Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
THE CHILDRENS HEALTH 
INSURANCE PROGRAM 
States Application and Enrollment Processes: 
An Early Report From the Front Lines 
JUNE GIBBS BROWN 
Inspector General 
MAY 1999 
OEI-05-98-00310  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Region V prepared this report under the direction of William Moran, Regional Inspector 
General and Natalie Coen, Deputy Regional Inspector General.  Principal OEI staff included: 
REGION  HEADQUARTERS 
John Traczyk, Team Leader  Wynethea Walker, Program Specialist

Nora Leibowitz, Project Leader

Rebecca Ogrodnick

To obtain copies of this report, please call the Chicago Regional Office at (312) 353-4124. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E   S U M M A R Y  
PURPOSE 
To identify promising practices, barriers and issues related to the application and 
enrollment procedures of the Children's Health Insurance Program (CHIP). 
BACKGROUND 
It is estimated that approximately 12 million children in the United States are currently 
without health insurance.  Many of these uninsured children are eligible for Medicaid but 
are not enrolled in the program.  The Balanced Budget Act of 1997 created Title XXI of 
the Social Security Act, the Childrens Health Insurance Program.  Title XXI provides $24 
billion over 5 years to develop health insurance programs for low-income children.  States 
have the option to expand their existing Medicaid program, design a new childrens health 
insurance program or develop a program that combines these strategies. 
Studies have shown that applications and enrollment procedures may be a barrier to 
families applying for Medicaid.  Consequently, the Health Care Financing Administration 
(HCFA) is encouraging States to streamline Title XXI applications and the application 
process. 
We conducted this study to identify promising approaches being used by States.  We also 
sought to identify barriers and issues States are confronting in their implementation of 
CHIP programs.  We hope that sharing the promising approaches and addressing 
emerging issues will be beneficial to both program administrators and potential program 
applicants. 
We collected blank application forms from 19 States that had CHIP programs in operation 
on or before July 1, 1998.  We conducted on-site interviews with the State CHIP director 
or their designee, in seven States, concerning their CHIP application and enrollment 
procedures.  Front-line workers, who assist families in completing CHIP applications, 
were also interviewed in these seven States.  We held telephone discussions about CHIP 
applications and enrollment procedures with the remaining 12 program directors or their 
staff. 
States Application and Enrollment Processes  1  OEI-05-98-00310  FINDINGS 
Emerging Application Formats and Enrollment Practices 
Many States are experimenting with CHIP application and enrollment practices.  They are 
finding that short applications are quicker and easier to complete, but may necessitate 
further contacts with State agencies.  Longer applications can deter people from applying 
for benefits. 
States are weighing tradeoffs when they develop joint applications.  The average joint 
Medicaid/CHIP application is longer than the average CHIP-only application.  The three 
States that use a single application for medical and other benefit programs tend to have 
longer applications. 
To improve access to CHIP for children whose parents do not speak English, many States 
make applications available in Spanish and other languages.  We found that the average 
reading level of the CHIP applications we analyzed was 10th grade.  The average CHIP 
applicant may find it difficult to comprehend many application questions. 
Most States make applications available at multiple sites and nearly all use toll-free 
telephone numbers to distribute CHIP applications and to provide program information. 
Most sampled States no longer require a face-to-face interview for CHIP or Medicaid and 
most now accept mail-in applications. 
Some States mentioned streamlined procedures and early effective dates of coverage as 
negating the necessity for presumptive eligibility.  Other States mentioned administrative 
difficulties and other problems as reasons for not adopting presumptive eligibility. 
Barriers to Enrollment: Citizenship Dilemmas 
State CHIP administrators stated that noncitizens are reluctant to apply for CHIP.  People 
involved in the CHIP application process stated that fear of being detected makes illegal 
aliens reluctant to complete an application even for their children who meet citizenship 
requirements.  Qualified aliens are also reluctant to complete an application for their 
children, fearing that use of a public benefit will adversely affect their applications for 
citizenship. 
Multiple Program Rules 
Medicaid, CHIP and other public benefit programs differ in their rules regarding issues 
such as verification of alien status, child support enforcement and verification of income. 
Different policies also exist for determining:  household/family composition, countable 
income, and disclosure of information.  These differences hinder the development of  joint 
States Application and Enrollment Processes  2  OEI-05-98-00310  applications, affect application size and complicate verification procedures.  States find 
themselves having to apply different rules for different programs, leaving them uncertain 
as to which program policies to apply in each case.  States have concerns that their 
decisions regarding definitions of income and household/family composition and 
verification processes will affect their quality control error rate. 
RECOMMENDATIONS 
Readability of Application Forms 
We recommend that HCFA work with States to improve the readability of CHIP 
applications.  The high reading level of some applications can dissuade prospective 
applicants from applying. Language complexity may lead applicants to incorrectly fill out 
forms, which may have an impact on whether applications for health care coverage are 
accepted or denied.  Reducing language complexity and reading level on CHIP 
applications can improve access to services. 
Simplification Efforts 
We recommend that HCFA continue to encourage States to simplify their application and 
enrollment processes for CHIP and Medicaid.  Many practices show encouraging results. 
However, it is too early to determine the effectiveness of these practices. 
We encourage HCFA to continue to support State efforts to: 
<  Reduce application length;

<  Use joint Medicaid/CHIP applications;

<  Use multi-program applications;

<  Print applications in Spanish or other languages;

<  Distribute applications at multiple sites;

<  Utilize toll-free telephone lines to provide information;

<  Provide assistance with the application process;

<  Increase the use of outstation and application collection sites;

<  Utilize mail-in applications and post-paid envelopes;

<  Eliminate face-to-face interviews.

