligibility Reviews

PDF of this report (19pp.)

By Sharon Parrott and Liz Schott

Revised June 20, 2005

Related Areas of Research

Families that receive assistance from benefit programs such as food stamps, Medicaid, SCHIP, child care, and TANF generally are required to participate periodically in a formal review of their eligibility, typically once or twice a year.  When families “renew” their eligibility for a particular program, they usually must provide updated information about their circumstances, such as their income, and sometimes they must go to a human services office to be interviewed.  If a family does not complete the renewal process, it will be terminated from the program.

States have significant flexibility in how frequently they conduct renewals across programs and what they require of families as part of the renewal process.  Not surprisingly, state practices in this area vary considerably.  A family in one state receiving benefits from multiple programs may have a single integrated review of all benefits once a year, while a similar family in another state may be required to complete three different renewal processes that take place at different times, frequencies, and locations.

As some states have already shown, states can coordinate and align renewal processes across programs so that a family need only make a single contact to renew for multiple programs.  First, states can synchronize renewals across programs so that they occur at the same time.  In addition, states can use information from one program to eliminate or reduce the additional actions a family must take to renew its eligibility in other programs.  This report explains how states can make these improvements.

 

Why Aligning Renewals Is Important to Families and States

Working families often face substantial hurdles in renewing benefits.   In many states, families — particularly those not receiving TANF — have to fill out different forms and meet with a different workers (and sometimes in different offices) to renew their eligibility for child care, food stamps, and Medicaid or SCHIP.  Families sometimes need to file duplicative paperwork to renew their eligibility for benefits and provide the same verification to multiple caseworkers.

Complicated renewal processes like these create barriers to retaining benefits.  Frequent and multiple review processes cause confusion and frustration over what is required to retain eligibility; some families conclude that maintaining eligibility is too much of a “hassle” even when the benefits provide important supports.  In addition, families that miss a deadline might lose benefits entirely and be forced to reapply to reestablish their eligibility.  Failure to complete eligibility reviews is one of the primary reasons why families lose benefits. 

A recent food stamp study found that half of all families that leave the Food Stamp Program do so at the time they are scheduled for a renewal.  Of those who left when their renewal was due, only 35 percent left the program because the household was found to be ineligible based on their income or other household circumstances.  The vast majority of the other households who lost benefits when their renewals were due were dropped from the program because they failed to complete the renewal process.   A survey of the others who failed to complete the recertification process found that 90 percent appeared to meet the food stamp eligibility criteria.[i]

Families may be more likely to complete a single, coordinated renewal process than multiple and staggered processes.  A simple renewal process benefits states as well.  Nearly all states faced fiscal crises in recent years, and human services agency staff have been asked to do more with fewer resources.  Multiple notices, rescheduled appointments, and terminations for failure to complete a review (often followed by a reapplication for benefits) add to the agency’s workload.

Simplifying and aligning renewal processes can reduce that workload.  For example, requiring benefits to be renewed less frequently (such as once a year rather than four times a year) means fewer notices to send out, fewer interviews to conduct, less verification to sort through, and fewer eligibility decisions to make.  States also can reduce agency workload by creating a single renewal process for multiple programs or using information from one program to complete eligibility reviews in other programs. When workers spend less time processing renewals (or reapplications after missed renewals), they have more time to focus on services for families, such as supporting employment.

 

How Simple Can States Make It?

The following represents an aligned renewal structure that complies with current federal policies.  Since some states may not be able to adopt such an approach fully, alternative alignment options are discussed later in this chapter.

  • Review eligibility for all programs at the same time and only once a year.  The same information about family circumstances is generally used for all programs and can be collected just once a year.  Even if the programs are not jointly administered, computer systems (or caseworkers) can share the updated information so the family only participates in one renewal process.

  • Use updated information gathered for the purposes of one program — such as the information on a food stamp semiannual report — to update families’ eligibility status in other programs and re-start the eligibility period for that program.  Some states, such as Arkansas, Louisiana, and Illinois, use updated food stamp information to renew Medicaid/SCHIP eligibility automatically.  (In many states, food stamp recipients renew their eligibility once per year.  At the six month mark, the household must submit a semi-annual reporting form which asks for some updated eligibility information, including information about the household’s current income.)
  • Allow families to submit their renewal information by phone, mail, or the internet.  Some states, including Washington State, Louisiana, and Pennsylvania, allow families to provide their renewal information for multiple programs over the phone or via the internet, rather than by mail.  (If the state requires verification at renewal, however, those documents would have to be submitted separately.)

  • Reduce the number of families that come into the human services office for face-to-face interviews.  States generally do not need to require a face-to-face interview as part of the renewal process, even for food stamps.  Some states, including Pennsylvania, Texas, and Utah, are making greater use of phone interviews.  However, certain clients, such as those with limited English proficiency or limited literacy, may fare better with an in-person interview; states should ensure that this remains an option for families.

  • Limit requests for verification and ensure that families are not asked to submit the same verification multiple times.  Very few eligibility factors need to be verified at renewal.  Those factors not subject to change – such as date of birth – should never be re-verified, and other factors need not be re-verified if they are unchanged.  States can use document imaging to share digitalized verification across programs or agencies.  In addition, states can use cross-matches and databases to minimize verification requests of the family. (Verification simplification is an important component of streamlining the renewal process.  Issues related to verification are discussed in forthcoming report in this series.) This simple and aligned vision draws most heavily on the processes already used in children’s Medicaid and SCHIP programs. 

