State Policy and Systems

1. Elizabeth Lower-Basch Senior Policy Analyst Stacy Dean Vice President for Food Assistance Policy State Policy and Systems Working Poor Families Project Policy Academy June 30, 2011

2. Continuum of Efforts Image thanks to Shelley Waters Boots

3. Bridging the Gaps Eligibility Threshold

4. Closing Eligibility Gaps States choose whether to provide state EITCs States have full control over eligibility rules in TANF, child care subsidies Health care programs have required minimum levels of coverage, but many state options for additional coverage States have more flexibility than generally acknowledged under SNAP

5. State EITCs Range from 3.5 % of federal credit (Louisiana) to 40% (Washington, DC)

6. Role for WPFP Members:Play Defense TANF benefit cuts approved in California, District of Columbia, New Mexico, South Carolina, Washington. Other cuts, such as shorter time limits, are also in play. State EITCs under threat, especially in Michigan and New Jersey Large UI cuts under consideration Medicaid/CHIP eligibility protected by “MOE” requirement, but not reimbursement rates, benefit package

7. 40 States and DC Have Expanded Asset Limit Policy for Food Stamps

8. SNAP Gross Income Limits

9. Closing Coverage Gaps Outreach and application assistance Passive enrollment Removing barriers to enrollment Simplifying rules to streamline documentation Longer recertification periods Smarter recertification processes

10. 1. Passive Enrollment • Direct certification under National School Lunch Program • Children in families receiving SNAP, TANF, or Food Distribution Program on Indian Reservations (FDPIR) automatically eligible for free lunch. • Under Healthy, Hunger-Free Kids Act of 2010, states must directly match with SNAP data – not enough to send families letter to bring in. • Express Lane Eligibility for CHIP

11. Express Lane Eligibility Allows use of findings from other public benefit programs to determine eligibility for Medicaid and CHIP Screen and enroll options Can’t find a child ineligible Must notify if child would qualify for less costly coverage under standard method

12. Express Lane “Findings” • Income, immigration status, state residence, household composition • Income can be used even if not defined exactly the same as under CHIP • Not U.S. citizenship • Findings “within a reasonable period of time” can be used (state defines)

13. Auto-Enrollment Option State-initiated enrollment without a formal application Family must give consent in writing, orally, electronic signature or other means State must inform family of services, premiums, other obligations

14. 2. Removing Barriers to Enrollment Allowing telephone or internet-based interviews instead of requiring face-to-face interviews. Dropping fingerprinting requirements Using SSA match for citizen documentation instead of requiring birth certificates or passports

15. “Cit Doc” • Deficit Reduction Act of 2005 — U.S. citizens applying for Medicaid must present proof of citizenship and identity • Some groups exempt; Children, parents and pregnant women most affected • States have found substantial declines in enrollment

16. Impact of Cit Doc in Virginia Monthly Enrollment in Medicaid for Children Citizenship Documentation is Required SOURCE: Presentation by Linda Nablo, Virginia Department of Medical Assistance Services, April 26, 2007

17. SSA Match Option

18. 28 States Were Implementing SSA Data Match to Document Citizenship - June 2010

19. 3. Simplifying Rules to Streamline Documentation • Few TANF families have countable assets – but all applicants must be asked about them • 5 states have dropped TANF asset limits • Standard Utility Allowance (SUA) • Increases benefit, but also reduces documentation • Any LIHEAP benefit qualifies recipient for SUA • Illinois waiver to use standard medical deduction

20. IL Standard Medical Deduction Demonstration Only applies to households with a member age 60 or older, or disabled Must verify $36 a month of allowable medical expenses Standard medical deduction of $245 a month, $485 a month for residents in group homes Can use actual medical expenses if higher

21. 4. Longer Recertification Periods • Every time you make people recertify eligibility, some people fail to complete process • Large share of those who fail to recertify are still eligible for benefits. Many will reapply within a short time period. • Churning has large cost in time and effort to both recipients and state agencies

22. Example: Nearly 3/4 of Closed SNAP Cases Reapply Within 30 Days

23. Twenty-two states set maximum child care subsidy eligibility at 12 months Churning of subsidies reduces continuity of care for children

24. Only 20 States Routinely Use 12-Month SNAP Certifications for Families with Kids

25. Only 14 States Routinely Use ≥24-Month SNAP Certifications for Elderly or Disabled Households

26. 5. Smarter Recertification Processes • Coordinate renewals across benefit programs • When clients provide updated information, states can use it to recertify for multiple programs. • Ex-parte renewals — using available information to renew health benefits. • Ex. LA first looks at the SNAP case to renew children’s Medicaid before contacting the family. • Express Lane Eligibility can be used for renewal as well as initial application

