Allowing Families to Self-Report Income, 12/28/01

A Promising Strategy for Simplifying Enrollment in
Children's Health Coverage Programs
by Laura Cox

A simple application process is fundamental to ensuring that eligible children obtain health coverage through Medicaid or the separate State Children's Health Insurance Program (SCHIP). Nearly all low-income children now qualify for such coverage, yet many remain uninsured.¹ Although states have made significant progress in removing enrollment barriers, research shows that difficult application procedures — particularly burdensome verification requirements — continue to prevent eligible children from being enrolled. Complicated enrollment procedures not only deter families from completing application forms, they also hinder community-based outreach efforts aimed at helping families navigate the enrollment process.

Several recent studies indicate that verification requirements are particularly troublesome for families. In a January 2000 survey conducted for the Kaiser Commission on Medicaid and the Uninsured, more than 70 percent of the families surveyed cited gathering the necessary verification as a barrier to enrolling their children in Medicaid.² In addition, a recent review of children's health coverage applications submitted in New Hampshire found that less than 50 percent of the applications received included the required verification of income.³ When applications are received without the required verification, state workers must take additional steps to collect this information from the family and it becomes more likely that a child's application will be denied because it is incomplete. For example, in California in 2001 more than 45 percent of all eligibility denials for Healthy Families, the state's separate SCHIP program, were due to incomplete applications.⁴ While some of these denials may have been caused by a missing signature or similar item, the experience of other states suggests that a significant proportion of such denials were likely the result of missing verification.

The time needed to gather numerous documents, fees associated with obtaining government documents, employers who are unwilling to provide documentation and confusion as to which documents are required are just some of the factors that can make it difficult for families to comply with verification rules. To address such barriers, several states have opted to eliminate the need for verification not required under federal law and will accept a family's declaration of its income and other information for the purpose of determining eligibility for children's Medicaid and SCHIP. As of November 2001, Arkansas, Connecticut, Florida, Georgia, Idaho, Maryland, Michigan, Mississippi, Oklahoma, Vermont, Washington, Wisconsin and Wyoming have adopted this option for children's Medicaid or for Medicaid and SCHIP, if the state operates a separate program. These states are using a variety of methods to verify income, and the available evidence suggests that these methods are reliable and do not adversely affect error rates.

States Have Eliminated Verification Requirements Other Than Income

Over the past few years, nearly all states have made some efforts to reduce verification requirements. While 13 states have opted to implement self-declaration of income for families applying for children's health coverage, others have reduced the amount of income documentation required or have eliminated other verification requirements not required by CMS. For example, in addition to eliminating proof of residency, Louisiana recently reduced the amount of income verification required of families from two months to one month. Alabama and Texas recently eliminated the requirement that families verify children's ages. Eliminating age verification can be particularly helpful for families, since they may incur a cost to obtain a birth certificate.

States implementing self-declaration policies have found that the procedures they have put in place result in accurate and efficient eligibility determinations. For example, between December 1999 and December 2000, a review of 543 approved children's Medicaid cases in Idaho reflected an accuracy rate of more than 99 percent.⁵ In addition, an ongoing monthly audit of the income reported on children's health insurance applications in Michigan has shown that self-declaration has not led to high error rates in children's Medicaid and SCHIP.⁶State officials in Michigan also report that caseworkers are now processing an average of four more applications per day, a productivity increase of 25 percent.⁷ Based on these and other data, states are increasingly recognizing the benefits of a self-declaration policy.

Under federal Medicaid law, the only information families must verify is the immigration status of a non-citizen child applying for benefits.⁸States are not required to obtain proof of income or other information. States have broad flexibility to determine what additional information, if any, families must verify to obtain coverage under children's Medicaid and SCHIP.