Table 1

Obstacles to Fully Aligning Renewals Across Programs

Area of Concern

Issues Presented

Ways to Address Concerns and Additional Considerations

 Fiscal

If eligibility is reviewed less frequently (once a year rather than twice a year), some recipients who are no longer eligible for benefits may continue to receive them.

For families receiving food stamps, updated information still will be collected every six months.  This information can be used to review eligibility across programs.



Administrative savings can result from fewer eligibility reviews.

Institutional

Renewals for different programs may take place in different locations or be conducted by different workers.

Information can be shared electronically across programs and locations.



Eligibility workers can share information with other programs, reducing their workload without changing who is making the eligibility renewal decision.

Computer-related

Different agencies and programs may use different eligibility determination systems.

Automated systems may not have the capacity to pre-populate forms at renewal with information the client previously provided, such as SSNs or income.

Internet applications and renewals are not yet in place in most states and face signature requirements for some programs.

Interfaces among systems can allow information reported for one program to be shared with programs administered through a different system.  In some states, eligibility workers are given “inquiry only” access into other eligibility systems.

Not all system changes have to be made at once.  Incremental improvements can be very helpful.

For some programs, online renewal can be accomplished without a signature or with digital signatures.

Philosophical

A state may want to have more frequent contact with recipients of some programs, such as TANF.

Even if a state has shorter eligibility periods in some programs (such as TANF), it can still eliminate duplicative reviews by ensuring that updated information collected for one program is used to update eligibility for all programs, even those for which a review is not due (such as Medicaid or SCHIP).

 

Barriers to Full Alignment of Renewals Across Programs

Most states have achieved a great deal of coordination and alignment of renewals among at least some programs.  But in nearly every state, there is room for increased simplification.

The barriers to aligning renewal procedures more fully fall four categories: fiscal, institutional, computer-related, and philosophical.  These barriers are outlined in Table 1.

 

Differences Among Federal Benefit Renewal Rules Should Not Be a Barrier

States have near-total flexibility to establish their eligibility renewal policies in TANF, child care, and SCHIP (although federal law does require states to renew SCHIP eligibility at least once per year).  There are more federal requirements associated with eligibility renewal procedures in food stamp and Medicaid, and important differences exist between these two sets of rules.  These differences in federal law, however, are not major obstacles to increased alignment and coordination.

  • Food stamp renewal periods are fixed while renewal periods for other programs are more flexible.  When a state approves food stamp benefits, it does so for a fixed period, which can be changed only for specific and limited reasons.[ii]  Moreover, food stamp eligibility can be recertified only at the end of a certification period.  By contrast, a state can renew benefits other than food stamps at any time during the eligibility period.  Thus, for benefits other than food stamps, states can be more flexible about setting, modifying, and re-starting eligibility periods.
  • Unlike other benefit programs, the Food Stamp Program requires households to apply for recertification.  In the Food Stamp Program, a household must apply for recertification at each renewal, and benefits must close if the recertification is not completed.[iii]  In Medicaid, by contrast, benefits cannot be terminated unless the state has determined that the family members no longer qualify for them.[iv]  TANF, child care, and SCHIP do not have federal rules in this area.



    Thus, for benefits other than food stamps, a state can use updated information about a family’s circumstances that it has received for the purposes of one program to renew benefits in another program with little or no action required by the family, because federal rules do not require families to apply for eligibility renewals in these other programs.  This process can be made “invisible” to the family — that is, the state can use updated information to renew and extend Medicaid eligibility without the family even knowing that this process took place.  (States may want to notify families that their Medicaid eligibility has been extended, however.)
  • The Food Stamp Program requires an interview at least once per year, but other programs do not have this requirement.  The Food Stamp Program generally requires a face-to-face interview at least once per year.  Yet states have flexibility to waive this requirement due to “hardship,” which states can (and do) interpret broadly.  In addition, at the state’s request, FNS will waive this requirement for all renewals in any state with a below-average error rate.[v]  If the face-to-face requirement is waived (for an individual household or the entire state), a phone interview must be conducted in its place, except that a state that recertifies food stamps more frequently than once a year, need not conduct more than one interview a year.



    Other programs do not have federally required interviews.  Most states conduct face-to-face interviews for TANF eligibility reviews but not for children’s health insurance.  Some states require face-to-face interviews for the renewal of child care assistance, while others do not.

As is discussed in more detail below, these differences in federal rules do not pose serious barriers to aligning and simplifying renewal policies.  States can construct a renewal procedure that meets the dual goals of ensuring that eligibility is periodically reviewed and simplifying the renewal process for families that receive multiple benefits.

 

Steps a State Can Take Toward Increased Alignment and Simplification

Even if a state cannot implement the fully aligned renewal structure laid out above, it can take smaller steps to improve alignment and simplification.  In particular, if a state cannot create a single annual renewal process for all benefits, it should consider other ways of lessening renewal burdens, such as limiting office visits and paperwork or sharing information across computer systems and eligibility workers.

It should be noted that aligning all renewal procedures to conform with those used by the program with the most frequent and rigid procedures — in other words, the “lowest common denominator” — might disadvantage families, particularly those who receive only benefits with less burdensome renewal procedures (such as SCHIP or child care).  Adopting such an approach also could increase state agency workloads.  This report discusses only those alignment options that reduce burdens on states and families.