We also encourage HCFA to continue helping States investigate the following practices: 
<  Contracting with enrollment brokers; 
<  Eliminating some verification requirements. 
Under Medicaid, eligibility is effective with the date of application or, at State option, the 
States Application and Enrollment Processes  3  OEI-05-98-00310  first day of the Month of application.  There is no requirement in the CHIP legislation that 
governs the effective date of CHIP eligibility.  We recommend that HCFA encourage 
States with separated CHIP programs to adopt CHIP eligibility policies that parallel their 
Medicaid policies.  We also recommend that HCFA encourage States to presume 
eligibility of all children effective with the date of application. 
Citizenship Issues 
We recommend that HCFA work with INS to encourage INSs development of clear 
guidance and policy statements on how applications for CHIP and Medicaid will impact 
noncitizens.  Qualified aliens should know whether using the CHIP benefit will affect their 
citizenship.  Illegal aliens should know if the information they provide on CHIP 
applications for their citizen children will be used to enforce immigration laws. 
Uniformity of Program Requirements 
We recommend that an interagency task force be formed to address conflicting public 
benefit application requirements.  We recommend that this interagency workgroup 
develop uniform policies for verifying income, using the Income Eligibility Verification 
System, determining household/family composition, defining countable income, counting 
child support and disclosing information. 
States Application and Enrollment Processes  4  OEI-05-98-00310  T A B L E   O F   C O N T E N T S  
EXECUTIVE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6 
FINDINGS 
Emerging Application Formats and Enrollment Practices  . . . . . . . . . . . . . . . . . . .  9 
Application brevity 
Joint applications 
Multi-program applications 
Spanish and other languages 
Readability 
Applications at multiple sites 
Toll-free telephone lines 
Application assistance 
Outstationing and collection sites 
Mail-in applications, post-paid envelopes 
Elimination of face-to-face interviews 
Presumptive eligibility 
Use of enrollment contractors 
Elimination of some verification requirements 
Denial rates 
Citizenship Dilemmas  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20 
The illegal alien dilemma 
The public charge dilemma 
Multiple Program Rules  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  23 
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26 
AGENCY COMMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  28 
APPENDICES 
Appendix A: Health Care Financing Administration Comments  . . . . . . . . . . . .  29 
Appendix B: Health Resources and Services Administration Comments  . . . . . .  34 
Appendix C: Assistant Secretary for Management and Budget Comments . . . . .  35 
States Application and Enrollment Processes  5  OEI-05-98-00310  I N T R O D U C T I O N  
PURPOSE 
To identify promising practices, barriers and issues related to the application and 
enrollment procedures of the Children's Health Insurance Program (CHIP). 
BACKGROUND 
The Agency for Health Care Policy and Research estimates that approximately 12 million 
children have no health insurance.  As many as 4.7 million uninsured children are eligible 
for Medicaid but are not enrolled in the program.  More than 90 percent of these children 
are in working families. 
The Balanced Budget Act of 1997 (Public Law 105-33) created Title XXI of the Social 
Security Act, the Childrens Health Insurance Program (CHIP).  The CHIP is a capped 
matching program which authorizes $24 billion over the next 5 years to establish and 
expand health insurance programs for low income, uninsured children.  The CHIP 
programs goal is to provide health insurance to children whose parents earn too much to 
qualify for Medicaid but not enough for private insurance.  The program also seeks to 
cover uninsured children whose parents health insurance does not cover their dependents. 
The program allows States to expand their current Medicaid program, design a new 
childrens health insurance program or develop a program which combines these 
strategies.  States that choose to expand the number of children eligible for Medicaid must 
follow existing Medicaid rules regarding family income, geography and residency.  These 
Medicaid expansion programs must also offer the same benefit package their Medicaid 
recipients currently receive.  States establishing separate CHIP programs may set their 
own eligibility standards within federally-established parameters and have more flexibility 
on the benefit package. 
Through Title XXI, States may cover children whose household/family incomes are higher 
than traditional Medicaid limits.  Medicaid family income limits for children vary from 
State to State and can range from the Federal poverty level to 300 percent of poverty. 
Under Title XXI, States may choose to cover children whose family income is above the 
Medicaid threshold but less than 200 percent of poverty.  States with Medicaid programs 
that currently cover children at or above 200 percent of poverty may raise their current 
eligibility standard as much as 50 percent. 
States Application and Enrollment Processes  6  OEI-05-98-00310  Under CHIP, States receive higher Federal matching dollars than they do for Medicaid. 
The CHIP legislation requires that States use their Federal money to cover uninsured 
children who are not covered by Medicaid or private insurance.  States must screen all 
children applying for CHIP for Medicaid eligibility.  Medicaid-eligible children identified 
during outreach must be enrolled in Medicaid rather than in a separate CHIP program.  To 
prevent States from moving children from Medicaid to the new program, the law prohibits 
States from receiving an enhanced match if they tighten the Medicaid eligibility standards 
that existed before March 31, 1997. 
Identifying and enrolling children are challenges facing States implementing CHIP.  Title 
XXI requires States to conduct outreach and enrollment activities.  Outreach involves 
locating children who are eligible for health insurance and enrolling them in Medicaid or 
CHIP.  The goal is to assure that all children who qualify for publicly-subsidized health 
insurance get enrolled in the appropriate program. 
Studies have shown that applications may be a barrier to families applying for Medicaid. 
Reducing the length and complexity of Medicaid and CHIP applications may improve the 
uptake rate for eligible children.  Researchers, advocacy groups and the Health Care 
Financing Administration (HFCA) have encouraged States to shorten their applications 
and simplify enrollment processes. 
On January 23, 1998 and September 10, 1998, HCFA issued letters to the States 
encouraging them to reduce the length and complexity of Medicaid and CHIP 
applications.  Another HCFA letter sent to the States on November 23, 1998 encourages 
States to develop joint applications, simplify application process and eliminate (or 
streamline) efforts to verify information on Medicaid and CHIP applications. 
METHODOLOGY 
We collected CHIP application forms from 19 States.  Most States have a single CHIP 
application form, but three States have multiple CHIP application forms.  Overall, we 
collected and reviewed 41 different CHIP application forms provided by the 19 States in 
our sample.  We analyzed the content of each application and the way questions are asked 
and how information is provided to applicants. 
We conducted site visits in seven States (AL, CA, CO, CT, FL, NJ, OK) that were 
enrolling children in a stand alone Title XXI program or a Medicaid expansion program. 
We discussed CHIP applications and enrollment procedures with State Medicaid and 
CHIP staff.  Discussions were also held with front line workers, contractors and others 
involved with helping families apply for CHIP.  We discussed application and enrollment 
procedures with the 12 remaining States (ID, IN, MA, MI, MO, NY, OH, OR, PA, RI, 
SC, TX) over the telephone. 
States Application and Enrollment Processes  7  OEI-05-98-00310  We asked respondents about their CHIP application and requested information as to how 
and where families could obtain an application.  We also asked how applicants could get 
help in completing an application and how they can submit an application.  We focused on 
the application process, including how eligibility for Title XIX (Medicaid) and Title XXI 
(CHIP) is determined, what verification the State requires, whether contractors are used 
for any portion of the process and how referrals between Title XIX and Title XXI occur. 
We also asked about presumptive eligibility and application denials. 
We conducted a readability analysis of randomly selected CHIP applications.  For each of 
the applications selected, we randomly selected instructions and questions for readability 
analysis.  Software was used to analyze reading grade level and vocabulary complexity 
using the Flesch-Kincaid formula.  This test is the standard test used by the Department of 
Defense to determine the ease of reading.  It determines the complexity and reading 
difficulty using a formula based on average sentence length and average number of 
syllables per word. 
The information presented in this report is for the period July through October 1998.  It is 
a point-in-time description.  Many States we interviewed for this study are in the process 
of making changes to applications and enrollment procedures.  Several States in our 
sample had implemented the first phase of their program and were in the planning stage of 
their second phase when we talked with them.  The findings are based on the programs at 
the time we spoke with the States involved, and may not reflect subsequent 
implementation of second or third phase Title XXI programs. 
We conducted our review in accordance with the Quality Standards for Inspections issued 
by the Presidents Council on Integrity and Efficiency. 
States Application and Enrollment Processes  8  OEI-05-98-00310  F I N D I N G S  
Emerging Application Formats and Enrollment Practices 
States are advised to make their CHIP applications uncomplicated and user-friendly. 
Researchers, advocates and HCFA have asked the States to develop simpler application 
forms and to improve enrollment processes for Medicaid and CHIP.  In their January 23, 
1998 letter to State health officials, HCFA stated that a key to successfully enrolling 
children . . . is a simple application and enrollment process.  In an effort to improve 
application and enrollment processes, HCFA has advised States to shorten CHIP and 
Medicaid applications, develop joint applications, simplify language and minimize 
verification requirements. 
With HCFAs encouragement many States have developed shorter applications not only for 
CHIP but also for their Medicaid programs.  The Center for Budget and Policy Priorities 
believes that shortened applications will facilitate enrollment.  The model joint Medicaid-
CHIP application developed by HCFA is four pages.  It consists of two pages on which 
families enter information plus two pages of program explanations and descriptions of 
requirements.  In the past, Medicaid applications were often long and complicated. 
