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Policy Innovation Profile

State Automatically Enrolls Low-Income Children in Medicaid Based on Information From Food Program Application, Reducing Number of Uninsured and Administrative Costs


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Snapshot

Summary

Through a policy known as Express Lane Eligibility, the state of Louisiana uses a data-matching program to allow qualified low-income children to automatically be enrolled in Medicaid based on information submitted to the state's Supplemental Nutrition Assistance Program. This policy takes advantage of the Children's Health Insurance Program Reauthorization Act of 2009, which offers states bonuses for implementing best practices to enhance children's access to Medicaid while reducing costs. The policy has enhanced access to Medicaid coverage and to health care services for low-income children, including minorities, other hard-to-enroll populations, and those with other forms of coverage. It has also significantly reduced the number of uninsured children in the state and administrative costs for the Louisiana Medicaid program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of enrollment patterns in Medicaid, the proportion of Medicaid-eligible children in Louisiana without insurance, the proportion of Medicaid claims accounted for by dental services, and Medicaid administrative costs. Additional evidence includes post-implementation feedback on the program collected through interviews and focus groups with administrators, eligibility staff, and parents.
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Developing Organizations

Louisiana Department of Health and Hospitals
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Use By Other Organizations

As of January 2012, Alabama and Maryland have also implemented Express Lane Eligibility for the Medicaid program. Georgia, Iowa, and Oregon have implemented it for Medicaid and in a separate program with the Children’s Health Insurance Program (CHIP). Pennsylvania has implemented it only with CHIP.5

Date First Implemented

2009
The data-matching program began in February 2010 for food program applications submitted starting in December 2009.begin pp

Patient Population

Vulnerable Populations > Children; Impoverished; Medically uninsuredend pp

Problem Addressed

Low-income, racial and ethnic minority children often lack insurance or are underinsured, though many actually quality for Medicaid coverage. Lack of adequate insurance frequently prevents these children from getting needed medical and dental care, placing them at higher risk than nonminorities of missed diagnoses, uncontrolled chronic conditions, preventable hospitalizations, and premature death.
  • Lack of adequate coverage among minority children: Racial and ethnic minorities represent more than 60 percent of the nation’s uninsured population. Low-income, minority children are especially likely to lack insurance. An estimated 1 in 5 Latino children and 1 in 8 African-American children lack insurance, compared to 1 in 13 white children. School-aged children are more likely to go without insurance than younger children. In addition, those low-income families with insurance often face high copayments and other out-of-pocket expenses that make it difficult for them to afford needed care.1
  • Failure to apply for Medicaid: Many uninsured or underinsured children qualify for Medicaid but their parents do not know they are eligible or have not applied for coverage.1 In Louisiana, for example, approximately 5.3 percent of Medicaid-eligible children had not enrolled in Medicaid before implementation of this program, and at one point (before the state implemented other programs to address this issue) this figure was as high as 12 percent.2
  • Reduced access to health care services: When children do not have insurance or when seeing a doctor requires out-of-pocket expenses, low-income parents are more likely to avoid or delay seeking care for their children's routine conditions such as sore throat, ear infections, dental problems, or mental health issues. They are also less likely to fill prescriptions. Children without insurance often rely on emergency departments (EDs) for chronic and/or nonurgent concerns, which results in more expensive, less consistent care.1
  • Poorer health outcomes: The lack of consistent care places uninsured children at increased risk of untreated dental caries, missed diagnoses, and uncontrolled chronic conditions (e.g., asthma, diabetes, obesity) that often require hospitalization and/or ED visits and are associated with poor long-term health outcomes. Minority children are also likely than their nonminority peers to have unmet mental health needs that may lead to higher rates of suicide and incarceration.1 Collectively, these poor health outcomes increase the risk of preventable death. In addition, ill health in childhood can compromise educational achievement and earning potential as an adult.3

What They Did

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Description of the Innovative Activity