1.  Adopt 12-month eligibility periods.

States that do not currently use 12-month eligibility periods in their benefit programs should consider adopting them.  Short eligibility periods with frequent renewals are burdensome for both families and state agencies, particularly when they are coupled with an in-person interview.  Studies of both the Food Stamp Program and of children’s health insurance have similar findings — significant numbers of recipients who appear to remain eligible frequently lose coverage for failure to complete renewal processes.[vi]  A recent Food Stamp Study — finding that many apparently eligible households are dropped from the food stamp program when they fail to complete the renewal process – illuminates how renewals can become a barrier to benefit receipt.  When those who lost eligibility at renewal (but appeared eligible) were asked why they did not complete recertification, 38 percent cited difficulty with the recertification process including confusion over renewal requirements and verification burdens.[vii]

Moreover, loss of benefits for failure to recertify is likely to increase when renewals are more frequent – for example, every six months rather than every 12 months.  A study of SCHIP disenrollment found that requiring more frequent renewals produced higher cumulative disenrollment levels over time.  The study noted that Oregon, with six-month SCHIP eligibility periods, had higher cumulative SCHIP disenrollment than states with 12-month eligibility periods (and otherwise similar patterns of disenrollment at renewal.)[viii]

States have the flexibility to use annual reviews for all of the benefit programs discussed in this report.  For TANF and child care, states can set their own review policies; for Medicaid and SCHIP, they must review eligibility at least once a year and may do so more frequently.[ix]  Most states use 12-month review periods for Medicaid and SCHIP, while a few states use six-month review periods.[x] State eligibility periods for child care range from three to 12 months with many states using six-month reviews.[xi]

For food stamps, states can use 12-month certification periods for many households, including nearly all households with earnings.[xii]  (There are some circumstances under which states must use longer or shorter certification periods for certain food stamp households without children.[xiii])  Most states have adopted the Food Stamp Program’s simplified reporting option, under which states typically use a six or 12-month certification period.  Those states that adopt a 12-month certification period also require a periodic report at the six-month mark.  This approach enables the state to collect updated information on key eligibility factors such as income and household composition every six months while requiring a full-scale recertification only once a year.  The semiannual report form is easier for families to complete — and easier for eligibility workers to process — than a full recertification. 

As states balance the benefits of extending program eligibility periods to 12 months for all programs with the increased risk that ineligible families will receive program benefits, they should consider whether using a mid-year report mirroring the food stamp semiannual reporting option will address this concern. 

2.  Eliminate duplicative reviews.

Whether a state uses the same eligibility period (such as 12 months) for all programs or reviews some programs more frequently than others, it can minimize renewal burdens by ensuring that families are not required to complete duplicative renewal processes.  There are two main strategies for accomplishing this:

  • Keep eligibility renewals for different programs synchronized by:
  • aligning renewals even when families apply for programs at different points during the year or their circumstances otherwise change; and
  • synchronizing renewals even if some programs are renewed more frequently than others.
  • When updated eligibility information is available, use that information to renew eligibility in other benefit programs where possible.

These two strategies are described in more detail below.

Synchronizing Eligibility Renewals

States that choose not to adopt 12-month eligibility periods across programs can still eliminate duplicative eligibility reviews.  For example, if a state conducts reviews every six months for some programs and annually for other programs, it can synchronize these reviews by renewing the annual programs at every other review of the six-month programs.  (As discussed below, states can also use the more frequent renewals to update or extend benefits that are not up for renewal.)

Many states already try to do this for most programs that they administer together, but in some states, some program renewals are not synchronized.  In addition, many states that try to synchronize eligibility periods can take additional steps to ensure that when eligibility periods fall out of alignment — which can happen for many reasons — they are quickly re-aligned.  The following are examples of the ways in which eligibility periods and renewal dates can fall out of synch:

  • A family applies for different benefit programs at different times and is assigned different eligibility periods based on each program’s date of approval.
  • A family’s circumstances change over time, leading it to enter different benefit programs at different times.  For example, a family already receiving food stamps and children’s Medicaid may qualify for family Medicaid or TANF after losing a job or experiencing a drop in income; as a result, its Medicaid or TANF eligibility period may end on a different date than its food stamp eligibility period.
  • A family leaves welfare and thus begins receiving transitional food stamps rather than standard food stamps.  If a state provides transitional food stamps for five months, it typically will postpone recertification to the end of the five-month period and require households to apply for recertification at that time.  In such cases, the new food stamp certification period could be out of synch with the existing Medicaid eligibility period.

States can keep eligibility reviews synchronized over time by using their flexibility to adjust review periods in programs other than food stamps to line these programs back up as circumstances change.  For example, Virginia recently instructed caseworkers that if an individual who is already enrolled in Medicaid recipient applies for TANF or food stamps and is approved for either of those programs, the worker should use the information on the application to complete an early Medicaid renewal.  This would bring the Medicaid renewal period into synch with the food stamp period.[xiv]

For households that receive food stamps, the best way to keep renewals synchronized across programs is to re-align eligibility periods each time the state receives updated eligibility information for food stamp purposes (either through a semiannual report or a food stamp recertification).  For families that do not receive food stamps but do receive child care and children’s health insurance, states can use updated information from one program to renew and extend eligibility in the other program and thereby align the eligibility periods.

Using Information from One Program to Update Eligibility in Others

When a family provides detailed and updated information to the state about its income and other circumstances, that information can be used in others programs to ensure the family still qualifies, to adjust benefit levels or co-payments, and to avoid conducting repetitive, duplicative eligibility reviews over short periods of time.

