November 30, 2018
The Supplemental Nutrition Assistance Program (SNAP) and Medicaid help millions of people make ends meet by providing food assistance and access to affordable health care. SNAP helps people afford adequate food, reaching nearly 40 million who are mostly seniors, children, and people with disabilities. Medicaid provides affordable health care to more than 70 million people, allowing millions of children to receive developmental screenings, providing adults with treatment for chronic and acute conditions, and helping seniors with their aging-related care.
Public conversation and advocacy around access to Medicaid or SNAP often considers only who is eligible, but many eligible people are not enrolled, and those who are enrolled frequently “churn” on and off programs over time, creating coverage gaps and increasing administrative burdens on recipients and state agencies. Often people who are eligible for both Medicaid and SNAP are only enrolled in one of them, while others must submit the identical information multiple times to remain enrolled in both programs.
The decisions that states — and, in some cases, counties — make about the enrollment and renewal processes greatly affect whether eligible persons can successfully enroll and how likely they are to remain enrolled. For example:
- What happens when someone walks into an assistance office? How long do they wait for assistance? If they need an interview, will it occur that day or will they have to schedule another day and time?
- How are electronic data sources used to verify information like identity, income, and address? How often do people have to gather and submit documents to the agency?
- How does the customer call center work? For example, can people complete applications (with a telephonic signature) and report changes by phone? Do callers have long wait times?
- What is the eligibility renewal process? Do caseworkers automatically update eligibility for other programs when clients provide information?
- Are the notices about eligibility and benefits written in plain language? Are they available in the preferred languages of enrollees?
Operational and administrative policy issues like these generally receive less attention than issues such as income eligibility limits or provider reimbursement rates. As a result, states may make operational decisions that significantly affect people’s lives without public discussion or input from advocates.
Over the past three years, CLASP and CBPP have supported advocates in ten states in expanding their administrative advocacy on benefit access through the Advancing Strategies to Align Programs (ASAP) project. This toolkit highlights advocacy lessons from the project. It also discusses some key policy and operational choices advocates have found that offer significant leverage on increasing participation and reducing churn.
Advancing Strategies to Align Programs
The Advancing Strategies to Align Programs (ASAP) project has worked with advocates in ten states over several years to help them secure improvements in Medicaid and SNAP access through administrative advocacy. These improvements include:
- Creating a dedicated unit within a SNAP agency to assist seniors with applications, renewals, and other needs
- Changing language on Medicaid and SNAP applications to avoid deterring parents who are ineligible due to immigration status from applying on behalf of their eligible children
- Broadening the exemption from the SNAP time limit for able-bodied adults without dependents (ABAWDs)
- Increasing the percentage of Medicaid applications determined eligible in “real time”
- Ensuring that Medicaid’s “reasonable compatibility” policy, which compares applicants’ attestations of their incomes to available data sources in determining eligibility, is implemented correctly in order to reduce the amount of income verification requested from applicants
- Reducing the number of paper verifications required for application and renewals by using electronic data sources and eliminating verification requests that are no longer needed.
- Issuing EBT cards over the counter rather than by mail when requested and when an applicant is approved for expedited benefits
- Issuing EBT cards immediately when an application is approved with the applicant present
- Making online application questions and portals more user-friendly.
Getting Started With Administrative Advocacy
Building a Relationship With Program Administrators
State administrators are busy managing programs on a day-to-day basis and ensuring compliance with state and federal regulations, so they may not be as responsive to advocates as elected officials are. Showing them why it helps the state to engage with advocates is the first step toward effective administrative advocacy. Advocates can accomplish this by:
- Getting a foot in the door. Advocates have several points of entry to the administrative process. Some operational and policy changes must be open for public comment before finalizing, which creates an opportunity for advocates to weigh in. Existing advisory boards often work collaboratively with state administrators, which offers another entry point. And state legislators or local elected officials can sometimes open doors for advocates that are otherwise closed.
- Offering solutions, not just critiques. Advocates often point out problems to state agencies without proposing concrete solutions. For example, they may identify the need to improve notices so applicants and enrollees better understand steps they must take. Offering to help draft the language for notices or to have program enrollees review sample notices could help the state and demonstrate that you’re equally engaged in the process.
- Drawing on the experience of other states and national expertise. Busy administrators often do not know what other states are doing and assume incorrectly that federal regulations require a given policy or practice. By exploring other states’ policies and practices, advocates may be able to identify opportunities for improvement.
- Engaging a variety of advocacy partners. Working with a diverse group of advocates will bolster your efforts and provide more perspectives. If your organization does not provide direct services (such as application assistance, outreach to eligible persons, or legal aid to those who need help navigating the system), consider partnering with organizations that do. The perspective of applicants and enrollees is critical to administrative advocacy. Without it, one cannot fully understand the barriers they may face and whether those barriers are due to a given policy or how it is implemented.
By identifying ways that an agency can better achieve its goals or implement a new project, advocates can open the door to a relationship that can evolve to address access barriers in the program. At other times, advocates can make the case that it is better for agencies to incorporate their feedback early in the rollout of a new system or process than to deal with bad publicity or litigation later.