The HCFA suggests making eligibility determination easier by eliminating asset tests and 
verification requirements that are not federally required.  According to HCFA, States can 
accept an applicants responses on a Medicaid or CHIP application without verification. 
The HCFA also encourages States to eliminate face-to-face interviews, to allow mail-in 
applications and to streamline verification procedures. 
The HCFA has also encouraged States to use a combined application for their Medicaid 
and CHIP programs.  The HCFA believes that joint Medicaid/CHIP applications would 
reduce State paperwork and simplify the process for families potentially eligible for CHIP 
and Medicaid.  In a November, 1998 letter to State Health Officials, HCFA encouraged 
States to develop and use a joint application that could be used for CHIP, Medicaid and 
other public benefit programs such as food stamps, child care and cash assistance.  The 
Center for Budget and Policy Priorities and the Childrens Defense Fund have praised 
several States for their streamlined application processes. 
Application brevity 
Of the 41 applications in our sample, the average application length was five and a half 
pages.  When declaration pages and informational pages are removed, the average number 
of pages  families are asked to complete drops to just over three pages.  Over half of the 
States Application and Enrollment Processes  9  OEI-05-98-00310  applications in our sample are four or fewer pages.  More than 75 percent are six or fewer 
pages.  One-fifth of all the applications studied were seven or more pages.  The longest 
application was 28 pages. 
Application length, in itself, does not appear to be an accurate measure of application 
burden.  Studies suggest that a short application may encourage more families to apply for 
Title XIX and Title XXI programs.  Generally, application length is counted as the total of 
both the pages the family must complete and any pages of information, instructions and 
declarations attached to the fill-in pages.  Some States include information, instructions 
and declarations in the application itself.  Others print information and instructions on 
sheets not attached to the application.  This may lead to unfair comparisons between State 
applications.  A State that attaches two pages of instructions to two pages of fill-ins does 
not have a longer application than a State that prints the two sections on separate sheets. 
States make tradeoffs when developing applications.  We examined an exceptionally long 
CHIP application.  In addition to the actual application, the package given to potential 
applicants contains many pages of explanations, instructions, flow charts, cartoon 
descriptions of the process and other informational pages.  The application, which is a joint 
CHIP/Medicaid form, contains more than 12 pages of instructions and explanations.  Four 
pages of application questions help applicants estimate family income. 
Using this States application, a CHIP or Medicaid applicant would fill out 12 pages.  This 
includes two pages of declarations and a checklist for required documentation. 
Respondents from this State indicated that the their application design was influenced by 
input from advocates and other groups.  Staff at the States CHIP program said they 
included many advocate suggestions, which increased the applications length.  This States 
application illustrates the tradeoffs that States consider when deciding what information to 
include and what questions to ask in their CHIP/Medicaid applications. 
CHIP Application Length 
Application Type  All Applications  CHIP-only  Joint Medicaid/CHIP 
Average Length  5.5 pages  3.8 pages  7.6 pages 
Median Length  4 pages  4 pages  6 pages 
Mode  4 pages  4 pages  4 pages 
Shortest and longest  1 - 28 pages  1 - 8 pages  2 - 28 pages 
States Application and Enrollment Processes  10  OEI-05-98-00310  Joint applications 
Two States with CHIP-only programs use a separate CHIP application. Nine States with 
Medicaid expansions or combination CHIP/Medicaid programs use a single application. 
Eight States with CHIP-only programs use a joint CHIP/Medicaid application. 
Using a joint Medicaid/CHIP application can simplify the application process for some 
families. Families only have to complete one application and do not have to determine 
under which program their children may be eligible. Joint applications facilitate the 
enrollment of CHIP applicants in Medicaid if they qualify for that program. With both 
programs on one application, States can ensure that they enroll children who are Medicaid 
eligible in Medicaid and children eligible for CHIP are enrolled in CHIP. 
Joint applications help reduce the stigma associated with welfare by making program 
differences invisible to families. This may be especially important for families who do not 
want Medicaid due to its association with welfare. Many State CHIP directors provided 
anecdotal information about families refusing Medicaid but willing to accept, and in some 
cases willing to pay for CHIP. 
Joint applications are often longer than CHIP-only applications. Joint Medicaid/CHIP 
applications have to include questions a State requires for either program. The average 
length of a combined application is longer than that of an average CHIP-only application 
(7.6 pages versus 3.8 pages). Some State laws may prescribe information to be collected or 
processes for Medicaid applicants that are not required for their separate CHIP program. 
Joint applications may require families of CHIP-eligible children to go through a more 
invasive process, such as face-to-face interviews, added questions and more extensive 
verification of information provided. 
Multi-program applications 
Of the 19 States in our study, three use a single application form to determine eligibility for 
Medicaid/CHIP and at least one other public benefit program. One State combines its 
Medicaid application with applications for cash assistance and food stamps. A second State 
uses a single application for cash assistance, food stamps and child care subsidies. The 
third uses a combined application for its medical programs and the Women, Infants and 
Children (WIC) program. 
A single application for health care and other programs can be a good way to ensure that 
families have access to all the programs for which they qualify. When a family fills out a 
joint application, a State can determine eligibility for several State and Federal programs. 
Some families may not want to fill out separate applications and interact with their States 
social services agency multiple times. A multi-program application may increase access to 
both health programs and other programs such as food stamps and subsidized child care for 
these families. 
States Application and Enrollment Processes  11  OEI-05-98-00310  The downside of a multi-program application is that different programs have different 
requirements.  The issues surrounding joint Medicaid/CHIP applications are intensified 
with a multi-program application.  States that use multi-program applications indicated that 
persons applying for subsidized health insurance often have face-to-face interviews because 
they are required for other programs.  One State noted that much of its documentation and 
verification requirements are the result of the food stamps program requirements. 
As an alternative to multi-program applications, one States joint CHIP/Medicaid 
application includes check boxes.  Applicants can indicate their interest in receiving 
information about other State and Federal programs by checking the appropriate box. 
Spanish and other languages 
Half the States running CHIP programs as of July 1, 1998 print their applications in both 
English and Spanish.  Most of these States print English and Spanish versions separately. 
Two States print a single version of the application, with all instructions and questions in 
both languages.  Five States make applications available in several languages.  One State 
distributes instructions and applications in 10 different languages.  Three States print 
applications only in English. 
All States offer telephone or in-person assistance to help non-English speaking persons 
apply for CHIP.  Some States staff their toll-free help lines with bilingual staff.  In addition, 
all States utilize telephone-based interpreter services. 
Readability 
Application complexity affects a readers ability to successfully and accurately complete  a 
CHIP application without assistance.  High reading level scores and complex vocabulary 
may hinder some peoples ability to complete a CHIP application.  Subjective analysis of a 
texts reading level is often inaccurate.  Teachers and others with higher than average 
reading levels tend to underestimate the difficulty of a given text by up to 8 years. 
Using the Flesch-Kincaid Formula, we analyzed randomly selected application questions 
and instructions from a sample of CHIP applications.  We found that most CHIP 
applications required a 10th grade education or higher to comprehend CHIP questions and 
instructions.  The grade level of the questions and instructions we analyzed ranged from 
4.86 to 14.79. 
Contributing to the difficult reading level of CHIP applications is the complexity of  the 
sentences and vocabulary used in questions and instructions.  Complex sentences and 
vocabulary make comprehension more difficult for applicants.  Compared with a 
Hemingway short story with a vocabulary complexity score of 5, the CHIP applications we 
examined had vocabulary complexity scores ranging from a low of 2 to a high of 71. 
States Application and Enrollment Processes  12  OEI-05-98-00310  States have shown concern that applications are comprehensible to families.  One State 
indicated that they changed a CHIP application question about the name of the person 
filling out the form.  What once read applicants name now reads your name. This 
change avoids confusion caused when parents or others filling out a CHIP application 
entered a childs name in the slot meant for their own name.  Other States have also 
responded to problems with individual questions or instructions, but none indicated that 
they have performed comprehensive application overhauls based on readability analysis. 
Applications at multiple sites 
Most of the States in our study made applications available at multiple locations.  These 
locations included State and local government offices, welfare and Medicaid offices, State 
and local health departments, county or city run health clinics and WIC clinics.  In addition, 
many States distribute applications through community groups, churches, nonprofit 
organizations, private health care providers, Federally Qualified Health Centers (FQHCs), 
child care centers, Head Start centers and schools.  Most States have made efforts to 
distribute applications at multiple sites.  Some States have made noteworthy efforts to 
distribute CHIP application by offering hundreds of application pick-up sites throughout 
their States.  See Table on the next page for a compilation of CHIP application sites 
mentioned by State respondents.1 
Many States are making efforts to solicit the cooperation of schools in identifying 
potentially eligible children.  Schools in many States are asked to distribute information and 