Through a program known as Express Lane Eligibility, the state of Louisiana uses a data-matching program to allow qualified low-income children to automatically be enrolled in Medicaid based on information submitted to the state's Supplemental Nutrition Assistance Program (SNAP). Key elements of this policy are outlined below:
  • Policy to automatically enroll in Medicaid based on SNAP application: The Department of Health and Hospitals agreed to grant eligibility (“certify”) for Medicaid based on information submitted to SNAP about household net income, State residence, identity, and Social Security number. Unlike SNAP, Medicaid also requires specific proof of citizenship. If the parent declares U.S. citizenship on the SNAP application (using the checkbox provided), then the child becomes eligible and is automatically enrolled in Medicaid. Previously, obtaining Medicaid coverage for a child required parents to submit a separate application by telephone or in writing, and many parents did not apply or realize their children qualified for coverage until they sought care in an emergency or urgent situation.
  • Synchronized database systems: Because SNAP tracks children individually and the standard Medicaid database tracks children by household, the Department of Health and Hospitals maintains information on children certified through Express Lane Eligibility in individual files. When representatives of the food program update an address or other information in a child’s file, the information is automatically transferred to that child’s Medicaid file.
  • Parental agreement for data matching: Because the Centers for Medicaid and Medicare Services (CMS) requires parents to give permission for Medicaid enrollment, the Louisiana program tried a few different methods to obtain parental permission. Originally, the Department of Health and Hospitals mailed information to parents enrolled in SNAP to explain the policy and give them a chance to opt out by calling a toll-free telephone number. Since January 2011, the Express Lane Eligibility program asks parents to check a box on the SNAP application giving their permission to use the information to determine if their children are also eligible for Medicaid.
  • Automatic renewal for children with active SNAP cases: The Department of Health and Hospitals automatically renews Medicaid coverage for all children (regardless of whether they enrolled through Express Lane Eligibility or a separate application) with active SNAP cases. Other parents receive a notice that they must contact the agency to renew their children’s coverage.

Context of the Innovation

The Louisiana Department of Health and Hospitals is responsible for protecting and promoting health and ensuring access to medical, preventive, and rehabilitative services for all citizens in Louisiana. It administers the Medicaid program, providing health care coverage to more than 1.2 million residents, including nearly half a million children. In recent years, the Louisiana Department of Health and Hospitals has made a special effort to increase enrollment of eligible children in Medicaid, and as a result Louisiana has reduced the rate of uninsured children from 25.5 percent to 11.8 percent in the decade before starting the Express Lane Eligibility program (including reducing the rate of uninsured among Medicaid-eligible children from 12 percent to 5.3 percent, as noted earlier).2

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) provided additional funding to states to expand public health insurance coverage for children. The act offers performance bonuses to states that implement 5 of 8 specified best practices, including the Express Lane Eligibility program. Express Lane Eligibility permits states to rely on findings (income, household size, and other eligibility information) from applications to other benefit programs to facilitate enrollment in Medicaid. These benefit programs include free or reduced lunches; Temporary Assistance for Needy Families; Head Start; Women, Infants, and Children; and SNAP.4 State officials in Louisiana, who had already made significant progress in streamlining Medicaid enrollment, saw the Express Lane program as another way to make it easier for families to get health insurance coverage for their children.

Did It Work?