In addition to obtaining proof of the immigration status of a non-citizen seeking coverage, state Medicaid agencies must comply with federal Medicaid regulations requiring state agencies to have an Income and Eligibility Verification System (IEVS) in place. IEVS, described in the post-eligibility requirements of Section 1137 of the Social Security Act, is used to verify income after an eligibility determination has been made. Under IEVS, the state is required to request information from other federal and state agencies, such as the Social Security Administration, the Internal Revenue Service and state Departments of Labor, to verify a Medicaid applicant's income and resources.The Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), encourages random post-eligibility checks or other procedures to verify income that can not be substantiated through IEVS. There are no federal income verification requirements for SCHIP. However, CMS encourages states using self-declaration of income for SCHIP to use random post-eligibility verification checks to assure program integrity.⁹

Social Security Numbers and Self-Declaration of Income

In order to verify income by conducting data matches with other agencies' databases, an adult's Social Security number may be needed. However, under federal Medicaid law states may not require a non-applicant parent or other family member to provide a Social Security number as a condition for a child's Medicaid eligibility. Assuring families that a Social Security number is only required for the applicant child is particularly important for families in which immigrant parents may be concerned about the ramifications of enrolling their eligible children in health coverage programs. States currently implementing self-declaration policies have found ways to deal with this dilemma. For instance, Mississippi offers families the option of providing either a Social Security Number or documentation of family income. State officials in Vermont report that they are often able to match income information with other state databases by using identifiers other than a Social Security number, such as birthdate or last name.

CMS and the Office of the Inspector General have issued guidance to states assuring them that reducing verification requirements is not incompatible with maintaining a high level of quality control and offering them strategies to ensure that their efforts to simplify do not compromise program integrity.¹⁰

What Procedures are States Using to Verify Income Provided On Medicaid/SCHIP Applications?

States are using a number of methods to ensure that their self-declaration policies yield accurate eligibility determinations. These methods include: conducting pre-implementation studies and pilot tests, matching data with information from various government databases, and conducting post-eligibility audits.

Some states have chosen to implement a self-declaration policy on a trial basis before expanding the policy statewide. By conducting pilot studies prior to statewide implementation, states can ensure their procedures are effective and then move forward with confidence.

Washington State has allowed self-declaration of income since December 1998. Prior to implementing this policy statewide, Washington piloted it at the centralized Medical Eligibility Determination Services Unit, which processes Medicaid applications for pregnant women and children (for the whom the income limits were relatively high — 185 percent and 200 percent of the federal poverty line, respectively). A policy memo issued to Community Service Office Administrators stated that: "... MAA [Medical Assistance Administration] conducted a study on the income declared on Children's Medical Applications. This study concluded that, even when the income was declared incorrectly, the children were eligible for medical benefits."¹¹ In the memo, the state instructed Community Services Offices to accept a family's self-declaration of income and noted that concerted outreach efforts would increase the number of medical assistance applications, and that streamlined procedures would help reduce the impact of the increased workload on eligibility staff.

States routinely access data from other government agencies, such as the Social Security Administration and state Departments of Labor, to verify an applicant's income after a Medicaid eligibility determination has been made. When used in combination with a self-declaration policy, such data matching can ensure program integrity while relieving families from having to gather documentation, sometimes from numerous sources.

The procedures in place in Georgia illustrate how data sharing arrangements can help ensure that information gathered from families is accurate. Caseworkers are required to review three databases before determining a child's eligibility for Medicaid or PeachCare, the state's SCHIP-funded separate program. The Department of Labor database provides caseworkers with information on the family's wages, unemployment history — including weekly unemployment benefit level, if applicable — and work history. This database also indicates whether an applicant not receiving unemployment compensation is eligible to receive it, providing the worker with another opportunity to assist the family. Information from the Department of Labor is reported quarterly, which the state has found to be adequate for income-matching purposes. Workers also review two databases provided by the Social Security Administration, which provide them with information on a family's former or current receipt of social security benefits. If the information found through the data match does not match the information provided by the family and indicates the child would be ineligible for Medicaid or PeachCare, the family is contacted and asked to provide verification of income. State officials report that this situation occurs infrequently.¹²

The accuracy of self-declared information also may be checked following an eligibility determination. Several states, including Idaho and Florida, conduct post-eligibility evaluations using a variety of methods. Post-eligibility audits can be accomplished either by asking a sample of families to provide documentation of their income after their children have been deemed eligible or by conducting computer matches with other state databases. The process underway in Idaho provides an example of how a post-eligibility evaluation can be conducted without contacting families unnecessarily.