applications to students.  Eight States specifically mentioned that applications are available 
at schools and education departments.  Many States noted that Department of Education 
cooperation was good.  However, a couple of States indicated that local school districts 
were not always willing to distribute information and applications.  One State felt that the 
Department of Education lacks a clear mandate to cooperate in this endeavor. 
Toll-free telephone lines 
Most States run a statewide, toll-free telephone line.  People can call to these toll-free 
numbers to get program information and applications.  Only three States do not make 
applications available via Statewide toll-free telephone lines.  Two of these States contract 
with individual managed care organizations (MCOs) to run customer service lines as part 
of their programs.  The contracted MCOs in these States provide information about CHIP 
and mail out applications to callers.  The other States toll-free line can be used to get 
information about the program and referrals to the appropriate State agency. 
1Figure 1 is a list of sites at which people can obtain CHIP applications. This list may not be 
comprehensive. It reflects only the sites mentioned by our State respondents. 
States Application and Enrollment Processes  13  OEI-05-98-00310  Locations used by States to distribute CHIP applications 
Health Care Providers, including: 
<  hospitals 
<  State, city and county health departments 
<  federally qualified health centers 
<  county health clinics 
<  community health centers 
<  clinics run by the Women, Infants and Children program 
<  dentist offices 
<  Physicians and other health care provider offices 
Government offices, including: 
<  Medicaid offices 
<  welfare offices 
<  regional offices of the State government 
<  unemployment offices 
Schools, including: 
<  State Department of Education offices 
<  local school district offices 
<  schools 
Community based organizations and not-for-profit agencies, including: 
<  churches 
<  libraries 
<  private social service agencies 
<  advocacy groups 
<  boys and girls clubs 
<  domestic violence shelters 
<  food banks 
Other organizations, agencies and businesses, including: 
<  managed care organizations 
<  contractors and enrollment brokers 
<  pharmacies 
<  child care centers 
<  Head Start centers 
<  legal services offices 
<  tax preparers offices 
<  insurance agencies 
<  grocery stores 
States Application and Enrollment Processes  14  OEI-05-98-00310  Application assistance 
Most States offer assistance with application-related questions by telephone.  In several 
States, the staff answer questions and explain what documentation should be sent in.  In 
some States, staff on the toll-free line will help families fill out an application.  The 
completed application is then sent to the family for a signature and needed documents. 
Several States train groups and individuals not employed by the State to help families with 
the application process.  In one State, organizations sponsor individuals to attend a day-
long training on the application.  These individuals are then approved to assist families with 
the application on behalf of their organization.  In another State, more than 300 interested 
organizations have signed agreements with the State regarding training and their role in the 
initial processing of the applications. 
State Medicaid or CHIP web sites describe their programs and explain how to get an 
application.  Several States allow families to print the application from the web site, fill it 
out and mail it in. 
Outstationing and collection sites 
About one quarter of the States in our study relies, at least in part, on outstationed workers 
to collect applications.  Many States allow families to return applications to places other 
than welfare or Medicaid offices.  These sites include health departments, Federally 
Qualified Health Centers, clinics and other agencies that volunteer to help families with the 
process.  Several States report that they increased the number of application drop-off sites 
in order to help families avoid the welfare or social services office.  In some States, 
applications dropped off at an outstation or volunteer agency site will be forwarded to the 
processing organization.  In one State, outreach sites (including medical providers) can fax 
in families applications for them, and then send the paper copy by mail later.  They hope 
that eliminating the stigma of welfare and making the process friendlier will encourage 
more families to apply. 
Rather than increase the number of outstation sites, several States collect CHIP 
applications predominantly or exclusively through a mail in process.  Many of these States 
distribute post-paid envelopes with their applications and encourage families with questions 
to call the toll-free help line. 
Mail-in applications, post-paid envelopes 
In its January 1998 letter to State health officials, HCFA stressed the benefits of mail-in 
applications, noting that they can reduce enrollment barriers found with in-person 
applications.  Mail-in applications keep families out of the social services office, thus 
reducing transportation costs, avoiding the stigma of the welfare office and eliminating the 
States Application and Enrollment Processes  15  OEI-05-98-00310  need to miss work.  In addition, HCFA noted that mail-ins increase the number of 
organizations that can help distribute applications and information to potentially eligible 
families. 
Many States currently have mail-in Medicaid applications, and all but one of the States in 
our study use it for Title XXI applications.  Over half the States in our study provide 
applicants with a post-paid envelope in which to return their application.  States that 
provide a post-paid envelope indicate that they do so to encourage families to return their 
applications.  Several States noted that they did not want low-income applicants to put off 
getting their children insured because they did not have the money for postage. 
States not using post-paid envelopes had several reasons for this decision.  One State 
reports that post-paid envelopes increase the mailing time.  This State claims that the extra 
processing time required to process post-paid envelops delays receipt of applications. 
Several States indicate that the weight of required documents varied from family to family. 
This variability, in weight, makes it difficult for States to provide postage paid envelopes. 
Despite these problems, the majority of States do pay for return mail postage, and several 
other States indicate that they may begin using post-paid envelopes in their next Title XXI 
implementation phase. 
In addition to mail in applications, some States will begin processing CHIP applications 
based on information faxed to them.  However, these States also require that the original 
application be sent to them also.  According to our respondents, an original signature is 
required to be on file in order to have a complete CHIP application.  Currently, no States 
accept Internet-based applications, as questions still remain about the security of 
information sent in this manner. 
Elimination of face-to-face interviews 
Although Federal law does not require either Medicaid or CHIP applicants to undergo an 
interview, some States do require families to have one.  Three States, all using Title XXI 
for Medicaid expansion programs, require an interview.  For two of these States the 
interview for Title XIX and Title XXI applicants must be in person, while the third State 
allows interviews to take place by telephone as well.  Administrators at these States 
indicated that their programs, including the application interviews, were shaped by their 
State legislators desire to ensure program integrity. 
Presumptive eligibility 
Four of the 19 States interviewed for this study have presumptive eligibility policies for 
CHIP applicants.  These States will pay for medical services provided to children while the 
State determines whether or not the child is eligible for CHIP or Medicaid.  In two of the 
States, this initial or temporary eligibility is determined by insurers seeking to enroll 
States Application and Enrollment Processes  16  OEI-05-98-00310  children in their managed care product.  To avoid over-optimistic determinations, one State 
has imposed a 3 percent limit on errors.  In the other two States, all children without 
insurance are granted presumptive eligibility while their applications are processed. 
There are no requirements governing presumptive eligibility in the CHIP legislation. 
Each State must determine how to handle presumptive eligibility if it chooses to use it. 
According to HCFA, many States have linked the eligibility effective date to the date of 
enrollment in a health plan.  States that have elected to expand their Medicaid programs 
under CHIP must comply with specific requirements set forth in Medicaid statute (Title 
XIX).  Under Title XIX eligibility is effective with the date of application, or at State 
option, the first day of the month of application. 
Some State application policies may adversely affect when a childs coverage begins under 
CHIP or Medicaid.  Some States return incomplete applications without establishing a 
protective filing date that would ensure coverage effective the date of application, or the 
first day of the month of application.  In some States, CHIP eligibility may not become 
effective until 45 days after an application is approved.  These practices may mean that 
eligible children are uninsured when they need medical care.  A few States have addressed 
this problem by assuring payment to providers who care for children during the CHIP 
application and eligibility determination process. 
There are myriad reasons why States have elected not to use presumptive eligibility in their 
CHIP program.  Several States indicate that they want children to have access to a 
consistent source of care.  They worry that parents of children determined presumptively 
eligibility will not follow through with a full Medicaid/CHIP determination.  One State 
noted that when its Medicaid program used presumptive eligibility for pregnant women, the 
number of presumptively eligible women who followed through to enroll in Medicaid was 
very low. 
Several States indicated that they currently back-date program eligibility to the date of 
application.  If a CHIP application is approved, these States will cover medical expenses 
incurred by applicants during the enrollment process.  States that back-date coverage prefer 
this process to presumptive eligibility.  They contend that use of the application date as the 
first day of CHIP coverage helps ensure that children can get immediate medical care while 
an application is processed.  The State promises providers that they will be paid for 
services provided to an applicant child before eligibility is officially determined. 
Several States felt that presumptive eligibility was difficult and expensive to administer, 
and was not a very high priority.  Several States said that they decided to streamline the 
regular application process in order to get children covered as quickly as possible.  One 
other concern is that a number of States have shaped their CHIP programs to look like 