For families that receive food stamps, states can significantly reduce the likelihood of duplicative eligibility reviews by using information from food stamp semiannual reports and recertifications to update and renew eligibility in Medicaid, SCHIP, child care, and TANF.  Two different ways of doing this are discussed below.

Approach 1: Renew eligibility for other programs when a food stamp semiannual report is received or recertification completed, even when renewal is not due for the other programs.

When a state receives a food stamp semiannual report or recertifies food stamp eligibility, the eligibility worker typically has all of the information needed to determine whether the family remains eligible for Medicaid, SCHIP, child care assistance, and TANF cash assistance.  The worker also has the income information necessary to determine whether SCHIP or child care co-payments or cash benefit levels should be adjusted.  Thus, the caseworker can use this updated information to update eligibility and co-payment/benefit levels and re-set the eligibility periods in each of those programs at this time, even though eligibility reviews may not yet be “due.” 

In effect, these early eligibility renewals in these other programs take place invisibly to the family.  As long as the family continues to participate in the Food Stamp Program, separate eligibility reviews in these other programs will not be necessary.  This reduces burdens on both families and state agencies.

This approach can be used even by states in which eligibility for Medicaid, SCHIP, or child care is administered separately from the Food Stamp Program. 

Example

The Smith family receives food stamps and the children receive children’s Medicaid.  The family’s food stamp eligibility period extends from January 2005 through December 2005; its Medicaid eligibility review is due September 2005.  (The eligibility periods are not aligned because the family applied for the two benefits at different times.)

In June 2005, the family submits a food stamp semiannual report.  Based on that report, the eligibility worker determines that the family remains eligible for food stamps and children’s Medicaid.  The eligibility worker re-starts the children’s Medicaid eligibility period to run from July 2005 through July 2006, even though the Medicaid eligibility review was not due until September 2005.  Thus, the family will not have to complete a separate Medicaid eligibility review in September, because its eligibility was reviewed in June and its eligibility period was re-started.

As long as the family continues to participate in the Food Stamp Program, it will not have to complete separate Medicaid eligibility renewals.

Under this approach, if a family fails to complete its food stamp recertification, its eligibility for the other programs continues until the end of those programs’ eligibility periods.  While the family would need to reapply for food stamps to reestablish its food stamp eligibility, its Medicaid coverage would not be interrupted.  This should limit the amount of administrative “churning” in the Medicaid program.

Example

The Smith family (from the example above) does not complete its food stamp recertification in December 2005 because it failed to attend the required face-to-face interview.  The family’s food stamps end, but the children remain eligible for Medicaid coverage through July 2006, the end of the eligibility period set previously. 

In February 2006, the family reapplies for food stamps and is found eligible.   At that point, the eligibility worker reviews the children’s Medicaid eligibility.  If they remain eligible, the Medicaid eligibility period is re-set to run from March 2006 to March 2007.

It should be noted that the food stamp semiannual report or recertification may not give the state all the information it needs to renew Medicaid and SCHIP eligibility.  In particular, the state may need information about whether the family now has private health care coverage.  As is discussed below, this additional question can easily be added to the food stamp semiannual report or recertification form so long as it is clear that this information is not required for food stamp purposes.

Using information gathered for food stamp purposes to renew and extend child care eligibility is somewhat more complicated.  States may need to collect some additional information to ensure that the number of days per week a family needs child care has not changed.  States can obtain that information through the food stamp form or collect it separately.  Even if some additional information is needed, though, there is no reason for the child care program to collect and verify income information that already has been collected and verified by the Food Stamp Program. 

Another issue to consider is that the food stamp semiannual report may provide information that some individuals in the household are no longer eligible for other benefit programs such as Medicaid or child care.  To the extent that states are not already acting on such information, for example because the child care and food stamp agencies are administered separately, improved coordination for the purposes of renewals may result in some people losing benefits earlier than they might otherwise.

 Several States Have Adopted This Approach

Several states or localities already use this approach, including Arkansas and Illinois Arkansas, for example, uses 12-month certification periods for Medicaid and SCHIP and 12-month certification periods with a semiannual report for food stamps.  When a food stamp household submits a semiannual report, the eligibility worker uses the information in the report to update Medicaid or SCHIP and extend the Medicaid/SCHIP renewal date forward 12 months for eligible persons.  By adding just two questions to the food stamp semiannual report form that solely apply to Medicaid, Arkansas was able to obtain all the information needed to determine Medicaid eligibility.[xv]  Under the Arkansas procedure, a family that receives both food stamps and Medicaid or SCHIP has its health insurance renewed automatically as long as it receives food stamps.  If a family fails to complete a food stamp semiannual report or recertification, its Medicaid or SCHIP coverage continues through the end of the Medicaid/SCHIP eligibility period.[xvi]

Similarly, Missouri is automating a process that will ensure that information collected for the purposes of recertifying food stamp eligibility will be used to automatically renew Medicaid eligibility for one year for eligible persons, even if renewal is not due for Medicaid at the time.

Approach 2: When a renewal is due for one benefit program, extend benefits based on recent information collected by another program.

A second way states can use food stamp information to update eligibility for Medicaid/SCHIP or child care is by waiting until a renewal in one of those programs comes due and then checking to see if updated eligibility information already has been collected by another program — and, if it has, using that information in lieu of collecting it from families a second time. 

