States simplify Medicaid applications, offer presumptive eligibility to improve outreach Under pressure to improve outreach to uninsured children who may qualify for Medicaid or new child health insurance programs, many states are moving to make the Medicaid application process more user-friendly. Several states, including Florida, Massachusetts and Connecticut, also plan to take advantage of a new opportunity to give children presumptive eligibility for Medicaid so that they can bring them into the system more quickly once they apply for benefits. The Center on Budget and Policy Priorities (CBPP) reports that, as of February, 38 states had dropped the assets test for Medicaid, 30 have developed short application forms and 25 were allowing mail-in applications. Having an assets test is a tremendous barrier to Medicaid applications, and eliminating it is an important step, said Donna Cohen Ross, director of the Start Healthy, Stay Healthy Project at the CBPP. Eliminating the assets test makes it possible to take another very important step simplifying and shortening the application form, she said. Some states have applications over 20 pages long, posing an often insurmountable challenge for families, states a Jan. 23 letter sent to state officials by the Health Care Financing Administration (HCFA). The letter informs state officials of steps they can take to improve outreach to the millions of uninsured children in the country who are eligible for Medicaid, but not enrolled. HCFA's letter reminds state officials that they can keep verification to a minimum because there are few verification requirements under federal law, said Ms. Cohen Ross. Asking families to assemble lots of documentation to verify income, etc. can create a significant barrier to families, she said. So can requiring that parents apply for benefits in person. Allowing applications to be mailed in lifts a tremendous obstacle for parents who have child care or transportation problems or who are not in position where they can leave work for a few hours to apply at a Medicaid office, she said. Some states require a telephone interview, which is a suitable compromise, she said. Screen and enroll For states that set up separate insurance programs under last year's historic Child Health Insurance Program (CHIP), simplifying the Medicaid enrollment process will make it easier for them to meet the new screen and enroll requirement. Families that apply to children's health insurance programs must be screened for their Medicaid eligibility and enrolled if they qualify. Merely referring them to Medicaid does not meet the requirement, said Ms. Cohen Ross. ÒA complicated Medicaid program is going to bog down their efforts, she said. You want to be able to make it simple for every family that's applying. HCFA has developed a four-page model application which can be used for both Medicaid and state child insurance programs. A single application form, a single point of entry and a unified message are some of the ways states can coordinate the programs, she said. It shouldn't be up to families to figure out where the child belongs, said Ms. Cohen Ross. With short applications, no asset test and ability to mail you can begin to think about how community-based organizations can really use these as tools to conduct effective outreach, said Ms. Cohen Ross. In Virginia, where there is a two-page application for Medicaid, community-based organizations that do home visits help their clients fill out the forms in their own homes. Presumptive eligibility for Medicaid is a new option provided by the 1998 Balanced Budget Act that will help states improve outreach to their uninsured children. Presumptive eligibility has been proven to be an effective tool for bringing pregnant women into Medicaid programs. Being able to access services right away helps motivate families to follow through with the application process. Presumptive eligibility Currently, traditional Medicaid providers, including federally qualified health centers (FQHCs), and entities that determine eligibility for Head Start, WIC and child care subsidies under the Child Care and Development Block Grant, can grant presumptive eligibility to children. The president's proposed budget for 1999 expands the number of entities that can grant presumptive eligibility to include schools, child-care resource and referral centers, child support agencies and CHIP eligibility workers. This is a huge expansion and an important one, Ms. Cohen-Ross said. Child care and referral centers are well- positioned to do presumptive eligibility for Medicaid, she said, because besides helping parents to find affordable child care, they offer other assistance such as determining whether the family qualifies for earned income tax credits. They are wonderful organizations that look at the total package of benefits, she said. She said schools could help capture older children who are now eligible for health care coverage. Under the president's budget proposal, costs for covering children during the presumptive eligibility period would come from Medicaid, according to Jennifer Baxendell, director of health legislation for the National Governors Association. The current requirement that states subtract the costs of presumptive eligibility for Medicaid from a state's CHIP allotment has made it a less attractive option to state. Connecticut will start giving children presumptive eligibility for Medicaid in May, said David Parella, director of medical care administration. Children will be issued numbers that they can use to access services on a fee-for-service basis for 60 days. Mr. Parella said the state is looking at using school health centers, Head Start sites, WIC programs and child care providers to do outreach and give presumptive eligibility. Connecticut has a separate child insurance program called Husky Part B. Medicaid has been renamed Husky Part A. Allowing CHIP eligibility workers to give presumptive eligibility for Medicaid, as proposed in the president's budget, could speed up the process (of enrolling into Medicaid) and reduce costs, Mr. Parella said. In addition to using the Husky name for both programs, the state also will use the same application form. (The current Medicaid application form is 14 pages long, but is being simplified.) Schools could help capture older children who are now eligible for health care coverage. Massachusetts plans to use presumptive eligibility for children beginning in March when children with family incomes below 200% of the federal poverty level (FPL) will be eligible for Medicaid. Sharon Torgerson, director of external relations for the Department of Medical Assistance, said legislative approval will be needed before the state can move ahead. Massachusetts has already been using presumptive eligibility for its children's insurance program, the Children's Medical Security Plan. The same application form will be used for both programs in the future. The state is now in the process of simplifying its Medicaid application for the second time in less than a year, Ms. Torgerson said. There will be a core four-page form with supplemental pages for children with disabilities or with other health insurance coverage. About 12,000 children who are now on the Children's Medical Security Plan are eligible for Medicaid, but moving those families over to Medicaid has been difficult, Ms. Torgerson said. Children with family incomes up to 133% of FPL became eligible for the Medicaid program last summer. While state officials have been promoting the more comprehensive benefits of Medicaid to these families, Ms. Torgerson said many are not motivated to make the switch if their children have had few health problems and they are happy with CMSP. They simply do not see the need to switch to another program, she said. She acknowledged that the more complicated enrollment process for Medicaid may also have discouraged switching. People will enroll in the program it's easiest to enroll in, said Kim Shellenberger of Health Care for All, a consumer advocacy group, adding that the stigma of Medicaid also could be a factor in why people aren't switching. The president's budget includes a proposal that would expand states access to a $500 million fund for outreach. The fund, set up under welfare reform, was established so states could do outreach to families affected by welfare reform. It provides an enhanced federal matching rate of 90% for certain outreach activities, but few states have taken advantage of this fund so far, in part, due to the difficulty of targeting outreach only to a subset of Medicaid-eligible children, states the Jan. 23 letter from HCFA. States could use the money to do outreach to all uninsured children. However, the budget also proposes to reduce the federal matching rate for states administrative expenses from 50% to 47%, leading state officials to say the president's budget is taking away money for outreach. Jennifer Baxendell, director of health legislation for the National Governors Association, said this is a significant reduction that would affect not only outreach but other activities such as policing for fraud and that the cut would be vigorously fought by governors. Contact Ms. Cohen Ross at 202-408-1080 or Ms. Torgerson at 617-210-5680.