Health Coverage and Human Service Program Eligibility: Considerations for States Weighing Systems Integration

Should states integrate their health insurance and human services eligibility and enrollment systems? Some state officials are weighing this question now that their revamped, Affordable Care Act (ACA) health coverage systems have been operational for several years and most of the early, initial glitches have been repaired. However, there are multiple factors to consider, some of which are new now that state health systems are expected to make eligibility determinations for Medicaid, the Children’s Health Insurance Program (CHIP), and marketplace subsidies.

Integration of health and human service systems is not a new concept. Most, if not all, states have used one integrated system to determine eligibility for Medicaid, Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and other means-tested public service programs. Over time, as these programs evolved, some states opted to create separate systems for their  health programs.

When faced with implementing the ACA’s requirements for new, streamlined, technology-driven enrollment systems that include  health insurance marketplaces and use Modified Adjusted Gross Income (MAGI), a new methodology to determine income eligibility, many states delinked eligibility determination for health coverage from other public programs. For these states, an integrated enrollment system for health coverage programs became the goal to ensure applicants could be screened simultaneously for Medicaid, CHIP, and marketplace subsidies in a way that appeared seamless for consumers.

Today, some state officials who are eager to close the uninsured gap, particularly for children, are considering the value of integrating health with other human services systems as a way to share applicants’ eligibility data across programs. In addition, as states work to address social determinants of health, seamless eligibility screening could help. However, considering many states separated their health programs in order to implement new health eligibility and enrollment systems to meet ACA requirements, most states seeking to integrate must now bring together very separate systems and in some cases very separate infrastructures.

Georgia and Rhode Island officials will attest that integration is challenging, but not impossible. Both have recently launched new, integrated systems that enable individuals to apply for as many as six programs simultaneously. Here are some of the key issues states need to address when developing integrated, eligibility-determination systems.

Tailor applications to enrollees’ diverse needs: Integrating systems to offer families a single application and entry point for all public programs may ensure  they enroll and have access to all of the supports for which they are eligible. However, families with slightly higher incomes who seek to enroll children in CHIP and adults in a qualified health plans (QHP) with marketplace subsidies may be deterred by a lengthier application  that includes questions for programs for which they know they are not eligible.

States that are integrating health and human services eligibility systems are creating two types of applications to meet applicants’ different needs and allowing them to choose which version to complete:

  • One that includes questions to collect data necessary to determine eligibility for multiple programs, and
  • One more simplified health coverage application.

Although developing two applications requires extra work for states, officials recognize the importance of designing applications that meet the needs of all individuals applying for these programs.

Prepare to explain notices to enrollees: State officials acknowledge that the “combined notice” created and sent by integrated eligibility systems can be confusing. For example, individuals who apply for QHPs will likely receive notices that they have been denied Medicaid and SNAP though they didn’t apply for or realize they would be screened for those programs. Educating frontline eligibility staff and call center workers who may receive questions about these denial notices can help clear up confusion.

Align policies, processes, and staffing: State officials report the more challenging aspects of integrating eligibility systems for multiple programs, aside from the substantial cost and detailed system programming, is whether a state’s infrastructure supports true integration. Is there an integrated workforce or do health and human service programs have separate eligibility staff? Is there an integrated business management process in place to support the workforce and systems or are there separate processes for each distinct program? Officials caution that without integrating policies, processes, and eligibility staff across public programs, the resulting integrated eligibility system will have limited success providing individuals and families with truly seamless access.

Establish effective IT governance structures: A strong governance structure that oversees and guides the integrated technology for these programs, known as IT governance, is essential. When departments of human services, Medicaid agencies (which may or may not include CHIP), and the health insurance marketplace all use one system, which agency decides on and pays for the priorities for upgrades and repairs? Different programs must collect and report distinct data to different federal agencies – some of that data may align well while other information is program-specific, which inevitably means each program will need its own database. Which program will use which database and how will they share data? What happens when data do not align – which data are used? All of these questions fall within IT governance purview and coordination of these issues is critical if a state is to efficiently and effectively operate an integrated, eligibility-determination system.

Other options to link health and human services eligibility systems: For states committed to streamlining enrollment in both health and human service programs, there are alternatives to fully integrating systems. There are data-sharing and enrollment-simplifying strategies, such as Express Lane Eligibility (ELE) that states can pursue  to identify families that are not enrolled in Medicaid but are enrolled in other means-tested programs. Louisiana uses ELE to link SNAP with Medicaid, even though the state’s health and human services systems are separate. Families can indicate interest in Medicaid on their SNAP application and eligible children can be enrolled in both programs. Although ELE is simple for families and, once fully operational, is efficient for a state, implementing this strategy was work-intensive for Louisiana’s state agencies, though not as complicated as integrating their eligibility systems.

There is no correct  answer to whether a state should integrate its health and human service programs. However, there are recent state lessons about application and design, policies, and governance for state officials to consider as they seek to share data and simplify eligibility and enrollment across public programs.

The National Academy for State Health Policy will continue researching and reporting case studies to highlight states’ experiences and lessons as they work to improve data-sharing across programs, which may include integrating eligibility systems.