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Results

The Express Lane Eligibility program has enhanced access to Medicaid coverage and to health care services for low-income children, including minorities, other hard-to-enroll populations, and those with other forms of coverage. It has also significantly reduced the number of uninsured children in the state and administrative costs for the Louisiana Medicaid program.
  • Enhanced access to Medicaid for low-income children, including minorities: Between February 2010 and August 2012, nearly 28,000 low-income children enrolled in Medicaid through the Express Lane Eligibility program. (Medicaid covers 475,000 children in the state.) More than 60 percent of these enrollees were African American, Latino, or other ethnic or racial minorities. (Minorities make up approximately 40 percent of the general population in the state.) Although many of these children may eventually have enrolled in Medicaid, the Express Lane Eligibility program likely resulted in faster and/or earlier enrollment and hence more consistent care.
  • Progress in reaching hard-to-enroll children: The program has reached several groups of children that have traditionally been less likely to have health insurance, as outlined below:
    • Older children: Nearly three-quarters of children enrolled through the Express Lane Eligibility program were older than age 7, well above the 57 percent that children in this age range represent among those enrolling through the traditional method.2
    • Children from disadvantaged areas: The program has reached children in areas that previously had higher-than-average proportions of uninsured children, such as New Orleans and Shreveport. Overall, 12 percent of children enrolled through Express Lane lived in New Orleans and 17 percent lived in Shreveport, compared to 10 percent and 12 percent (respectively) of children enrolled in the traditional manner.2
  • Substantial decline in uninsured children statewide: From 2009 (just before program implementation) to 2011, the percentage of uninsured, Medicaid-eligible children in Louisiana fell from 5.3 percent to 2.9 percent. During that same time period, the proportion of uninsured rose in other groups, including among employed and low-income adults.2
  • More comprehensive coverage for underinsured children: More than 12 percent of the children enrolled through the program report also being covered by their parents’ employer-sponsored insurance (compared to less than 5 percent of children enrolled in Medicaid the traditional way). For these children, Medicaid fills gaps in coverage, such as for dental care and copayments.2
  • Enhanced access to dental and appropriate medical care: Approximately 16,000 of the new enrollees used their insurance to gain access to needed care, particularly dental care. Although no hard data are available, program leaders believe that these enrollees are also receiving more appropriate medical care.
    • Dental care: Many children used the coverage to access dental care, which represents 25 percent of all claims among children enrolled through Express Lane Eligibility (compared to just 8 percent of claims for children enrolled the traditional way). Agency officials believe that before implementation of this program, many uninsured and underinsured children went without regular dental care (which often is not covered even for those with insurance). When they finally accessed dental coverage, they often required extensive work to rectify problems from previous lack of care.2
    • More appropriate medical care: Before implementation of this program, many uninsured children likely received medical care from safety net providers. Although the program has not attempted to document “diversions,” or cases in which children enrolled through the program now receive care in clinics or physicians’ offices rather than the ED or hospital, program officials believe that this shift has occurred and is resulting in more consistent, cost-effective care.
  • Significant time and cost savings for agency: The program has saved the agency an estimated $1 million on enrollment costs in 1 year and between $8 and $11 million on renewal costs in the first year, as outlined below.2
    • Faster, cheaper enrollment: The traditional enrollment process takes an average of 30 to 45 minutes per case, and costs the agency about $116. With Express Lane Eligibility, enrollment requires virtually no staff time and costs the agency approximately $12 to $15 per successful application. If the 11,149 children enrolled through the program had been enrolled through traditional methods, the cost would have been $1.3 million as opposed to approximately $300,000 using the new streamlined method.2
    • Easier, less expensive reenrollment: Renewal for all children enrolled in both the food program and Medicaid takes place now automatically and saves even more time and money for the agency. The previous method required manual "crosswalk" of information from the food program's database to Medicaid's different definitions and requirements. Now that is done automatically by batch file, saving approximately $51 per renewed case and allowing enrollment agents to focus on eligible adults and children who do not enroll through the food program. In the first year, 156,279 children were renewed (more than 1 in 4) through the Express Lane Eligibility program. Parents also note that they find the automatic renewal process to be much easier.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of enrollment patterns in Medicaid, the proportion of Medicaid-eligible children in Louisiana without insurance, the proportion of Medicaid claims accounted for by dental services, and Medicaid administrative costs. Additional evidence includes post-implementation feedback on the program collected through interviews and focus groups with administrators, eligibility staff, and parents.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Discussions with CMS: Soon after the ratification of the CHIPRA, Louisiana officials initiated talks with CMS officials about implementing Express Lane Eligibility for children.
  • Decision to partner with SNAP: Given the large number of Medicaid-eligible children who participate in SNAP, the Department of Health and Hospitals identified this food assistance program as a good partner to share data and thus identify eligible children who have not enrolled in Medicaid.
  • Conducting feasibility study: Before moving forward, representatives of both agencies conducted a study to determine if an interface for this type of data sharing was possible. The two agencies housed their databases on the same mainframe computer and had already created other interfaces between their systems. The study convinced them that it was possible to create and implement a data-matching function.
  • Determining how to sync databases: Because the two systems organized data differently (Medicaid by household and SNAP by individual, as outlined earlier), the Department of Health and Hospitals decided to maintain Express Lane Eligibility cases as individual files by child's name. This decision ensured that updates and renewal information would automatically transfer between the two databases without requiring an expensive restructuring of the entire Medicaid database. This decision also made it easier to evaluate program outcomes. Representatives of both agencies and their information technology (IT) contractors worked together to determine appropriate data structure, data-matching processes, and how updates in one system would affect the other.
  • Creating procedure for parental permission: CMS requires that parents give permission to use information provided on the SNAP application to determine Medicaid eligibility. Initially, the Louisiana program automatically sent the parents of eligible children a Medicaid identification card for the eligible child, and parents could signal their permission by using the card to seek care for the child within 1 year. When problems developed with this method, the agency looked at different methods, finally settling on the current “opt-in” checkbox on the SNAP application (as described earlier).
  • Notification and training of eligibility staff: The Department of Health and Hospitals sent an e-mail explaining the new program to eligibility staff and provided a short online orientation and training program that reviewed the goals of the program and what procedures had been changed and how, including what information and processes would now be automated.

