Medicaid and CHIP Eligibility Verification Flexibilities Help States Keep up with Increased Application Volume due to COVID-19

As more and more Americans file unemployment claims, we can expect an increase in Medicaid applications. This increased demand comes at a time when Medicaid eligibility enterprises are challenged with transitioning eligibility workers to telework and may be experiencing workforce shortages due to worker illness or family caretaking responsibilities resulting from the COVID-19 pandemic. But there are actions states can take to streamline the eligibility process.

Let’s start with the basics of eligibility verification for income-based MAGI-groups – children, pregnant women, parent/caretakers, and low-income adults – in Medicaid and CHIP. States:

  • must verify citizenship and qualified immigration status prior to enrollment
  • must verify income but may do so either prior to or post-enrollment.
  • have the option to accept self-attestation for most non-financial criteria including age/date of birth, household size, and state residency.

For any criteria that the state is required to or chooses to verify, it must first seek to verify through electronic sources before asking applicants to provide documentation. States must describe their verification policies in a state verification plan that must be submitted to CMS, although CMS approval is not required. These plans detail how the state verifies eligibility, including the data sources used. For states to make temporary changes to verification policies, CMS has created a verification plan addendum template that alters state policies and procedures during the public health emergency.

Although citizenship and immigration status must be verified, states may extend the reasonable opportunity period for non-citizens attesting to a satisfactory immigration status to provide documentation. When the state is unable to verify citizenship or satisfactory immigration status through electronic sources, it must provide a reasonable opportunity period for individuals to provide proof. In the meantime, applicants must be enrolled in coverage. States may elect to provide extra time for applicants to provide documentation during the public health emergency. (See Medicaid disaster relief SPA template Eligibility Section, Item 6.)

States may accept an individual’s self-attestation of income during the public health emergency. Medicaid rules require that income must be verified but states may enroll individuals based on their attestation of income and verify post-enrollment, although only five states do so. However, the new verification plan addendum allows states to accept self-attestation of income without pre- or post-enrollment verification during the public health emergency. States may also change their election to post-enrollment verification but CMS has clarified that, as a condition of the receiving the FMAP bump of 6.2 percentage points, those individuals are considered enrolled and cannot be disenrolled while the emergency declaration is in effect. (See Eligibility and Enrollment Flexibilities Section, Question 7 in the running COVID-19 FAQs.)

States may accept self-attestation of non-financial criteria except citizenship/qualified immigration status. Almost all states (49) accept self-attestation for household composition, while most states (40) use self-attested data for state residency. Just over half (27 states) also accept self-attestation for age/date of birth. States may make permanent verification policy changes via an update to their verification plan or temporarily accept self-attestation by submitting the verification plan addendum template.

States using the Federally-facilitated Marketplace (FFM) could allow the FFM to make the final Medicaid and CHIP determinations. The 38 states that use the FFM to process applications submitted through can choose to accept the FFM’s eligibility determination and directly enroll individuals. Otherwise, the state accepts the application data from the FFM and processes eligibility as it would a new application received directly by the state. Becoming an FFM determination state is a strategy that several states, such as Louisiana and Virginia, have used when they expanded Medicaid to help meet the increased application volume resulting from the expansion. It can be equally effective during this public health emergency. (See a full list of state elections in table 9 of the 2020 50-State Survey on Medicaid and CHIP.)

States could increase their reasonable compatibility standards in determining income eligibility. It’s not unusual for there to be discrepancies between what applicants report for income compared to the data source used by the state to verify income. Variability exists when the data source is somewhat dated or when individuals provide an income attestation that doesn’t match how income is determined for Medicaid or CHIP eligibility. For example, are there 4 weeks in a month or on average 4.33 weeks in a month? To avoid states having to reconcile differences, they have the option to apply a reasonable compatibility standard (RC) that disregards differences when self-attested income and electronic data sources yield differing eligibility results.

Setting a reasonable compatibility standard will cut down on the number of applications for which states need to seek additional documentation from applicants. States may adopt a permanent RC standard by updating its verification plan or temporarily adopting a standard during the public health emergency using the verification plan addendum template.

Example of Reasonable Compatibility

Reasonable compatibility gets really weedy so let’s look at a specific example. The monthly income cutoff for a Medicaid expansion adult is $1,467. If the state sets a 10% reasonable compatibility standard (the most common among the 33 states using the policy), the difference between the income source and self-attested data can be no more than $146. If an applicant reports income of $1,450 but the data source shows $1,510, the difference of $60 is less than the RC standard and the individual is enrolled.

Easing eligibility standards with one or more of these options can help states keep up with the influx of new applications as individuals lose their job-related insurance or are unable to afford private insurance as a result of reduced income or job loss. These choices not only reduce administrative burden on states but they will help ensure that more low-income individuals have access to the health coverage they need during the pandemic and beyond.

Tricia Brooks
Tricia Brooks is a Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families