When the Medicaid renewal is due, for example, the state can extend Medicaid based on information from the most recent food stamp renewal or semiannual report.  The state would need to contact the family only if additional information is required to complete the Medicaid renewal.

HHS has indicated that the food stamp information provided from the last eligibility renewal or periodic report is sufficient to renew Medicaid so long as the family continues to receive food stamps.  HHS has specifically authorized states to extend Medicaid for a full year from either the Medicaid renewal date or the date of the most recent food stamp review.[xvii]

Mechanisms for Sharing Information Across Computer Systems

The options described here require states to share information across programs.  This is not difficult if the same eligibility worker processes renewals for all of the programs, or if the programs are administered through the same automates system.  If that is not the case, however, sharing information can be more challenging.  Some states have developed mechanisms to overcome such challenges.

  • States can provide eligibility workers who process one set of benefits (such as SCHIP or child care) with limited access (such as inquiry-only access) to the automated eligibility systems that are used to process other benefits (such as food stamps, TANF, and Medicaid).  For example, when a child care renewal comes due, a child care worker could check current enrollment status in food stamps or Medicaid, the date on which other benefits were last renewed or for which a periodic report was submitted, and the income that was last reported.
  • Programming across systems can automatically implement an action in one system based on actions taken in another system.  For example, Missouri, which currently uses different automated systems for food stamps and Medicaid, is planning to automate communication between its eligibility systems so that Medicaid eligibility will automatically be renewed for a year based on the information used to recertify food stamp eligibility.
  • In some states, the eligibility system used for one set of programs — such as Food Stamps or TANF — can be set up to generate a list when renewals or semiannual reports are completed in those programs.  That list then can be shared with agencies administering other benefit programs to alert eligibility workers for these programs that updated information in available for these cases.  For example, if a Medicaid eligibility worker was provided with an alert that in march 2005, ten of her cases completed a food stamp recertification or submitted a completed food stamp semiannual report, she could use the updated information in those reports to review the families’ Medicaid eligibility and re-start their eligibility periods in lieu of mailing out a Medicaid renewal form to the families.

Louisiana uses this approach, even though its Medicaid and food stamp programs are administered by separate staffs in separate physical locations.In Louisiana, the Medicaid and SCHIP workers have “inquiry” access into the food stamp computer eligibility system.  Each month, Medicaid eligibility workers are given a list of the Medicaid cases due for renewal that also receive food stamps; workers can get all of the information needed to renew Medicaid by checking the food stamp income and household information for these cases on the food stamp eligibility system.  This “automatic renewal” occurs before Medicaid renewal forms and notices are sent to the family.  The Medicaid deputy director noted that it would be inappropriate to send a renewal form to a family that receives food stamps, since no form need be completed or returned. 

Virginiahas recently clarified its instructions to agency workers, explaining that renewal information should first be drawn from information known to the agency and that information that is less than six months old generally can be considered current.  The state emphasized that recipients are not required to complete a renewal form when the necessary information can be obtained through an internal (ex parte) renewal process.

Aligning Renewal Procedures for Families That Do Not Receive Food Stamps

For households that do not receive food stamps, the options discussed above would not apply.  In some states, a significant number of families receive Medicaid/SCHIP coverage and child care assistance but are above food stamp income limits.  States can ensure that these families also do not face duplicative eligibility renewal processes.

If Medicaid/SCHIP and child care are administered jointly, states can synchronize the eligibility periods and ensure that when an eligibility review is conducted for one program, eligibility is updated for both programs and the eligibility periods are re-set so they are in step with each other. 

If Medicaid/SCHIP and child care are administered through separate agencies or workers, states can share information across programs to minimize duplicative renewal requirements.  For example, if the child care and Medicaid agencies have inquiry access to each other’s eligibility system, state workers can check to see if recent information has already been provided in the other program before conducting an eligibility review.  This is analogous to the approach Louisiana has taken in which Medicaid workers use information already collected in the Food Stamp Program to renew Medicaid eligibility.

3.  Allow families to renew eligibility by phone, by mail, and over the internet.

Reduce or Eliminate Face-to-Face Interviews

Much of the burden of renewal — for caseworkers as well as families — lies in the required office visit and face-to-face interview.  Appointments are often scheduled automatically by computer without regard for the family’s work schedule, for example, which means that agencies must follow up on missed appointments and field requests from families to reschedule appointments.  In addition, many families that fail to complete an interview are terminated from programs, which may cause them to lose benefits altogether (even if they remain eligible for assistance) or to re-apply for assistance, which is time consuming for both families and eligibility workers.

States already have taken steps to eliminate face-to-face interviews for health coverage.  Almost no states require an interview for renewing children’s Medicaid or SCHIP, and the vast majority of states do not require an interview for renewing family Medicaid.[xviii]  Some states do not require interviews for child care renewals.[xix]  Interview requirements are most common in TANF and food stamps.     

Limiting the number of families who are required to participate in a face-to-face interview is one of the easiest things states can do to reduce renewal burdens on families.  Yet states should retain the option of face-to-face interviews for those families for whom an office visit is an easier and more reliable method of completing an eligibility review. For example, individuals with limited reading proficiency may need an eligibility worker to help them complete the renewal forms, and individuals with limited English proficiency may benefit from a face-to-face interview if a translator is available.