Some organizations that provide direct services, particularly legal aid organizations, may have complicated relationships with state agencies due to their legal advocacy on behalf of clients. In these situations, partnering with an organization that is not involved with legal challenges against the state can prove beneficial. A collaboration may best position advocates for success when it brings together organizations that can offer client stories and perspectives to the table and organizations that may have a better opportunity for advocacy discussions with the state.
Legal advocates have a valuable tool that other advocates lack: suing the state. Holding the state accountable through legal measures has proven effective in preserving or increasing access to benefits. However, one lesson from the ASAP project is that, even when legal action may be warranted, attempting to resolve the issue without legal action may be a better advocacy route. If the state sincerely desires to resolve the issue, discussion can lead to a quicker resolution and open a channel of communication that could help resolve other issues that may not be subject to legal action.
For example, the best practice for clients is for the state to review applications as soon as they are submitted and approve or deny them expeditiously, ideally within a few days. However, this is a much higher standard than the federal government’s requirements (30 or 45 days, depending on the program). Holding agencies to the legal standard is not necessarily the best result for applicants in situations like these. Advocates should consider other forms of advocacy to encourage states to process applications more quickly than federal standards require.
Understanding How the Program Operates
Advocates need detailed program knowledge to effectively engage administrators. This can make it difficult for advocates to identify a clear “ask” of administrators. For example, while advocates may know that Medicaid has a high churn rate and want to seek ways of reducing churn, they may not have access to the data needed to understand the causes of churn or know the policy options available to the state.
Engaging in administrative advocacy to improve program access requires understanding what choices states or counties have, how agencies apply policies, what operational procedures look like in offices, and what applicants or enrollees experience when they interact with the state agency. This information provides a fuller picture of where access barriers exist and how to address them.
Understanding these operational components of programs is not always easy, but advocates involved in this work for several years can offer important lessons learned. While information is available through agency websites and reports, the most effective way to truly understand how the agency operates is to talk with key staff and learn what happens inside local offices. Strategies for learning how the state administers programs include:
- Establishing regular meetings with key decisionmakers. Such meetings provide opportunities to get updates, ask questions, understand implementation timelines, follow up on persistent problems facing applicants or enrollees, and share what you hear from clients about enrollment barriers. An ongoing dialogue with decisionmakers allows for constructive discussions, whereas engaging with them only in a crisis situation likely will not open the door to other important topics. A regular dialogue also provides an opportunity to highlight what is going well for applicants and enrollees.
- Shadowing a caseworker in a local agency. Watching a caseworker process applications, review verifications provided by applicants, and conduct interviews will give you a much better understanding of what happens when an individual applies. It will also show you the various pressures on caseworkers and the barriers they may face in processing applications.
- Reviewing the state’s administrative rules, policies, and procedures. This will help inform your questions and allow you to cross-check written policy with client stories to identify areas where the state may not be applying a policy correctly. This may also identify gaps in worker training, the need for policy clarifications, differences between online systems and written policy, and other problems.
As you embark on administrative advocacy, questions to explore include:
How is the agency structured?
- Are Medicaid and SNAP administered by the same agency? How well do program staff work together?
- If Medicaid and SNAP are administered by the same agency, do program staff work together or are they “siloed” within the agency? Do the same caseworkers determine eligibility for both SNAP and Medicaid? Can applicants apply for both programs at once?
- Are any decisions delegated to county or regional offices? If so, which ones?
What data does the state collect or publish regularly?
- Does the state publish data other than monthly enrollment, such as the average number of days required to make a determination for an application or wait times for the call center?
- Does the state share information it collects about the timeliness of eligibility determinations? How does this compare to federally reported timeliness data?
What other data would help the state and advocates better understand barriers that clients face?
- What are the common reasons an application is denied? Is the applicant found ineligible, or was required information (e.g., proof of income) missing or an interview not completed?
- What percentage of enrollees successfully complete their renewals?
- What percentage of applications are from people who recently lost benefits at renewal? (This is one way to measure churn.)
- What share of Medicaid renewals are completed automatically, based on available information?
- How many people participate in SNAP but not Medicaid, or vice versa?
What does the IT system look like?
- What company does the state use as its vendor for eligibility systems?
- Are SNAP and Medicaid in the same eligibility system?
- How complicated is it for the state to change something within the eligibility system?
- How much lead time does the state need to program a change?
- Do advocates have a formal or informal opportunity to provide input on technology changes?
- What data sources do workers have access to when making eligibility determinations?
Focusing on administrative advocacy and operational aspects of programs is time intensive but ultimately has a positive effect on the lives of everyone who seeks to participate in benefit programs. Successful administrative advocacy reduces enrollees’ frustration about the enrollment and renewal processes, eliminates unnecessary paperwork for both enrollees and state agencies, and can provide more stability in people’s lives (such as by reducing the loss of benefits due to churn). The accompanying papers in this toolkit take deeper dives into areas that advocates across states identify as having barriers to Medicaid and SNAP, such as the interview process for SNAP and renewals for both programs, and different policy solutions.
Advancing Strategies to Align Programs (ASAP)
Advancing Strategies to Align Programs (ASAP) is a joint CLASP-CBPP project designed to assist states with improvements to the administration of SNAP and Medicaid through policy and operational changes at the state and local level. To view other resources in our toolkit highlighting lessons from the project, visit www.cbpp.org/asap or www.clasp.org/asap.