private insurance coverage, and presumptive eligibility may not fit within this model.  One 
such State indicated that they want their program to look like a regular health plan, and do 
States Application and Enrollment Processes  17  OEI-05-98-00310  not want to use presumptive eligibility, which looks like welfare. 
Use of enrollment contractors 
While six States do not use enrollment brokers or other contractors for any part of their 
CHIP enrollment, the other 13 contract for large and small parts of their enrollment 
process.  As managed care is becoming the common mode of service delivery, many 
separate CHIP and Medicaid outreach programs use contractors to provide information to 
families choosing a health care plan or medical provider. 
Several States contract with health plans to run the program in various areas of the State. 
Two such States make the health plans responsible for outreach, enrollment and customer 
contact.  The health plans must work within the rules outlined by the State plan, but have 
some flexibility to design their own enrollment forms and procedures within those 
boundaries. 
Five States have contracts with enrollment brokers to process CHIP applications and 
determine eligibility for the States separate Title XXI programs and the CHIP portion of 
combination plans.  In some States, contractors screen children for Medicaid, forward 
potential Medicaid eligible to the State and determine Title XXI eligibility for non-
Medicaid eligible children.  In at least one State, the nonprofit entity running the health 
program screens all applications for Medicaid eligibility.  This organization forwards the 
applications to State Medicaid workers or the private contractor for a final determination 
of eligibility. 
Several States use contractors for parts of the enrollment process.  Four States contract out 
their customer service lines, using private groups to answer applicant questions, send out 
applications and in some cases help families fill out applications.  Some States use their 
own staff to determine program eligibility but contract for data processing tasks, 
documentation verification, application pre-screening and database maintenance. 
Contractors may also send out insurance cards and information to families and collect 
premiums from them. 
Elimination of some verification requirements 
Title XXI programs are not required to use asset tests in their applications, and most States 
do not.  Two States that have separate CHIP programs ask for asset information.  Two 
other States, both using Title XXI funds for Medicaid expansions, also have asset tests. 
To limit the amount of documentation families are required to provide, many States use 
electronic or other databases to verify applicants responses.  Many States indicated that 
they do not want to force families to provide information the State can obtain from third 
party sources.  Several States electronically access information on unemployment and 
States Application and Enrollment Processes  18  OEI-05-98-00310  earned income, as well as on social security numbers and immigration status.  One State 
routinely contacts the health department for pregnancy verification.  Workers in this State 
also contact the local human services department for documentation of welfare income and 
childrens ages. 
Many States allow families to self-certify application information.  One State accepts all 
application statements and does not require any documentation other than on alien status. 
This States eligibility process includes a check of the Social Security database, State 
unemployment wage files, and unemployment compensation database.  The family is only 
contacted if third party information is inconsistent with the application responses.  Other 
States are reluctant to accept self-certification because they fear their error rate may 
increase and affect their Federal funding.  They also worry about ensuring program 
integrity if they do not verify information. 
Denial rates 
Collecting comparable data on the precise number of CHIP denials is difficult.  It is difficult 
to determine the number of applicants who apply and are subsequently denied CHIP 
eligibility.  Some States have no information about the number and identity of children 
whose CHIP application was returned because it was incomplete or lacked documentation. 
Several CHIP programs consider the application date to be the date the State receives a 
completed application along with all documentation. 
In several States, technical denials occur at CHIP intake sites.  Workers at these intake 
sites only forward completed applications for potentially eligible applicants to the State. 
One CHIP intake site reports an application denial rate in excess of 30 percent, while the 
State reports a CHIP denial rate of less than 5 percent.  States with low, or no, CHIP 
application denials may not be the most effective at enrolling children in CHIP.  Their 
processes may obscure the true nature of denials. 
Intake sites that collect and process joint CHIP/Medicaid applications may fail to protect an 
applicants filing date by returning an incomplete application without establishing a record 
to protect the date of CHIP/Medicaid eligibility.  Several States that return incomplete 
applications did not record information about applicants or the date they applied .  This 
missing information could adversely affect the date a child becomes eligible for CHIP or 
Medicaid.  It also distorts data on the number of CHIP applicants and the data on the 
disposition of each childs application.  Without better controls over applications, 
information about the number of children seeking CHIP coverage is unreliable.  Refusing to 
accept applications that are incomplete distorts information on the number and reasons for 
denials. 
A few States do not deny applications with missing information.  One State deactivates 
cases with missing information after 60 days.  Another dismisses, rather than denies, 
States Application and Enrollment Processes  19  OEI-05-98-00310  applications with insufficient information or ineligible applicants.  These practices may 
distort information about denials.  More importantly they may obscure information as to 
the precise reason for denial that might be useful in improving the CHIP program. 
Several States engage in aggressive follow-up with families to get information missing from 
applications.  In several States, State employees or contractors help families fill out 
applications.  They also help families secure needed documents to establish eligibility. 
Several States accept applications that are not complete and then re-contact families to 
collect needed information or obtain the information through a third party.  One State 
indicated that its low denial rate of 3.6 percent was due to active follow-up done while 
incomplete applications are pending.  Several States do not require extensive 
documentation. 
Citizenship Dilemmas: Barriers To Enrollment 
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 
(PRWORA) requires that all agencies administering Federal public benefits ensure that 
benefits are provided only to citizens and qualified aliens.  In addition to providing benefits 
to citizens and qualified aliens, the law also provides for the emergency treatment of non-
qualified aliens who otherwise meet Medicaid eligibility criteria.  The Immigration and 
Naturalization Service (INS) has developed guidelines to assist State and local 
governments and their contractors in determining whether an alien qualifies for public 
benefits. 
When applying for Federal public benefits, applicants must declare whether they are 
citizens of the United States2.  Any person who is not a citizen is considered to be an alien 
and his or her eligibility for public benefits as a qualified alien must be verified.  The 
exception to this rule involves non-qualified aliens seeking emergency medical care.  Non-
qualified aliens are not required to make a such a declaration in order to get emergency 
medical care coverage. 
States verify citizenship and alien status using a variety of documents and systems.  States 
can accept an applicants certification that they are a national (citizen) of the United States 
if no information to dispute that claim exists.  When a question of citizenship or qualified 
alien status arises, the States must verify that the applicant is a qualified alien.  An extensive 
list of primary and secondary evidence to establish citizenship and alien status is prescribed 
2  We have elected to use the term citizen throughout this report. The law requires that an applicant for 
public benefits declare whether he or she is a national of the United States rather than U.S. citizen because national 
of the United States is a term specifically defined as a citizen of the United States, or a noncitizen owing 
permanent allegiance to the United States. Non-qualified (illegal) aliens are not required to make a declaration 
whether they are national of the United States to obtain emergency medical care. 
States Application and Enrollment Processes  20  OEI-05-98-00310  by INS in law.  In addition to documents provided by applicants, agencies administering 
public benefits must verify alien status using INSs Systematic Alien Verification for 
Entitlements (SAVE) system.  Currently, no system exists for verifying citizenship. 
The Illegal alien dilemma 
Illegal aliens have concerns about revealing information that might affect their applications 
for citizenship or result in their deportation.  State employees and individuals helping 
families fill out applications told us that parents residing in the United States illegally were 
reluctant to complete a CHIP application for their children born in the United States. 
Children of illegal aliens born in the United States are citizens and eligible for CHIP and 
other public benefits.  The siblings of these eligible children may be illegal aliens and 
ineligible for CHIP, Medicaid and other public benefit programs. 
Illegal aliens fear that the information they provide on CHIP applications about themselves 
and their children will be shared with INS.  They fear that INS will use the information to 
locate and deport them.  Title XXI requires that the age, social security number and 
citizenship of children seeking enrollment in the CHIP program be determined. 
In a September 10, 1998 letter to State Health Officials, HCFA clarified that title XXI does 
not, and cannot require applicants (parents, guardians and others) to disclose their social 
security number or citizen status when completing a CHIP application.  States that have 
elected to expand their Medicaid program under CHIP can only require the SSN of the 
children applying for CHIP enrollment.  Information about the citizenship and SSN of the 
person applying for CHIP benefits on behalf of a child is not required by Federal law. 
Moreover, HCFA policy prohibits States from taking into account the parents citizenship 
when determining a childs CHIP eligibility. 
To determine Medicaid eligibility, all States solicit some information about a childs parents 
on their application for benefits.  States that have elected to use Title XXI (CHIP) funds to 
expand their Title XIX (Medicaid) programs also solicit information about parents.  The 