Resources Used and Skills Needed

  • Staff: The Department of Health and Hospitals did not hire additional staff for this project, but did contract with an IT vendor for database design and synchronization.
  • Costs: The IT setup and initial training cost approximately $600,000.
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Funding Sources

Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation covered the costs of the initial IT set up and training through the "Maximizing Enrollment" project.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Be patient: Although the policy to share data may sound simple on the surface, implementation can quickly become complicated. By taking time to think through different scenarios for the database structure, the Department of Health and Hospitals avoided major technical problems and associated changes during the "go-live" process.
  • Avoid enrolling large groups at one time: At the start of the program, the agency identified more than 10,000 children in the SNAP database who qualified for Medicaid. Enrolling all these children at once created an administrative backlog (which continued for up to 1 year when the cases came up for renewal). As a result of these challenges, the agency switched to the opt-in checkbox, which ensures that the caseload stays fairly consistent and that staff do not have to process a large number of enrollees at one time.
  • Design system to minimize administrative tasks: When designing the data-matching process, agency officials stressed the need for automated procedures and updates, thus reducing administrative tasks. For example, by keeping the data structure the same in both databases (though the two agencies historically organized their data differently), information entered by food program staff could be automatically updated in the Medicaid system during nightly synchronizations.
  • Be consistent: Although eligibility staff were generally positive about the program, any change in procedures can meet resistance. Agency officials overcame this resistance by using consistent messages during training, staff meetings, and other communications.
  • Avoid expensive system redesigns: Program costs and scope can quickly expand if major system overhauls become necessary. For example, the hybrid solution for storing Medicaid files (as described previously) avoided the need for a prohibitively expensive overhaul of the entire Medicaid database.

Sustaining This Innovation

  • Remind staff about differences in program requirements: Ensure that staff remain aware of the differences in eligibility requirements for various State programs (e.g., Medicaid versus SNAP), as well as the reasons for these differences.
  • Look for additional partners: To further increase enrollment, the Department of Health and Hospitals is looking at other agencies with which to share data. For example, department leaders would also like to partner with the Department of Education. However, each parish in Louisiana has its own system for collecting student information, making data synchronization an expensive and complicated process.

Use By Other Organizations

As of January 2012, Alabama and Maryland have also implemented Express Lane Eligibility for the Medicaid program. Georgia, Iowa, and Oregon have implemented it for Medicaid and in a separate program with the Children’s Health Insurance Program (CHIP). Pennsylvania has implemented it only with CHIP.5

More Information

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Contact the Innovator

Lesli Boudreaux
LaCHIP Program Manager
State of Louisiana Department of Health and Hospitals
628 N. 4th Street
Baton Rouge, LA 70802
Phone: (225) 342-0327
Fax: (877) 523-2987
E-mail: lesli.boudreaux@la.gov

Innovator Disclosures

Ms. Boudreaux reported receiving an honorarium and travel support from Mathematica for participation on a technical advisory group for an evaluation of the Express Lane Eligibility program; in addition, information on other funders is available in the Funding Sources section.

References/Related Articles

Dorn S, Hill I, Adams F. Louisiana Breaks New Ground: The Nation’s First Use of Automatic Enrollment through Express Lane Eligibility. The Urban Institute, April 2012. Available at: http://www.shadac.org/publications
/louisiana-breaks-new-ground-nations-first-use-automatic-enrollment-through-express-lane
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Footnotes

1 Children's Defense Fund. Racial and Ethnic Disparities. Available at: http://www.childrensdefense.org/policy-priorities/childrens-health/racial-ethnic-disparities.
2 Dorn S, Hill I, Adams F. Louisiana Breaks New Ground: The Nation’s First Use of Automatic Enrollment through Express Lane Eligibility. The Urban Institute, April 2012. Available at: http://www.shadac.org/publications
/louisiana-breaks-new-ground-nations-first-use-automatic-enrollment-through-express-lane
.
3 Baker Institute Policy Report. The Economic Impact of Uninsured Children on America. June 2009. Available at: http://www.bakerinstitute.org/publications/HPF-pub-HoShortUninsuredChildren-060309.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
4 Centers for Medicare and Medicaid Services. Express Lane Eligibility for Medicaid and CHIP Coverage. Available at: http://www.insurekidsnow.gov/professionals/eligibility/express_lane.html.
5 Henry J. Kaiser Family Foundation State Health Facts. State Has Express Lane Eligibility for Children in Medicaid and CHIP, January 2012. Available at: http://www.statehealthfacts.org/comparemaptable.jsp?ind=898&cat=4.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 19, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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