In Idaho, eligibility workers routinely verify the information from children's health insurance applications by matching it with data from other government agencies at the time of application. In addition, the state is conducting an ongoing formal audit of a sample of applications. These reviews are done post-eligibility generally without making contact with the family, by accessing information from other public benefit programs such as food stamps or TANF, or by checking databases from the Social Security Administration, the Department of Labor or the Department of Transportation.¹³ Between December 1999 and December 2000, 543 approved children's health coverage cases were reviewed. According to Randy Allen, Program Evaluation Manager for the Division of Medicaid, this review found that more than 99 percent of such approvals were accurate. In addition, the state found that the majority of inappropriate approvals — which constitute less than one percent of all children's health insurance cases — were due to factors other than income, such as a family's failure to report that a child had insurance at the time of application.¹⁴

Since October 2000, Michigan has been conducting a monthly audit of the income reported on children's health insurance applications. Approximately 80 families are randomly selected each month. These families are contacted and asked to provide verification of income and also are provided with a toll-free number for questions about the audit. As of July 2001, the error rate has not exceeded three percent in any given month. Moreover, the results of the audit do not show an increase in the Medicaid error rate following the implementation of self-declaration of income.¹⁵

Kentucky implemented a self-declaration policy in its children's health coverage programs for almost one year, discontinuing the practice in June 2001. According to Kentucky's Cabinet for Health Services, this change was made after a preliminary review of applications for the Medicaid expansion program indicated some children were inappropriately enrolled in Medicaid. The review of these applications, which began in October 2000 and included face-to-face interviews with families, did not include an assessment of eligibility for the state's separate SCHIP program; it is unclear whether some children ineligible for Medicaid could have been enrolled in the separate SCHIP program. Applications of children found eligible for the separate program were not included in this review. Examination of this issue in Kentucky is ongoing.¹⁶

What State Officials Say About Self-Declaration

Although in most states that are implementing self-declaration policies, comprehensive evaluations of the process are in progress, state officials are reporting their efforts so far to be successful.

Eligibility determinations are made in a more timely fashion. Several states, including Georgia, Michigan and Oklahoma, report a reduction in the number of "pending" cases in which caseworkers do not have sufficient information to determine eligibility. According to William Keller, Section Manager of the Office of Federal Liaison, Department of Community Health, Michigan has seen a dramatic decline in the number of pending applications since its implementation of self-declaration of income on August 1, 2000. Prior to implementation, approximately 75 percent of applications received were placed in a pending category, due in large part to missing verification. Following implementation of the self-declaration policy, fewer than 20 percent of applications received are placed in the pending category.¹⁷

Caseworkers are more productive. Reducing the amount of verification required has resulted in increased productivity among eligibility workers. This impact was noted by officials in several states, including Georgia, Michigan, Oklahoma and Vermont. State officials in Vermont, which has been using self-declaration of income since 1995, report that caseworkers simply would not be able to keep up with the increased caseload if not for self-declaration.

Evaluation provides lessons for improving application forms. A number of states, including Georgia and Michigan, found that discrepancies between a family's self-declared income and the income reported on other government databases are often due to the family's confusion about how to report income on the children's health coverage application. For example, applicants may not understand the difference between net and gross income, or may have trouble figuring out how to report monthly income if they are paid weekly or bi-weekly. To address this problem, Michigan revised its application in June 2001. The form now asks families to write in both net and gross income. State officials predict that such revisions will help clarify for families what information is being asked and will result in less confusion and more accurate self-declarations of income.

States are seeking to simplify their Medicaid and SCHIP programs in ways that do not compromise program integrity. Some states have expressed apprehension about accepting a family's self-declaration of income, as well as other simplification strategies, due to the potential impact on the state's Medicaid error rate.

