During the COVID-19 pandemic, health coverage is more important than ever. States are seeing a surge in Medicaid applications, as individuals who have lost income become eligible for the program. However, documentation and paperwork burdens can pose barriers to Medicaid enrollment— particularly during the pandemic, when it may be more difficult to gather documents verifying income or other eligibility factors.
Documentation and paperwork requirements
Meanwhile, documentation and paperwork requirements also impose burdens on state agencies, which are under unprecedented strain as they adapt to changes like office closures and employees’ caregiving responsibilities.
Fortunately, states have a number of options to simplify Medicaid enrollment procedures. These changes can help people get coverage faster, and ease burdens on state eligibility systems.
Options available to streamline Medicaid enrollment
Below, we describe several federal options available to streamline Medicaid enrollment during the pandemic, and provide examples of what states have been doing.
Template State Plan Amendment (SPA) Options
Expand Presumptive Eligibility (PE)
Presumptive eligibility provides immediate, temporary coverage to individuals that a qualified entity screens as appearing to be eligible for Medicaid. The PE determination is based on preliminary information and does not require verification. CMS’s template includes several ways a state can expand presumptive eligibility determinations.
Expand Hospital Presumptive Eligibility Populations
Under the Affordable Care Act, hospitals are allowed to make PE determinations for MAGI populations in all states. States can also permit hospitals to make PE determinations for additional state plan populations or populations covered under an 1115 waiver.
Washington has expanded hospital presumptive eligibility for certain non-MAGI groups.
Allow State Agency to Conduct PE Determinations
A state can designate itself as a qualified entity, which allows the state to accept presumptive eligibility applications directly for MAGI eligibility groups.
Illinois amended their state plan to allow the state to conduct presumptive eligibility for MAGI adults.
Designate Additional Qualified Entities to Conduct PE
States can allow additional entities to conduct presumptive eligibility.
New Mexico expanded the qualified entities permitted to conduct PE to encompass a wide range of organizations, including: groups that furnish Medicaid state plan services; groups authorized to determine a child’s Medicaid or CHIP eligibility; groups authorized to determine eligibility for Head Start, WIC, or public housing; schools; Tribal entities; and correctional facilities.
Nebraska now allows the entities that were qualified to make presumptive eligibility determinations for pregnant women to also make determinations for parents/caretakers, children, and former foster care children. These qualified entities include all entities that furnish Medicaid state plan services, as well as health care facilities operated by the IHS, Tribes, Tribal organizations, and Urban Indian Organizations.
Adopt 12-month Continuous Eligibility for Children
Extend Reasonable Opportunity Period
Individuals have 90 days to provide documentation of their citizenship/immigration status, if the information cannot be verified through the state’s electronic databases. Through the SPA, states have the option of extending this reasonable opportunity period, if the individual is making a good faith effort to resolve the inconsistency or the public health emergency makes the state unable to complete the verification process.
Nebraska elected to extend the reasonable opportunity period.
Use a Simplified Application
States have the option of using simplified online, paper, and/or telephone applications.
Disaster Verification Plan Addendums
CMS has also released a template disaster addendum for states verification plans. These verification plans outline the states’ eligibility verification procedures for MAGI groups. While the plans should be sent to CMS, they do not require CMS approval.
Changes to Income Verification
The CMS template allows states to modify income verification in four ways.
First, states can accept self-attestation of income, in circumstances specified by the state, without any verification.
Alternatively, states can keep verification, but ease the requirements. For instance, states can alter their reasonable compatibility standards, so that discrepancies between the income an applicant attests, and the income a data-matching source reveals do not hold up the application. States can also elect to conduct post-enrollment verification of income, within a timeframe specified by the state.
Finally, states can stop checking income-based data sources, such as IRS, SSA databases, and state databases, between regular renewal periods.
States can select any one or a combination of these options.
Louisiana, for instance, specified that during the COVID emergency period, the state will accept self-attestation of income, and will conduct post-enrollment verification of income once the emergency period has ended. Technically, the state’s eligibility system still compares the person’s self-attested income to the state’s data sources.
However, the state has changed its reasonable compatibility standard to 1000% for the duration of the public health emergency, to ensure that the self-attestation is considered reasonably compatible with the income from the electronic data match. Moreover, the state’s eligibility system has been adjusted so that self-attestation is accepted when there is a conflict with the data sources. Louisiana also elected to stop checking data from the State Wage Income Collection Agency between renewals.
Wyoming’s plan allows self-attestation of income or assets when verification is not available due to the emergency.
Changes to Verification of Non-Income Eligibility Criteria
The CMS template verification plan addendum also allows states to either accept attestation for certain non-income factors or to wait to verify those factors until after enrollment. For the post-enrollment option, the state may specify the timeframe in which it will conduct the verification.
States may select attestation or post-enrollment verification for residency, age/date of birth, household composition, receipt of other coverage, or other factors as permissible under existing statutes and regulations.
Other Things States Are Doing
In addition to submitting SPAs and modifying their verification plans, states have been making a number of other changes to make Medicaid enrollment easier.
New York is allowing self-attestation for all factors other than citizenship and immigration status.
Oregon is accepting self-attestation for all eligibility criteria except citizenship and immigration status. The state will send a request for information to applicants if necessary to verify citizenship and immigration status, but benefits will not be terminated for failure to respond.
Expedited Processing of COVID-19 Applications
Illinois is encouraging hospitals to assist individuals who need COVID testing or treatment with an application, even if the hospital or provider is unsure whether the individual is eligible. The state is also planning to provide expedited processing for these applications.
Extended Call-Center Hours
Kentucky extended the hours of their Medicaid application call center and added hours on Saturdays.
Treatment of Unemployment Income
Under the new federal CARES Act, most individuals receiving unemployment insurance payments are entitled to a $600 weekly supplement to their unemployment, called Pandemic Unemployment Compensation. This $600 a week does not count as income for Medicaid purposes, so states must make changes to their enrollment processes to ensure the income is disregarded.
Oregon has directed caseworkers to subtract $600 per week from the income of individuals receiving unemployment benefits.
Kentucky has modified their integrated public assistance application to include a field for pandemic unemployment compensation. The eligibility system counts the compensation for the purposes of programs like SNAP, but disregards the income for Medicaid.
States have numerous options to make Medicaid enrollment easier during this critical time. State policies in this area are rapidly evolving; if your state is using an enrollment simplification strategy that isn’t described here, we would appreciate you letting us know at [email protected] and [email protected].