More than half the people in West Virginia who signed up for Medicaid since last October have done so using a bureaucratic trick of sorts. In fact, five states have used the same shortcut to enroll about a half million Americans without using one of the new health care websites or even processing a paper application. And it’s all because of food stamps.
If you are a single person living alone in West Virginia and making up to 130 percent of the federal poverty line ($1,245 a month before taxes and other deductions), then you qualify for food stamps -- officially known today as the federal Supplemental Nutrition Assistance Program. To receive benefits, you have to prove you meet criteria for income, residency, household size and citizenship status. Ordinarily, you would have to undergo a separate vetting process to qualify for Medicaid, even though the questions and documentation are roughly the same.
The vast majority of people on food stamps -- not including the elderly and disabled -- also qualify for Medicaid under the new eligibility rules in states that decided to expand Medicaid. The reverse is less true: About two-thirds of people on Medicaid are eligible for food stamps.
The Medicaid application process, even with professional assistance, is time consuming. “For a single individual, you could probably do it in a half hour or 45 minutes,” said Perry Bryant, executive director for West Virginians for Affordable Health Care, a nonprofit that helps people sign up for public health insurance. For families, Bryant said, the online applications are more complicated and might take as long as 90 minutes to complete. And for anyone who tries to enroll at an actual welfare office, it could take even longer. “You’re probably waiting for a couple hours before you even see anybody,” Bryant said. “It’s just a slow, painful, bureaucratic process.”
About a year ago, the Centers for Medicare and Medicaid Services (CMS) sent a letter to states suggesting some strategies for dealing with what it anticipated would be an enormous surge in applications for Medicaid and a troublesome burden for state and local welfare offices. Under “Strategy 3,” the federal agency recommended that states consider an “Express Lane Eligibility option” for people already enrolled in the food stamps program. Research by the Urban Institute and the Center on Budget and Policy Priorities (CBPP), two think tanks in Washington, D.C., had already found that while the eligible populations for food stamps and Medicaid aren’t 100 percent identical, they’re pretty close, at least after excluding the elderly and disabled. CBPP found that in states that expanded Medicaid eligibility under the Affordable Care Act, between 90 percent and 95 percent of food stamp recipients should also be eligible for Medicaid.
That’s why West Virginia, Oregon, Arkansas, California and Illinois asked for a waiver from CMS to skip most of the Medicaid application process for people already on food stamps. New Jersey also received a waiver, though it has yet to implement the fast-track option through its food stamps program.
In West Virginia, the Department of Health and Human Resources cross referenced its database for food stamp recipients with a separate database for Medicaid enrollees. Then the agency mailed 118,000 letters to people who were on food stamps and appeared to qualify for Medicaid, but hadn’t enrolled. To get Medicaid insurance, all people had to do was check a box and sign their names. (A sample of Oregon's version of the same type of letter is available online here.)
The state then verified that they were indeed eligible using information it already had on file from a recent application or renewal application for food stamps. The agency followed up with phone calls from local welfare offices and a second salvo of letters to people who didn’t respond the first time. So far, the outreach in West Virginia has resulted in slightly more than 63,000 food stamp recipients enrolling in Medicaid.
Between September of last year and March, 513,762 food stamp recipients have enrolled in Medicaid in the five states with the waiver, according to CMS. About 206,000 have enrolled in California; 138,000 in Oregon; 36,000 in Illinois; and 64,000 in Arkansas.
The reasons states asked for the waiver varied. In West Virginia, state officials worried that residents would be confused by changes in health care coverage and that the health exchange website might experience technical glitches. The food stamp waiver was part of a “risk mitigation strategy,” said Jeremiah Samples, deputy secretary of public insurance in West Virginia’s Health and Human Resources department. “We were very aware that the federal marketplace had not been properly tested.”
In Arkansas, the espoused reason was convenience. “We felt like it was a really efficient method for reaching out to people,” said Amy Webb, a spokeswoman for the Arkansas Department of Human Services. “We could prevent longer wait times and delays for clients and enormous caseloads for our case workers.”
A coalition of anti-poverty groups and think tanks conducted a webinar (now archived) in late April to explain how states can implement the Express Lane eligibility option.
The sooner that people enroll in Medicaid, the sooner they can use their health insurance to address health needs, said Sami Jarrah, deputy director for integrated clinical services at the Multnomah County Health Department. Without health insurance, some of the food stamp recipients now on Medicaid in Oregon might have incurred added costs to the state’s emergency rooms, for example. Because the federal government has agreed to cover the full cost of newly eligible people under the Medicaid expansion for the first three years, it also makes sense for states to get those people signed up as quickly as possible, he said.
Samples, in West Virginia, said that if states choose to use the waiver, they should know that it may not result in a net savings in administrative costs. “The process was simplified and required less worker input,” he said of his state's experience. But the added cost of mailing the letters and developing software to compare food stamp and Medicaid datasets offset those potential savings.