CMS issued guidance to State Quality Control Directors on September 12, 2000, assuring them that complying with the federal Medicaid Eligibility Quality Control (MEQC) program does not preclude simplification efforts, including reduction of verification requirements. This letter noted that at least one state has found that extensive verification requirements resulted in a number of inappropriate denials of eligibility for Medicaid, and stated that "the elimination or reduction of documentation and verification requirements by applicants is one way to simplify the enrollment and application process, and to minimize barriers to enrollment." In the letter, CMS advised states concerned about error rates to consider operating a Medicaid eligibility quality control (MEQC) pilot, which allow states to pilot quality control strategies in their Medicaid programs absent the concern of increased error rates. During the course of the pilot, the state is assigned an error rate that is equal to the state's error rate for the period preceding the MEQC pilot. Thus, the state is held harmless for error rate variation during the course of its pilot.¹⁸

In subsequent guidance issued to State Medicaid Directors on January 19, 2001, CMS and the Office of the Inspector General (OIG) jointly stated that Medicaid simplification is compatible with high program integrity, and that many states have applied simplified procedures without experiencing an increase in error rates. Moreover, by simplifying procedures, states can reduce the rate of negative case actions - situations in which eligible children are denied Medicaid for procedural reasons. The January 19 letter stated: "It is just as unacceptable to deny eligibility to program benefits as a result of complicated and burdensome application and retention procedures as it is to enroll ineligible individuals."¹⁹

Reducing Verification Requirements Can Foster Program Coordination and Effective Outreach

Most states that have adopted self-declaration policies have done so for both children's Medicaid and SCHIP. Aligning application procedures — including verification requirements — is important for several reasons. First, alignment assures families do not have to satisfy two sets of rules if they have one child eligible for Medicaid and another child eligible for the state's separate SCHIP program. Alignment also promotes equity — when program procedures are not aligned, one group (often the lower-income Medicaid-eligibles) will face obstacles not encountered by the other group. Finally, aligning application procedures makes it easier for states to comply with the federal screen and enroll requirement. Under federal law, a child applying for the state's separate SCHIP program must be screened for Medicaid eligibility and, if found eligible, enrolled in Medicaid. If a state eliminates income verification requirements for the separate SCHIP program, but not for Medicaid, families with children who appear to qualify for Medicaid as a result of the screening would have to complete additional steps before a final eligibility determination could be made.

Since the inception of Kid Care, Wyoming's SCHIP-funded separate program, families have been allowed to self-declare family income. As of April 1, 2001, Wyoming began allowing families with children eligible for Medicaid to self-declare their income as well. This policy — as well as several other simplified procedures — was carried over to Medicaid after the Wyoming Department of Health discovered that families with children eligible for Medicaid were having difficulty completing the application process. In December 2000, 68 percent of families applying for Medicaid for their children were denied coverage for failing to complete the application process. Procedural denials were significantly reduced following the implementation of self-declaration and other simplified procedures in Medicaid. For example, in October 2001, 19 percent of families applying for Medicaid for their children were denied coverage for failing to complete the application process.²⁰

A unique opportunity to enroll entire families using the self-declaration option exists in several states. Nearly all of the 18 states that currently cover parents with income up to 100 percent of the federal poverty line or higher also allow parents to apply using the same application used to determine children's eligibility. The adoption of self-declaration in these states — a step already taken in Connecticut, Vermont and Wisconsin — would ease the application process for children and parents, helping states to enroll entire families.

Self-declaration of income can simplify the application process and facilitate enrollment. When applied at renewal, it can also facilitate retention of Medicaid and SCHIP coverage. It may be easier for states to adopt self-declaration at renewal, because the state often has other information against which to check a family's self-declared income. In fact, when possible, states are required to use such data, which may include food stamp information, Social Security information or Department of Labor information, to conduct ex parte eligibility reviews.²¹ Currently, all 13 states implementing self-declaration for Medicaid and SCHIP at the point of application are also using this simplified procedure at redetermination.

In addition to easing the application process for families and reducing the workload for eligibility workers, self-declaration of income holds promise for making other outreach strategies more feasible and effective.

It is widely recognized that connecting families with community-based organizations that can assist them in completing applications can be a highly effective outreach strategy. Many states are supporting such efforts by providing training for staff of community-based groups and by awarding grants and application assistance fees. A major reason community-based organizations have been successful in helping to enroll children is that they have ongoing contact with families and are in a good position to follow up with them. However, effective follow-up requires significant staff time and there may be other costs associated with helping families obtain needed documents. By reducing income verification requirements, states can enable community-based organizations to free up resources previously needed to help families gather and submit the required documents and thereby expand outreach to more families.