CHIP legislation requires States to screen for Medicaid eligibility every child applying for 
CHIP benefits.  Some States routinely screen all household/family members (parents and 
children) for Medicaid eligibility.  According to outstation workers, aliens fear that States 
will share CHIP application information with INS during the screening and verification 
processes many States conduct to determine eligibility for other public benefit programs. 
The process for verifying the qualified alien status of applicants for Medicaid requires that 
States input certain information about alien applicants into SAVE or some approved 
alternative system.3  States that operate CHIP programs independent of their Medicaid 
3  Most States use SAVE for their Medicaid program. The current law does not require States to use the 
system. A proposed rule, if enacted, would make use of the SAVE system mandatory for all agencies providing 
States Application and Enrollment Processes  21  OEI-05-98-00310  program are required to use interim guidelines provided by the INS.  These guidelines do 
not require the use of the SAVE system.  The SAVE response provides information 
relevant to benefit eligibility.  It is INSs position that the actual determination as to 
whether an applicant meets a programs eligibility requirements is left to the State benefit 
granting agency. 
Some States have adopted policies and practices designed to protect disclosure of 
information concerning illegal aliens.  One State informs applicants that they do not need to 
disclose their social security number (SSN).  This State assigns a fictitious SSN to 
applicants who do not have or refuse to provide an SSN.  Other States would like to use 
private, not-for-profit agencies to execute CHIP applications on behalf of children whose 
parents are reluctant to apply because they fear immigration repercussions.  Several States 
report that despite changes in the law, new application and verification requirements and 
elimination of the face-to-face interview, the number of CHIP applications from eligible 
immigrants is lower than expected especially among Spanish-speaking individuals. 
Illegal aliens fear personal information on CHIP applications will be entered into the SAVE 
system and used by INS to enforce immigration laws including removal from the United 
States.  This fear is not unfounded.  The INS may use SAVE information for the purpose 
of enforcing any civil and criminal violations of immigration law.  By statute the INS is 
prohibited from using SAVE for administrative (non-criminal) enforcement.  In December 
1997, HCFA notified the States that benefit information should not be shared with INS or 
the State Department, except in cases involving fraud and abuse. 
Conflicting HCFA and INS positions leave States, intake workers and applicants uncertain 
as to whether information on CHIP applications will or will not be used to enforce 
immigration laws. Despite HCFAs assurances to the contrary, States and intake workers 
report that noncitizens believe information collected on CHIP and Medicaid applications 
might be used to enforce immigration laws at some time in the future.  The HCFAs 
position is that Medicaid agencies are not required to report illegal aliens to the INS. 
However, a State Medicaid or CHIP agency may, if it chooses, report illegal aliens to INS. 
Statutes acknowledge that no law can prohibit a State (including Medicaid State Agencies) 
or locality from reporting Illegal aliens to INS. 
Illegal aliens are reluctant to apply for CHIP for their eligible children.  They fear that INS 
may use the information to locate and possibly deport them.  Though statutes appear to 
limit INS's use of SAVE information, our respondents indicate that illegal aliens fear the 
information will find its way to the INS either through the SAVE system or through direct 
referral to INS by a State agency. 
Respondents told us that until INS and HCFA issue a joint statement that CHIP and 
Federal public benefits within 2 years of the rules final enactment. 
States Application and Enrollment Processes  22  OEI-05-98-00310 Medicaid applications will not be used to enforce immigration laws, parents and guardians 
in the United States illegally will be reluctant to enroll their eligible children in CHIP.  The 
absence of  a clear and uniform policy statement from HCFA, the States and INS as to their 
use of application information deters people from enrolling in the CHIP program. 
Immigrant parents fear that the information they provide will help the INS identify them or 
one of their children or other family member as an illegal alien. 
The public charge dilemma 
Eligible aliens are reluctant to complete a CHIP application because they fear, or have 
misunderstandings related to, public charge requirements under immigration laws.  Many 
aliens fear that the use of any government services (including Medicaid and CHIP) would 
threaten their request for permanent residence status.  State CHIP program administrators 
and individuals working with families of CHIP eligible children told us that qualified aliens 
fear that their childrens receipt of CHIP or Medicaid will adversely affect application for 
citizenship. 
Qualified aliens fear that they will be denied citizenship if INS determines that the public 
charge provision of the Title V, Illegal Immigration Reform and Immigrant Responsibility 
Act of 1996 (Public Law 104-208) has been violated.  They also fear that they will have to 
pay back the entire cost of their childrens health insurance if they ever apply for 
citizenship. 
States and intake workers reported that noncitizen parents felt the law and regulations did 
not explicitly state that the CHIP application they executed on behalf of their children did 
not fall under public charge provisions of the Immigration Act.  The INS, which has 
jurisdiction over these matters, has not issued an official statement or policy guidance on 
public charge determinations.  When INS does issue policy guidance on public charge 
determinations, HCFA plans to notify the States as to how the INS policy affects CHIP or 
Medicaid recipients. 
Multiple Program Rules 
States expressed concern about the Federal push for States to develop a single application 
for Medicaid, CHIP and other public benefit programs such as food stamps and the WIC 
program.  States find that creation of a single application for multiple public benefit 
programs is impeded by the different requirements each program has in place. 
Conflicting application and verification requirements pose a processing problem for States. 
Federal Medicaid and CHIP statutes allow States considerable latitude in how they 
implement these programs.  The HCFAs August 10, 1998 letter to State health officials, 
advises States that they must verify the alien status for Medicaid and CHIP applicants. 
States Application and Enrollment Processes  23  OEI-05-98-00310  Beyond that requirement, States can decide what information to collect and can choose 
what and how they will verify information. 
Some States allow families to apply for CHIP at local Medicaid and social services offices. 
Intake workers, familiar with Medicaid and other public benefit programs, may be resistant 
to changes in application processes.  Some States expressed concern that front-line 
workers continue to require CHIP applicants to use the old, more burdensome application 
processes. 
State efforts to streamline the application and enrollment processes for public benefit 
programs, including Medicaid and CHIP, are hindered by different Federal program 
requirements.  While States have considerable latitude to decide what information will be 
collected and what information on applications will be verified, they are concerned that 
different definitions and standards for verification used by different Federal public benefit 
programs will affect their error rate. 
States mentioned the following Federal requirements as causing problems: 
<	 Income verification.  The HCFA told the States that they have considerable 
latitude to decide if they will verify income of applicants for CHIP and Medicaid. 
Section 1320b-7 of 42 U.S.C. appears to require all States to have in effect and 
use an income and eligibility verification system for Medicaid, food stamps and 
other public benefits.  To use IEVS, States must obtain the social security numbers 
of the childrens parents and other adult members whose income will be considered 
in determining eligibility.  It is HCFAs position that the SSN of parents and other 
adult household/family members is not required for CHIP. 
<	 Household/family composition.  States told us that conflicting rules for 
determining household/family composition impede the development of a single 
application for CHIP, Medicaid and other public benefit programs.  In one State, 
the family unit for CHIP includes every person living in the household/family. 
Medicaid only counts persons living in the household/family that have a legal 
relationship. 
<	 Household/family income.  Some State CHIP programs count the incomes of 
all persons living in the household/family.  Under Medicaid rules, States may only 
consider the income of a parent or a spouse living in the household/family. 
<	 Child support.  States that have elected to establish a separate CHIP program 
are unsure as to circumstances, if any, that would require them to make a referral 
to Child Support Enforcement.  Some public benefit programs including Medicaid 
require States to pursue the establishment of paternity and child support.  Failure 
to pursue child support can result in a denial of benefits. 
States Application and Enrollment Processes  24  OEI-05-98-00310  <	 Disclosure of Information.  Each Federal public benefit program has its own 
rules concerning disclosure of information.  Title XIX permits disclosure only for 
Title XIX purposes.  The Food Stamp program requires that the applicant know to 
whom information is disclosed and for what purpose. 
States expressed interest in establishing an interagency workgroup to address these 
conflicting Federal policies.  The purpose of the workgroup would be to examine the 
different program requirements of Federal public benefit programs.  The workgroup would, 
to the extent possible,  recommend changes in agency policies that would reduce or 
eliminate the variations cited above and other conflicting requirements. 
States are apprehensive about developing joint applications and uniform verification 
procedures when Federal laws governing the public benefit programs they administer 
appear to conflict. 
States Application and Enrollment Processes  25  OEI-05-98-00310  R E C O M M E N D A T I O N S  
Readability Of Application Forms 
We recommend that HCFA work with States to improve the readability of CHIP 
applications.  The high reading level of some CHIP applications can dissuade prospective 
applicants from applying. Language complexity may lead other applicants to incorrectly fill 
out forms, which may have an impact on whether applications for health care coverage are 
accepted or denied.  Reducing language complexity and reading level on CHIP applications 
can improve access to available services. 
Simplification Efforts 
We recommend that HCFA continue to encourage States to simplify their application and