Limiting Face-to-Face Interviews in the Food Stamp Program

States have the flexibility to eliminate the required annual face-to-face interviews for many — and in some states, for all — households receiving food stamps and use telephone interviews instead.  In states that do not require face-to-face interviews in other programs, eliminating a face-to-face interview for food stamp renewals could mean that a working family could retain all of its benefits without being required to come into the human services office during the year. 

States that eliminate face-to-face interviews for food stamp renewals still would need to conduct phone interviews for food stamps annually.  A phone call, however, can be easier to schedule and less burdensome to conduct than an office visit; states could combine a mail-in application for recertification with a brief phone call.

  • Many states can qualify for an FNS waiver of face-to-face interviews for all recertifications.  FNS has indicated that it will grant a statewide waiver of the requirement for a face-to-face interview at recertification for any state requesting it if the state’s Quality Control payment error rate is below the most recently announced national average (6.64 percent for FY 2003).
  • Even without this new waiver, a state has the ability to waive face-to-face interviews based on individual hardship (as defined by the state).  Some states have defined hardship to include the difficulty that working families have in coming to the human services office.  For example, both Texas and Washington State define hardship to include work or training schedules that make attending an in-person office interview difficult or impossible.[xx]
  • States need not conduct an interview more often than every twelve months.[xxi]  Some states that have six-month certification periods require an interview at each recertification, but federal rules only require such an interview once per year.  Thus, those states can conduct every other renewal by mail without requiring any interview, even one by telephone.

A state that decides to continue to require in-person renewal interviews can take steps to lessen the inconvenience of office visits.  States can adopt extended night and weekend hours to ease the difficulty many working families face in meeting with caseworkers during business hours.  (Some caseworkers may welcome a flex-time schedule, which can give them free time during normal working hours for activities such as participating in their child’s classroom.)   Some local offices have reported success with walk-in recertification appointments, which allow the participant to choose a convenient time to come in during the recertification period.

Reconsidering Local Office Staffing Structures

In some states, TANF families may have a single caseworker and an integrated set of renewal requirements for programs such as food stamps and Medicaid, while non-TANF families may have multiple caseworkers and uncoordinated renewal times.  Further, in many states child care eligibility and renewals are processed by a separate entity in a different location.

There are many reasons why some states and local offices have adopted such staffing patterns.  States may assign separate food stamp workers to non-TANF families as a strategy for reducing errors, and they may have Medicaid-only eligibility workers because of the complexity of specialized Medicaid programs.  In addition, some offices may address problems related to staff turnover by training new workers in a more limited set of areas, which reduces the amount of training needed.

Nevertheless, states should revisit the question of whether these administrative benefits are outweighed by the costs assigning families multiple eligibility workers.  While much can be done using technology and information sharing, assigning multiple eligibility workers makes it far more difficult to minimize duplicative renewals and information collection and verification.  Such duplication is problematic for families and costly for states.

If states cannot change their staffing structures, they can take other steps to ease the burden of eligibility renewals.  As discussed in this chapter, states can renew Medicaid invisibly — without contacting the family — using the current or recent food stamp information.  This could be done automatically through systems programming, or by a specialized Medicaid worker based on information on a completed food stamp renewal form or semiannual report.

Interviews in TANF

States may want caseworkers to have personal contact with TANF families to ensure that families are complying with work requirements and making progress toward finding employment, particularly as time-limit deadlines approach.  States should consider, however, the contradiction between requiring a TANF household to work or participate in work activities while at the same time requiring it to miss these activities to come to a human services office interview.  Phone interviews — at least for employed TANF recipients — may make it easier for families to fulfill their interview requirements and reduce caseworker workload associated with rescheduling missed appointments, while still allowing caseworkers to discuss issues related to work requirements and time limits with the family.

Telephone or Internet Renewals

States typically use the mail for renewing benefits when an office visit is not required.  Some states, however, also allow families to complete the renewal process entirely by phone or through the internet.  Federal law does not require a recipient signature on any renewal forms other than an application for food stamp recertification, so states can use phone calls to renew benefits in other programs.

  • Washington Staterenews child care by phone in many offices.  (Washington State also enrolls families in child care through telephone applications, and families can file six-month reports for food stamps, Medicaid, and TANF by phone.)
  • Louisiana uses telephone contacts for Medicaid and SCHIP renewals (if a contact is necessary).  Workers regard telephone renewals, together with the state’s innovative use of current food stamp information to complete renewals for those on food stamps, as one of their most useful tools in reducing the number of families who lose benefits because of a failure to complete the renewal process.  (See the box on page 17 for more on Louisiana’s efforts in this area.)

  • Washington State and Pennsylvaniahave online renewal functions as part of their online multi-program application processes.