A Self-declaration Policy Lets Outreach Workers Reach More Families

Baltimore Health Care Access Project (BHCAP), created in 1997 by the Baltimore City Health Department, helps families navigate Medicaid managed care, and also operates a unit in which eligibility workers enroll children in the Maryland Children's Health Program Since the adoption of self-declaration for children's health coverage in July 1998, applications have been processed much more quickly by the eligibility workers stationed at BHCAP. Prior to the implementation of self-declaration, the eligibility unit was able to process 30 to 50 percent of applications within 10 days. Currently, they are able to make eligibility determinations within 10 days for 80 percent of the applications received. According to Susan Gratzer, Eligibility Director for the Maryland Children's Health Program, self-declaration also "frees up outreach people for outreach." Outreach workers who previously spent a great deal of time helping families gather necessary documentation are now able to spend their time in the community - canvassing door-to-door, visiting Head Start programs and helping families in schools.²²

In addition, a number of states, including Alaska, California, Colorado, Nevada and Washington, are experimenting with a new tool for community-based application assistance — web-based applications. Web-based applications can be used by both community organizations and individual families to avoid photocopying, postage and transportation costs associated with obtaining and submitting applications. Self-declaration of income can make web-based applications more efficient by eliminating the need for families to submit income verification after completing an on-line application. For example, the web-based application currently being used in California requires that applicants print out a pre-printed fax sheet and fax the required verification to the entity that determines eligibility. This additional step may make it difficult for families to complete the application process.

An analysis by the Urban Institute indicates that nearly three quarters of low-income uninsured children participate in other government programs, such as the Food Stamp Program, WIC and the National School Lunch Program.²³Thus, strategies that aim to connect children to health insurance when they apply for other benefits may be especially promising.

Across the country, child health insurance agencies and school districts are forming partnerships to link children with health insurance when they apply for the National School Lunch Program. Since the School Lunch Program accepts a family's declaration of its income, states that require income verification for Medicaid and SCHIP need to collect this documentation from families separately. This additional step increases the likelihood that a family will fail to complete the application process. By reducing Medicaid and SCHIP verification requirements, efforts to link children with health insurance through the School Lunch Program can be simplified for both the administering agencies and families seeking health insurance for their children.

Florida Enrolls Children in Health Coverage
When They Apply for Subsidized Child Care

In Florida, children who qualify for subsidized child care are likely also to qualify for free or low-cost health coverage under Medicaid or one of the state's SCHIP-funded health coverage programs. A partnership among the state's Child Care Resource and Referral (CCR&R) agencies , the Florida Department of Children and Families and the Florida Healthy Kids Corporation has enabled families to apply for both benefits at once. The computer software used by the CCR&Rs to determine subsidized child care eligibility is the starting point. The child care application is completed during an interview, at which time the CCR&R staff person enters the family's information directly into the computer. When eligibility experts analyzed both applications, it appeared that only eight points of information — mainly "yes or no" questions — needed to complete the health coverage eligibility determination were missing from the child care application. The intake software now has been reprogrammed to ask whether families are interested in health coverage for their children; if so, the additional questions pop up on the screen for the family to answer. Finally, the computer prints the information supplied by the family on the Florida KidCare application. Since Florida's children's health coverage programs have a self-declaration policy, the family simply signs the form and mails it to the Florida KidCare office in a stamped, pre-addressed envelope. In the period between December 2000 and August 2001, applications were instituted for 1,476 children through the child care link.²⁴

A project currently underway in Florida — a state that does not require families to verify income for Medicaid or SCHIP — provides an example of how children can be connected with health insurance when they apply for subsidized child care.

Requiring families to verify income by providing pay stubs and other documents presents a substantial barrier to the enrollment of eligible children in health coverage programs. It can be time-consuming and difficult for families to gather such verification and for state workers to process applications. States have the authority to eliminate these barriers by implementing a self-declaration policy for their children's Medicaid and SCHIP programs. Many states have found self-declaration to be reliable and have developed various methods for verifying the accuracy of self-reported income. Adopting self-declaration policies can result in increased program enrollment, improved administrative efficiency and increased family satisfaction with the programs.