enrollment processes for CHIP and Medicaid.  State efforts to simplify application and

enrollment processes are showing encouraging results in several States, however, a

successful practice in one State may have different results in another.  It is too early in the

CHIP program to determine the effectiveness of State changes to application and

enrollment processes.

We encourage HCFA to continue to support State efforts to:

<  Reduce application length;

<  Use joint Medicaid/CHIP applications;

<  Use multi-program applications;

<  Print applications in Spanish or other languages;

<  Distribute applications at multiple sites;

<  Utilize toll-free telephone lines to provide information;

<  Provide assistance with the application process;

<  Increase the use of outstation and application collection sites;

<  Utilize mail-in applications and post-paid envelopes;

<  Eliminate face-to-face interviews.

We also encourage HCFA to continue helping States investigate the following practices:

<  Contracting with enrollment brokers;

<  Eliminating some verification requirements.

Under Medicaid, eligibility is effective with the date of application or, at State option, the

States Application and Enrollment Processes  26  OEI-05-98-00310  first day of the month of application.  There is no requirement in the CHIP legislation that 
governs the effective date of CHIP eligibility.  States can decide what the effective date of 
coverage will be under CHIP.  We recommend that HCFA encourage States with separate 
CHIP programs to adopt CHIP eligibility policies that parallel their Medicaid policies.  We 
also recommend that HCFA encourage States to either utilize presumptive eligibility or 
back-date coverage for eligible children from the date of application. 
Citizenship Issues 
We recommend that HCFA work with INS to encourage INSs development of clear 
guidance and policy statements on how applications for CHIP and Medicaid will impact 
noncitizens.  Qualified aliens, concerned about public charge issues, should know 
whether using the CHIP benefit will affect their citizenship.  Illegal aliens should know if 
the information they provide on CHIP applications for their citizen children will be used to 
enforce immigration laws. 
We recommend that HCFA work with the INS to develop a joint policy as to whether INS 
will use SAVE system information about CHIP applicant children to find and prosecute 
parents and siblings residing illegally in the United States.  Illegal aliens should know if the 
information they provide on CHIP applications for their citizen children will be used to 
enforce immigration laws.  While HCFA and INS have indicated that information from the 
SAVE system will not be used to find and prosecute illegal residents, the American public 
needs a clear and public joint, written statement on this issue. 
Uniformity Of Program Requirements 
We recognize that program rules often differ due the exigencies of running each program. 
We realize that amending program rules can be a difficult process.  Several groups have 
been formed to look into the problem of conflicting program rules, not all of which have 
been successful.  Despite this, there may be places of agreement between programs which 
can allow rule changes to bring programs into closer alignment. 
We recommend that an interagency task force be formed to address conflicting public 
benefit application requirements.  We recommend that this interagency workgroup develop 
uniform policies for verifying income, using the Income Eligibility Verification System, 
determining household/family composition, defining countable income, counting child 
support and disclosing information.  Where necessary, agencies should seek statutory 
change to permit uniformity across programs.  Taking first steps on this project will be a 
useful endeavor and may particularly benefit States wishing to use multi-program 
applications for their child health insurance and other benefit programs. 
States Application and Enrollment Processes  27  OEI-05-98-00310  A G E N C Y   C O M M E N T S  
We would like to thank HCFA, the Health Resources and Services Administration (HRSA) and 
the Assistant Secretary for Management and Budget (ASMB) for commenting on the draft of this 
report.  Based on comments we received from HCFA and ASMB some wording changes and 
clarifications were made to the report. 
The HCFA concurred with our findings and recommendations.  They highlighted their ongoing 
efforts in the areas we discussed in the report.  The HRSA found the draft report to be acceptable 
and had no comments.  The full text of HCFAs and ASMBs comments on the draft report, along 
with HRSAs response, can be found in Appendices A, B and C. 
States Application and Enrollment Processes  28  OEI-05-98-00310  APPENDIX A 
Health Care Financing Administration 