4.  Use pre-populated renewal forms or passive renewal process to make renewal easier for families to complete.

The renewal process also can be simplified by using pre-populated renewal forms that include the agency’s most current information on the family, including the people in the household, their Social Security numbers, and the family’s income.  The family is asked to update any information that has changed and sign and return the form.  For example, Washington State uses pre-populated forms for renewals of family and children’s Medicaid.  As states consider this approach, they should pay attention to design issues so that the family-specific information is easy to spot; this will make it easier for families to understand and update the information the state has on record.  Some states have found that families are confused by pre-populated forms and do not always understand which information applies specifically to their circumstances.[xxii]

Some states go a step further and use the concept of “passive renewal” (generally in combination with a pre-populated form).  Under a passive renewal, the family only needs to return the form if there are any changes.  Georgia, Nevada and Hawaii all use passive renewal in their SCHIP programs.  Florida previously used passive renewal but ended to practice due to budget pressures.  A study comparing Florida’s passive renewal SCHIP policy with the renewal rates of three other states (not using passive renewal) found that passive renewal led to a stark and marked difference — fewer children lost benefits at renewal.[xxiii]  (Unfortunately, this study did not measure whether the passive renewal policy increased the ineligible children receiving SCHIP.  Studies have shown that reducing or eliminating verification requirements does not lead to high error rates.)[xxiv]

While states have not yet extended passive renewal beyond Medicaid or SCHIP, this approach could be combined with some of the options discussed above for using recent information known to the state to renew benefits.  For example, consider a family in a state that administers food stamps and child care separately but allows the child care worker to obtain the information on which the latest food stamp renewal was based.  The child care worker may want to provide the family with an opportunity to provide information about any very recent changes or any child care-specific changes, such as changes in the numbers of days per week the family needs child care.  (Since the state must know the provider for payment, it will need to receive any provider change information promptly from the family.)  The state can send the last known information on a pre-populated form to the family and then instruct the family to return the form only if some of the information needs to be updated.

Reducing Procedural Medicaid Closures in Louisiana

Louisiana has taken a number of steps to reduce the closure of Medicaid cases for failure to complete the renewal process.  For persons already receiving food stamps, the Medicaid worker renews Medicaid based on current food stamp information and never sends a renewal form. (This is referred to as ex parte in the comments below.)

If additional information is needed, the worker tries to contact the client by phone and conduct the entire review on the phone; no renewal form is sent to the client.  Workers also have flexible schedules that allow them to reach clients outside of regular business hours. (This is referred to as “compressed time” in the comments below.)

These efforts have decreased the rate of procedural closures at renewal to 3.3 percent for family and children’s Medicaid and SCHIP.  Moreover, workers reports that the changes make their jobs easier and enable them to serve clients better.

Below are comments made by caseworkers to the state’s Medicaid Deputy Director in response to her inquiry about what they considered to be the most important factors or strategies that let to the state’s reduction in procedural closures at renewal. [Emphasis in original indicated by bold]:

“Calling the client at renewal instead of mailing the renewal form has really paid off.  Being able to conduct the interview over the phone has helped tremendously.”

“My staff gives a lot of credit to compressed time & the renewal via telephone.  They say they have a much better opportunity to reach their clients in the early morning or the late afternoon.  I believe one of our offices designated the telephone renewal as “the best thing that happened at work in the last year!”

“The greatest advance I feel we have made is the telephone interview.  The next greatest tool is using the [automated systems] information for verification of income and household.  We are able to contact our customers and assess their needs with much more ease.  I think they appreciate the ease of renewal, especially our older customers.  The renewal process for them was confusing and intimidating.  Speaking with them on the telephone helps answer any questions they have and puts them at east with the entire process.”

“I think the ex-parte procedures have helped us reduce the number of procedural closures.  Especially being able to use the [TANF/Food Stamp system] information.  The biggest help that has taken place recently is the use of telephone renewals for our higher income families who (like the rest of us) procrastinate or misplace the mail, or our elderly who are sometimes afraid to fill out “wrong” it did not take workers long to recognize how much time and aggravation they saved themselves by not having to wait on a form to come in the mail.  Once you tell clients specifically what information you need, most quickly return the information.  To be as effective, however, if we did not have compressed work schedules which allow [caseworkers] to contact clients early in the morning or late in the afternoon when you are more likely to catch them at home.”

“TELEPHONE Renewals!!!   I thought it couldn’t get any better than Ex-parte, but it has… The ones that I’ve completed telephone interviews with have been very thankful for this simplified process.  I know you receive a lot of negative feed-back that simplification is “making it simpler for the clients, but harder for the workers.’ I know I hear this a lot.  That is absolutely not the case with phone renewals.  This has been the best simplification process yet for me.”

5.  Request minimal documentation or verification at renewal and only ask for it once.

States have opportunities to reduce the amount of verification they require from families, particularly families renewing benefits who already have established certain eligibility factors that are not subject to change or that have not changed.  In some states, recipients are asked to provide verification for renewal to multiple agencies or workers.  Sometimes verification is sought of circumstances that have previously been established and are not subject to change or have not changed.

Strategies for reducing verification burdens on families — and reducing the administrative costs associated with gathering and reviewing verification — are discussed in a forthcoming report in this series.

 

Conclusion

No single approach to simplifying the renewal process will fit every state.  The options that will work best for a particular state will depend on which programs are administered by the same agencies, how the computer eligibility systems used by different programs communicate with each other, and what choices the state makes in other areas (such as change reporting rules).

Nevertheless, there are many ways states can make it easier for families to maintain benefits and also reduce caseworkers’ workload.  These include adopting longer certification periods, combining or synchronizing renewals, using information provided for one program to renew another program, and using family-friendly procedures such as telephone renewals.

End Notes:

[i] Susan Bartlett, Nancy Burstein, and William Hamilton, with the assistance of Ryan Kling, Food Stamp Program Access Study: Final Report, by, Abt Associates Inc., November, 2004, pp. E-4, 6-2 and 6-3, http://www.ers.usda.gov/publications/efan03013/efan03013-3/.