27. By Simplifying the Medicaid Renewal Process, Louisiana Reduced Procedural Closings

28. Work Support Strategies Initiative Ford Foundation effort, led by the Urban Institute to improve participation amongst eligible families in a package of work supports: SNAP, health and child care. http://www.urban.org/worksupport/

29. WSS GranteesOR, ID, CO, NM, IL, KY, NC, SC, RI

30. Promising Practices for Improving Work Supports Bringing Eligible Families to the “front door” Limiting in-person requirements Reducing documentation requirements Improving reporting rules Simplifying renewals/improving retention Business Process Reengineering Using data to provide feedback loop

31. States Are Struggling

32. A Simple Pathway to the Package • Multi-program screeners • Prompts to clients and workers • Outreach to 1-program clients • One program as a gateway to another – “no wrong door” • Unless consumers opt-out, they are routed to other appropriate benefit programs • Using renewals as a chance to leverage other benefits • E-application “smart” forms that limit questions, based on earlier answers • One agency’s findings establish eligibility for other programs Note: Health Care Reform may change how many clients interact with the state for Medicaid.

33. Same Day (or Faster) Service • Many states offer “same day” service for in-person or phone applicants. • WA, ID, and UT 4/5 applicants receive benefits on the same day • NM 80% are processed within 24 hours. • AZ 65% of applicants in pilot offices can be processed in a single visit (down from 3 to 5 visits). • OK local offices offered same day service for SNAP, MA and child care

34. Striving for Same Day Service Raises Important Questions • Should experienced staff be up front or in the back room? • Who can resolve an issue? • How long does an interview need to be? Where does it need to take place? • Do we require unnecessary verification? • Can I make a decision today based on what I know? • Did the client already provide the information to another program? • How many of the steps clients must complete did we create?

35. Process Gaps Application Scheduling 80% of apps are dropped off in-person Takes 12 steps and 2 weeks to get an appointment, or clients walk out in 2 hours with a full package

36. Role for WPFP Members • Support adoption of specific high impact policies, such as Express Lane Eligibility • Encourage inclusion of participant and advocate voices in systems redesign • Advocate for and monitor performance goals • Reduced coverage gap • Same day service • Reduced churning

37. Health Reform Overview • Estimated to expand coverage to 32 million uninsured Americans by 2019 • Individual mandates • Two buckets of coverage: • Medicaid (and CHIP) • The “exchanges”

38. Medicaid Eligibility Expansion • Beginning January 1, 2014, states must expand Medicaid to all non-elderly adults and children up to 133% of the federal poverty level • ($14,403 for an individual, or $33,729 for a family of four in 2010) • The Medicaid expansion could reduce the rate of uninsured adults with income <133% FPL by 69.5% (Kaiser/Urban, May 2010). • CHIP continues at 2009 eligibility levels (at least for a while)

39. Median Medicaid/CHIP Income Eligibility Thresholds, 2009 Medicaid Eligibility under Health Reform = 133%FPL SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission on Medicaid and the Uninsured, 2009.

40. Premium Tax Credits • Assistance for those who are not eligible for Medicaid and cannot afford coverage in the exchange • Starting in 2014, individuals and families earning up to 400% FPL ($88,200 for a family of four in 2010), will get help paying their health insurance premiums in the form of tax credits

41. New Income Definition Modified Adjusted Gross Income (MAGI) No disregards other than 5% Eliminates assets tests Based on information already available to the state, e.g. previous year’s tax returns Can apply based on more recent info if circumstances have changed

42. No Wrong Door Single application form for Medicaid, CHIP, and subsidies in the exchange Can file on-line, by mail, in person, by phone Medicaid, CHIP, exchanges work together behind the scenes to determine eligibility seamlessly Presumptive eligibility option

43. IT Infrastructure • Vast majority of states will have to develop new IT systems in order to support new rules • HHS is providing 90% federal funding for Medicaid eligibility IT infrastructure development through 2015 • Opportunity to build framework for modernized eligibility systems across programs • “Interoperability” • HHS Eligibility and Enrollment Workgroup

44. Not Just Health Care §1561. HIT Enrollment, Standards and Protocols. Not later than 180 days after the enactment, the Secretary, in consultation with the HIT Policy and Standards Committees, shall develop interoperable and secure standards and protocols that facilitate enrollment in Federal and State health and human services programs through methods that include providing individuals and authorized 3rd parties notification of eligibility and verification of eligibility.

46. Challenges 2014 is coming fast Some states are still resisting ACA “Horizontal and vertical integration” “Woodwork” concern

47. “Woodwork” Concern

48. Role for WPFP Members:Seize Window of Opportunity • If states don’t build in capacity to expand to other programs, will be harder to add it later. • 90% federal funding only available for limited time • If advocates don’t insist that human service programs are included in the planning process, it probably won’t happen