August 5, 1997

Facilitating Enrollment of Children in Medicaid

Nearly three million children are eligible for Medicaid, yet remain uninsured. The Center on Budget and Policy Priorities' recent analysis of Census data found that these children are likely to be in working families not receiving cash assistance. Moreover, the "delinking" of eligibility for cash assistance and Medicaid, resulting from the implementation of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, and other welfare program changes, are likely to result in an increase in the number of children who are eligible for Medicaid but who are not enrolled.

Disseminating accurate information about Medicaid eligibility is an important way to help reduce the numbers of uninsured children, but it is only a first step. Unless outreach efforts are linked to the Medicaid application process the job is only partly done. Designing a Medicaid application process that is simple and accessible in community settings is essential.

There is no specific formula for ensuring that all children who are eligible for Medicaid are enrolled in the program. For some families, a clearly-worded brochure explaining how to obtain health insurance for their children is enough to encourage them to apply. For others, the availability of a mail-in application will be a key factor in whether they apply or not. Still others will need the help of an community outreach worker who speaks their language at a local outstation site.

State Medicaid agencies can ensure that systems are in place to facilitate Medicaid enrollment. Medicaid administrative funds can be used to pay for outreach and enrollment activities. New enhanced federal matching funds for increased administrative costs resulting from welfare reform, announced in the Federal Register on May 14, 1997, make it more feasible for states to implement such activities.


Steps States Can Take to Facilitate Medicaid Enrollment of Children

1. Shorten and simplify the Medicaid application. Medicaid applications can be long and complicated. Verification requirements can be onerous, as well. Applicants who have trouble gathering the required documents can be denied Medicaid even though they are eligible. Shorter applications have a number of advantages. For example, they are likely to require fewer documents to verify the information on the application. Simplified applications also make outstationing sites more effective and allow staff of community-based organizations to play a direct role in assisting families in navigating the application process. Simple applications also promote a more positive image for the Medicaid program.

The Health Care Financing Agency (HCFA) has issued a four-page model application form. Twenty-eight states currently use applications that are the same length or shorter than the HCFA model. While not all of these applications are as simple as they could be, several of them could be used as models for states interested in simplifying their Medicaid applications.

2. Eliminate the assets test used to determine eligibility for Medicaid for pregnant women and children. Thirty-four states and the District of Columbia have dropped the assets test in determining Medicaid eligibility for children. An additional three states no longer count assets for some groups of children.

Dropping the assets test is one way to simplify the Medicaid application and minimize the verification burden.

3. Allow applicants to submit their completed applications through the mail; encourage community organizations to keep mail-in forms on hand to distribute to families. For working parents or residents of rural areas, making a trip to the Medicaid office can be difficult or costly. Medicaid offices often are open only during regular work hours and overcrowding may cause long waits for service. Community-based organizations and institutions can provide the mail-in applications to families interested in applying for Medicaid for their children, along with basic information about Medicaid eligibility and a list of the documents required to verify the information on the application. States that conduct training on the basics of the Medicaid program for staff of community organizations can assure that families are receiving proper information and appropriate guidance on how to proceed with the application process. In addition to allowing applications to be submitted by mail, there needs to be a system in place for receiving and processing such applications in a timely and efficient manner.

Currently, 22 states and the District of Columbia allow Medicaid applications to be submitted by mail. Of these, 14 states and the District of Columbia do not require a personal interview; the remaining 8 states will allow the interview to be conducted by telephone.

4. Expand the use of Medicaid "outstations" to include settings other than disproportionate share hospitals and community health centers, that are required by law. Regulations pertaining to outstationing indicate that states may consider other locations, such as family support centers and school-linked service centers, that are frequently visited by the targeted populations. The notice of enhanced federal matching funds for administrative costs resulting from welfare reform, announced in the Federal Register on May 14, 1997, designates as a priority activity outstationing eligibility workers at other feasible locations such as WIC clinics, child care programs and churches.

Staff at outstation sites may be employees of the state Medicaid agency or they may be provider or contract employees, or volunteers. All must be trained to perform the initial processing of Medicaid applications, which includes taking applications, assisting applicants in completing the application, providing information and referrals, obtaining required documentation to complete the processing of the application, assuring that the information contained on the application form is complete and conducting any necessary interviews. Outstationed eligibility workers employed by the state agencies also can make eligibility determinations. Staff may be assigned to a particular location or may rotate among several locations.