2. Michael Perry, Susan Kannel, R. Burciaga Valdez and Christina Chang, Medicaid and Children Overcoming Barriers to Enrollment Findings from a National Survey, The Kaiser Commission on Medicaid and the Uninsured, January 2000.

3. New Hampshire Healthy Kids Corporation, Special Report: Healthy Kids Mail-in Application and Documentation, Spring 2001.

4. Managed Risk Medical Insurance Board, Healthy Families Program Children Eligibility Statistics, www.mrmib.ca.gov, November 2001.

5. Telephone interview with Randy Allen, Program Evaluation Manager, Division of Medicaid, Idaho, July 2001.

6. U.S. General Accounting Office, Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect Children's Access to Care, (GAO-01-883), September 2001.

7. Telephone interview with William Keller, Section Manager of the Office of Federal Liaison, and Bonnie Barnes, Manager, Division of Managed Care Support, Department of Community Health, Michigan, July 2001.

8. Sally Richardson, Director, Center for Medicaid and State Operations, Letter to State Health Officials, Health Care Financing Administration, September 10, 1998. For a series of questions and answers related to federal verification requirements, see Sarah Shuptrine and Kristine Hartvisgen, The Burden of Proof: How Much is Too Much for Child Health Coverage?, Southern Institute on Children and Families, December 1998.

9. Sarah Shuptrine and Kristine Hartvisgen, The Burden of Proof: How Much is Too Much for Child Health Coverage?, Southern Institute on Children and Families, December 1998.

10. Timothy Westmoreland, Director, Center for Medicaid and State Operations and Michael Mangano, Acting Inspector General, Office of the Inspector General, Letter to State Medicaid Directors, Health Care Financing Administration, January 19, 2001.

11. David Hanig, Memo on Medical Applications, Washington State Medical Assistance Administration, December 3, 1998.

12. Telephone interview with Jana Key, Program Director, PeachCare for Kids, Department of Community Health, Georgia, October 2001. Telephone interview with Jon Anderson, Director, Right from the Start Medicaid Project, Division of Family and Children Services, Georgia, July 2001.

13. Idaho has not eliminated its asset test for poverty-level children. Department of Transportation data is used to verify the ownership and value of a vehicle.

14. Telephone interview with Randy Allen, Program Evaluation Manager, Division of Medicaid, Idaho, July 2001.

15. Telephone interview with Bonnie Barnes, Manager, Division of Managed Care Support, Department of Community Health, Michigan, July 2001.

16. Kentucky Cabinet for Health Services Office of Communications, Health Services Announces Enrollment Changes for Medicaid and KCHIP, Kentucky Cabinet for Health Services, April 2001. Telephone interview with Thomas Seacat, Human Services Program Section Supervisor, Cabinet for Families and Children, Office of Program Enhancement, December 2001.

17. U.S. General Accounting Office, Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect Children's Access to Care, (GAO-01-883), September 2001. Telephone interview with William Keller, Section Manager of the Office of Federal Liaison, and Bonnie Barnes, Manager, Division of Managed Care Support, Department of Community Health, Michigan, July 2001.

18. Timothy Westmoreland, Director, Center for Medicaid and State Operations, Letter to State Quality Control Directors, Health Care Financing Administration, September 12, 2000.

19. Timothy Westmoreland, Director, Center for Medicaid and State Operations and Michael Mangano, Acting Inspector General, Office of the Inspector General, Letter to State Medicaid Directors, Health Care Financing Administration, January 19, 2001.

20. Telephone interview with Kristina Musante, Covering Kids Project Manager, Wyoming KidCare Program, Community and Family Division, Wyoming Department of Health, October 2001.

21. Timothy Westmoreland, Director, Center for Medicaid and State Operations, Letter to State Medicaid Directors, Health Care Financing Administration, April 7, 2000.

22. Telephone conversation with Susan Gratzer, Eligibility Director, Maryland Children's Health Program, March 2001.

23. Genevieve M. Kenney, Jennifer M. Haley, and Frank Ullman, Most Uninsured Children Are in Families Served by Government Programs, The Urban Institute, December 1999.