[ii] While a state can adjust food stamp benefit amounts during a certification period, it generally cannot end a household’s certification period before the assigned termination date unless the household becomes ineligible.  Similarly, once the food stamp certification period has been established, the state can extend it only under limited circumstances.  7 CFR 273.10(f)(4) and ((f)(5).

[iii]No household may participate beyond the expiration of the assigned certification period without a determination of eligibility for a new period. 7 CFR 273.14.

[iv] While a state can conduct Medicaid renewals without any contact with the family when the state has all the information it needs to determine ongoing eligibility, states are not prohibited from requiring a signed form at renewal.  Continuing the Progress: Enrolling and Retaining Low-Income Families and Children in Health Care Coverage, HCFA, p. 14-5.

[v] FNS has indicated that it will approve state requests to waive face-to-face interviews at recertifications across the board if the state’s Quality Control Payment Error Rate is below the most recently announced national average (6.64 for FY 2002).  Letter to FSP Regional Directors, July 25, 2003.

[vi] Susan Bartlett, Nancy Burstein, and William Hamilton, with the assistance of Ryan Kling , Food Stamp Program Access Study: Final Report, by, Abt Associates Inc., November, 2004,  pp. 6-7 and 6-8. http://www.ers.usda.gov/publications/efan03013/efan03013-3/.; Andrew W. Dick, R. Andrew Allison, Susan G. Haber, Cindy Brach, and Elizabeth Shenkman, “Consequences of State Policies for SCHIP Disenrollment,” Health Care Financing Review 23 (3), Spring 2002.

[vii] Susan Bartlett, Nancy Burstein, and William Hamilton, with the assistance of Ryan Kling , Food Stamp Program Access Study: Final Report, by, Abt Associates Inc., November, 2004,  pp. 6-7 and 6-8. http://www.ers.usda.gov/publications/efan03013/efan03013-3/.

[viii] Andrew W. Dick, R. Andrew Allison, Susan G. Haber, Cindy Brach, and Elizabeth Shenkman, “Consequences of State Policies for SCHIP Disenrollment,” Health Care Financing Review 23 (3), Spring 2002.

[ix] 42 CFR 435.916 (Medicaid) and 42 CFR 457.340 (SCHIP).

[x] Selected Simplified Renewal Procedures in Medicaid for Parents and Children’s Health Coverage Programs (Table 9) from Center on Budget and Policy Priorities, Start Healthy, Stay Healthy Project, available at  http://www.cbpp.org/shsh/renewal-parents.pdf.

[xi] Gina Adams, Kathleen Snyder, Jodi Sandfort, Navigating the Child Care Subsidy System: Policies and Practices that Affect Access and Retention, Urban Institute, March 2002.

[xii] While states have long been able to use 12-month certification periods for many food stamp households, in the late 1990’s a number of states began to use three-month certification periods for many households, particularly wage-earners, because of concerns about Quality Control errors.  Now, under the simplified reporting option, states can use longer certification periods without exposure to QC errors.  Over 42 states have implemented simplified reporting and are using six- or 12-month certification periods.  (While simplified reporting can be used for certification periods of four, five, six, or 12 months, most states use either six- or 12-month review periods.)  Several other states are in the process of implementing simplified reporting.  A handful of states use 12-month certification periods with monthly or quarterly reporting.

[xiii] 7 CFR 273.10(f).  States may use 24-month certification periods with annual reviews for households in which all adult members are elderly or disabled.  States must use shorter certification periods (generally three to six months) for households with unstable circumstances or with able-bodied adults without children.

[xiv] Virginia Department of Social Services, Entitlement Policies and Procedures, MS 1520.200 (Transmittal Notice #78, 12/04).

[xv] The questions relate to the purchase, sale, or transfer of real property and other health coverage.  These questions are labeled on the form as relating solely to Medicaid.

[xvi] Arkansas Department of Human Services, Division of County Operations, Medical Services Policy Manual Issuance MS 01-14, issued Dec. 5, 2001.

[xvii] Center for Medicare and Medicaid Services, letter to State Medicaid Directors, April 7, 2000, available at http://www.cms.hhs.gov/states/letters/smd40700.asp.

[xviii] Selected Simplified Renewal Procedures in Medicaid for Parents and Children’s Health Coverage Programs (Table 9) from Center on Budget and Policy Priorities, Start Healthy, Stay Healthy Project, available at  http://www.cbpp.org/shsh/renewal-parents.pdf.

[xix] Gina Adams, Kathleen Snyder, Jodi Sandfort, Navigating the Child Care Subsidy System: Policies and Practices that Affect Access and Retention, Urban Institute, March 2002.

[xx] See Texas Human Resources Code 33.015(b) (statute) and Washington Administrative Code 388-452-0005(9) (rules).

[xxi] 7 C.F.R 273.14

[xxii]States may also pre-populate some fields on the report and leave others blank.  For example, Utah uses a pre-populated form for multiple benefit programs but has decided to deliberately leave the “income” information blank so as to always require current income information from the family.

[xxiii] Andrew W. Dick, R. Andrew Allison, Susan G. Haber, Cindy Brach, and Elizabeth Shenkman, “Consequences of State Policies for SCHIP Disenrollment,” Health Care Financing Review 23 (3), Spring 2002.

[xxiv] See Preserving Recent Progress on Health Coverage For Children and Families: New Tensions Emerge, by Donna Cohen Ross and Laura Cox, Center on Budget and Policy Priorities, July 2003, pages 14-16 for a brief review of research related to reduced verification requirements.

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