5. Contract with community-based groups to conduct Medicaid outreach and enrollment activities. Community-based organizations can make important contributions to a state Medicaid outreach effort. They can help develop and disseminate outreach materials, assist families in completing Medicaid applications, host and help staff community-based Medicaid outstations. Administrative funds designated for outreach activities can make productive partnerships with community organizations possible.


Promising Outreach Strategies for the Future

Two new state options contained in the Balanced Budget Act of 1997 could significantly expand Medicaid coverage for children. One provision would allow child health providers, Head Start programs, WIC clinics and agencies that determine eligibility for subsidized child care to presumptively enroll children into the Medicaid program. This option could assure that children receive health care without experiencing a delay caused by the time it takes to process a Medicaid application. Allowing child care, Head Start and WIC sites to make presumptive eligibility determinations has other benefits as well. These programs have frequent contact with working families and are trusted by those families for advice about child health issues. In addition, these programs are often set up to accommodate the needs of working parents.

A GAO study ("Prenatal Care: Early Success in Enrolling Women Made Eligible by Medicaid Expansions", February 1991) examined ten states that implemented various options to expand Medicaid to pregnant women. The study found states that simultaneously implemented presumptive eligibility and dropped the assets test used in determining Medicaid eligibility experienced the most rapid growth in enrollment. Since a majority of states have already dropped the assets test for children, presumptive eligibility is likely to provide the "missing link" needed to improve Medicaid enrollment rates among children.

The second new option allows states to enroll children for 12-month continuous periods, without regard to changes in family circumstances. The option would help stop some of the churning of cases that now occurs within the Medicaid program, allowing children access to more stable coverage. This option should be favored by states moving to managed care delivery systems, as it guarantees 12-months of enrollment to managed care companies and would facilitate plans' ability to deliver the primary and preventive care benefits that managed care promises to children. This option also may make it easier for other public programs that have 12-month eligibility, such as Head Start, to coordinate outreach and enrollment efforts with Medicaid outreach and enrollment efforts.

For more information about Medicaid outreach efforts, contact Donna Cohen Ross, Director of Outreach, at the Center on Budget and Policy Priorities, (202) 408-1080.


States Can Simplify the Medicaid Application Process

As of August 1997, the following states have taken steps to simplify their Medicaid application processes, either by allowing mail-in applications, by eliminating the assets test for children, by shortening the Medicaid application form or by using a combination of these techniques.

  Mail-In No Assets Test** Short Application***
Alabama Yes Yes Yes
Alaska Yes* Yes Yes
Arizona No Yes No
Arkansas No No Yes
California No No No
Colorado No No Yes
Connecticut Yes Yes No
Delaware Yes Yes No
District of Columbia Yes Yes No
Florida No Yes No
Georgia No Yes Yes
Hawaii Yes* No Yes
Idaho No No No
Illinois Yes* Yes Yes
Indiana No Yes Yes
Iowa No No Yes
Kansas No Yes No
Kentucky No Yes Yes
Louisiana No Yes No
Maine Yes* Yes No
Maryland No Yes No
Massachusetts Yes Yes No
Michigan Yes - local decision Yes Yes
Minnesota Yes No No
Mississippi Yes Yes Yes
Missouri Yes Yes Yes
Montana No No No
Nebraska No Yes No
Nevada No No No
New Hampshire No Yes Yes
New Jersey No Yes No
New Mexico Yes* Yes Yes
New York No Yes Yes
North Carolina No Yes No
North Dakota Yes* No No
Ohio Yes Yes Yes
Oklahoma No No No
Oregon Yes No Yes
Pennsylvania Yes Yes No
Rhode Island No No No
South Carolina No Yes Yes
South Dakota No Yes Yes
Tennessee No Yes Yes
Texas No No Yes
Utah Yes* No Yes
Vermont Yes Yes Yes
Virginia Yes Yes Yes
Washington Yes Yes Yes
West Virginia No Yes Yes
Wisconsin No Yes No
Wyoming Yes* No Yes
Total 23 35 28
* After the mail-in application is received, the Medicaid agency will conduct a telephone interview.
** AR, CA, HI, and UT still count assets in determining Medicaid eligibility for some "poverty level" children.
*** Applications are the same length or shorter than the HCFA Model Application.