How States Can Accelerate Their Enrollment Efforts

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June 2013

Robust outreach campaigns and in-person application assistance will be critical to connecting many to coverage, but states must often invest significant amounts of time and resources to make sure those efforts achieve enrollment goals. States can significantly reduce the number of uninsured people they will need to reach through these efforts by taking full advantage of other options to simplify and streamline enrollment. This fact sheet provides a checklist of strategies that are available to all states to automate and streamline enrollment in Medicaid, regardless of their decision on the Medicaid expansion or the type of health insurance marketplace that will be available in the state.

Automatically enroll people who are already known to be eligible.

States have extensive information about many uninsured individuals and families because of these people’s connections to other public programs. This includes groups like parents of children enrolled in Medicaid or the Children’s Health Insurance Program (CHIP); adults participating in programs like the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps); and individuals who are receiving support through state-funded mental or behavioral health programs, assistance for the homeless, or other state or local means-tested programs. This information can be used to make outreach, application, and eligibility determination processes easier for both the consumer and the state.

  • Use data from the Supplemental Nutrition Assistance Program (SNAP) to determine eligibility for Medicaid and CHIP. More than 90 percent of SNAP households have members with incomes below 138 percent of the federal poverty level (about $15,420 for an individual, $26,340 for a family of three in 2013).1 States that are expanding Medicaid under the Affordable Care Act can leverage this information to automate the enrollment and retention process for residents. In a letter sent to state health officials and state Medicaid directors on May 17, 2013, the Centers for Medicare and Medicaid Services (CMS) outlined a variety of ways that states can implement this enrollment automation strategy.2
  • Connect eligible parents to coverage if their children are already enrolled in Medicaid or CHIP. There are approximately 4.7 million uninsured parents with incomes below 138 percent of poverty who already have a child who is either enrolled in Medicaid or CHIP or eligible for Medicaid or CHIP but not enrolled.3 Many of these parents will be eligible for Medicaid beginning on January 1, 2014. States have an opportunity to automate enrollment for these parents by reviewing children’s cases and sending their parents a pre-populated application, or by reconsidering applications from parents who recently have been denied.4 In addition, many uninsured parents of children who are enrolled in Medicaid and CHIP may be eligible for coverage through the new health insurance marketplaces. As part of other communications with these households (like renewal notices and premium statements), states can notify these parents that they will have an opportunity to apply for coverage starting this fall.
  • Mine existing databases to identify and enroll uninsured residents who are already known to be eligible for coverage programs. For example, the majority of young adults who were formerly in a state’s foster care system will automatically become eligible for coverage.5 Beginning on January 1, 2014, many former foster youth will be eligible for Medicaid until they reach the age of 26, so states should use their existing foster care data to proactively reach out to and enroll as many of these eligible youth as possible.

Streamline the enrollment process.

Under the Affordable Care Act, people seeking health coverage will no longer need to submit different applications to different agencies for different health coverage programs. Instead, Medicaid and CHIP agencies and the health insurance marketplaces must coordinate behind the scenes to make the process easy for consumers. There are a number of steps states can take to better coordinate and simplify this process.

  • Eliminate unnecessary handoffs and encourage real-time enrollment. Integrate eligibility information technology systems to the greatest extent possible and treat any Medicaid eligibility assessments conducted by the new health insurance marketplaces as final eligibility determinations. Even states that are not building their own marketplaces have the option to accept Medicaid eligibility determinations completed by the federal marketplace as final determinations.6
  • Adopt the new Modified Adjusted Gross Income (MAGI)-based rules early. Under the health care law, eligibility for all health coverage programs, including Medicaid, CHIP, and the premium tax credits, will generally have to follow MAGI-based rules.7 Although people can begin applying for coverage on October 1, 2013, states are not required to begin using MAGI-based rules in Medicaid and CHIP until January 1, 2014. This means that everyone applying for coverage between October 1 and December 31, 2013, will need to have their eligibility assessed twice: once using MAGI-based rules, and once using current Medicaid or CHIP rules. States can avoid this complexity and better coordinate the open enrollment period by adopting MAGI-based rules in Medicaid and CHIP early–on October 1, 2013.8
  • Adopt 12-month continuous eligibility. States can reduce administrative costs by guaranteeing a full year of coverage to all people who are found eligible for CHIP or Medicaid. States have the option to offer 12-month continuous eligibility to children, parents, and other adults.9 This will also reduce the problem of “churning”–the burdensome disenrollment and re-enrollment of eligible people when they lose coverage due to procedural reasons or to slight fluctuations in income.
  • Accept attestations. According to the federal eligibility rules, states must develop an eligibility verification plan and standards for when they will require applicants to provide additional documentation. Accepting attestations, rather than requiring the consumer to provide additional paperwork, can expedite and simplify the process for consumers. If a state does not accept attestations for certain eligibility criteria, it should be as flexible as possible in the types of documentation that it accepts.


1 Stan Dorn, Laura Wheaton, Paul Johnson, and Lisa Dubay, Using SNAP Receipt to Establish, Verify, and Renew Medicaid (Washington: Urban Institute, May 2013).

2 Letter to State Health Officials and State Medicaid Directors, from Cindy Mann, Director, Centers for Medicare and Medicaid Services, May, 17, 2013.

3 Martha Heberlein, Michael Huntress, Genevieve Kenney, Joan Alker, Victoria Lynch, and Tara Mancini, Medicaid Coverage for Parents under the Affordable Care Act (Washington: Georgetown University Health Policy Institute Center for Children and Families, June 2012).

4 Letter to State Health Officials and State Medicaid Directors, op. cit.

5 Brooke Lehmann, Jocelyn Guyer, and Kate Lewandowski, Child Welfare and the Affordable Care Act: Key Provisions for Foster Care Children and Youth (Washington: Georgetown University Health Policy Institute Center for Children and Families, June 2012).

6 Center for Medicaid and CHIP Services, Coordination across Insurance Affordability Programs: Answers to Frequently Asked Questions (Baltimore: Centers for Medicare and Medicaid Services, May 2012).

7 Letter to State Health Officials and State Medicaid Directors, op. cit.

8 Ibid.

9 Ibid.

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