Comments on the Draft Report

DATE:  APR 2 7 1999 
TO:	 June Gibbs Brown 
Inspector General 
FROM:	 Nancy-Ann Min DeParle 
Administrator 
SUBJECT:	 Office of Inspector General (OIG) Draft Report: The Children's Health Insurance 
Program: State Application and Enrollment Process: An Early Report from the 
Front Lines, (OEI-05-98-003 10) 
We appreciate OIG's efforts to help the Health Care Financing Administration (HCFA) identify 
promising practices, barriers, and issues related to the application and enrollment procedures of 
the Children's Health Insurance Program (CHIP).  We support the recommendations in this draft 
report, especially those that will make the application process easier and more user friendly for 
potential beneficiaries. 
HCFA has been providing technical assistance to states in order to simplify enrollment 
procedures.  We are encouraged to see in the findings that States are following this advice and 
simplifying their application and enrollment processes.  In a letter to State Health Officials issued 
on January 23, 1998, we described options for successful outreach and enrollment and provided 
examples of such activities, such as out-stationing sites for filing applications, use of mail-in 
applications, joint applications for both CHIP and Medicaid, and presumptive eligibility.  In a 
second letter issued on September 10, 1998, we highlighted the flexibility States have to simplify 
the application and enrollment processes.  In that same letter, we clarified two eligibility-related 
issues that were seen as barriers to enrollment.  States were advised that a child's eligibility for 
Medicaid or CHIP is not contingent on disclosure of parents' Social Security Number (or lack 
thereof) or on information about non-applicant parents' immigration status. 
Additionally, a multitude of other initiatives are underway to promote successful implementation 
of CHIP.  The following describes some examples which illustrate Federal support for State 
outreach programs. 
	 Continuing the Outreach Campaign.  The national campaign initiative between the 
National Governor's Association and the White House which includes a national toll-free 
States Application and Enrollment Processes  29  OEI-05-98-00310  APPENDIX A 
telephone number (1-877-KIDS-NOW) to provide information to potential enrollees and a 
series of radio ads in both English and Spanish. 
	 Providing Technical Assistance.  HCFA and Health Resources and Services 
Administration recently completed a series of Technical Advisory Panels (TAPs) involving 
twenty States.  The purpose of these sessions was to: (1) provide a forum for exchange of 
experiences with the development and implementation of outreach strategies, (2) establish 
partnerships for outreach between States and the Federal government and (3) develop 
strategies for involving the private and voluntary agencies in outreach programs. 
	 Publishing Useful Information.  Federal support for State outreach is the lead being taken 
by HCFA in developing a Technical Assistance Guide that describes for State Medicaid 
agencies and partners the latest information on how to provide appropriate information 
to consumers in an easy to understand format.  This guide will address issues related to 
cultural sensitivity and will include information on methods of material distribution and use 
of the media, among other topics, and will be available in the Fall of 1999. 
Our detailed comments on the report recommendations follow.

OIG Recommendation #1

HCFA should work with States to improve the readability of CHIP enrollment applications.

HCFA Response

We concur.  By reducing language complexity and reading level on CHIP applications, States can

improve access to available services.  HCFA will continue to bring this concern to the attention of

States and will offer technical assistance to States on improving the readability of application

forms.

OIG Recommendation #2

HCFA should continue to encourage States to simplify their application and enrollment processes

for CHIP and Medicaid.

HCFA Response

We concur.  We will continue to encourage States to simplify their application processes, and

promote successful examples of simplification procedures and action States have already taken. 

We have released a model application form that States can use to see how easy it is to have a

simple application.  We have also released a guide book titled, Working Families that discusses

the importance of a simple application.

States Application and Enrollment Processes  30  OEI-05-98-00310  APPENDIX A 
OIG Recommendation #3

HCFA should encourage States with separate CHIP eligibility policies that parallel their Medicaid

policies.  We also recommend that HCFA encourage States to presume eligibility of all children

effective with the date of application.

HCFA Response

We concur.  States should be encouraged to adopt CHIP eligibility policies that parallel their

Medicaid policies which make eligibility effective either with the date of application or the first

day of the month of application.  Since there is no requirement under Title XXI for retroactive

eligibility, as there is under Medicaid, States have flexibility.  It should be noted that many States

have linked the eligibility effective date to the date of enrollment in a health plan.

OIG Recommendation #4

HCFA should work with Immigration and Naturalization Service (INS) to develop clear guidance

and policy statements on how applications for CHIP and Medicaid will impact noncitizens.

HCFA Response

We concur.  We have taken the initiative to work with INS to develop and release the much

needed policy guidance regarding the public charge issue.  However, the recommendation

seems to imply that HCFA is responsible for public charge policy.  As was discussed in the body

of the report, it is the INS of the Department of Justice which has jurisdiction over public charge

determinations and policy guidance.  INS is, however, consulting with the Department of Health

and Human Services about its views on this issue.  Once such policy guidance is issued by the

INS, HCFA plans to notify the States as to how the receipt of Medicaid or CHIP benefits relates

to the determination of public charge.

OIG Recommendation #5

HCFA should work with the INS to develop a joint policy as to whether INS will use the

Systematic Alien Verification for Entitlements (SAVE) system information about CHIP applicant

children to find and prosecute parents and siblings residing illegally in the United States.

HCFA Response

We will consult with the INS on this, but it is our understanding that their policy already prohibits

the use of SAVE for administrative (non-criminal) immigration enforcement purposes, i.e., to

deport people.  The proposed INS rules pertaining to Verification of Eligibility for Public

Benefits, published on August 4, 1998, in the Federal Register, contain an entire subpart (Subpart

C) which addresses the SAVE system.  Specifically, Section 104.51 states that the INS cannot use 
the information in the SAVE system for administrative (non-criminal) immigration enforcement 
purposes.  Such information may, however, be used for the purpose of enforcing any provision of 
criminal law.  Additionally, we have clarified through a representative of the INS that receiving a 
States Application and Enrollment Processes  31  OEI-05-98-00310  APPENDIX A 
no match through the SAVE system does not necessarily imply that an alien is in an illegal

status.

OIG Recommendation #6

We recommend formation of an interagency task force to address conflicting public benefit

application requirements.  We recommend that this interagency workgroup develop uniform

policies for verifying income, using the Income Eligibility Verification System, determining

household/family composition, defining countable income, counting child support, and disclosing

information.

HCFA Response

We concur.  We support the establishment of an interagency task force to address conflicting

public benefit application requirements.  Greater uniformity in various program rules can be

beneficial to the administration of the programs as well as to beneficiaries.  Complete uniformity

across all programs, however, may not be possible due to the differences in statutory requirements

of such programs as Medicaid, Food Stamps, and SSI.

Technical Comments

Pg. 1, paragraph 4: In the last sentence add at the end and have more flexibility on the benefit

package.

Pg. 2, first line: After . . . the law prohibits States, please add from receiving enhanced match if 
they tighten . . . Delete . . . from tightening the . . . 
Pg. 6, paragraph 2: It would be better to have one paragraph devoted to the advantages and 
another to the disadvantages.  The first sentence might be stronger if it were reworded: Using a 
joint Medicaid/CHIP application can simplify the application process for families because they 
only have to complete one application and the families do not have to determine which program 
their children may be eligible for.  The second sentence of this paragraph should be rewritten as 
follows: Joint applications ensure the enrollment of CHIP applicants in Medicaid if they qualify 
for that program. 
Pg. 7, paragraph 7: Please verify that the number 71 is correct?  It seems very high. 
Pg. 12, paragraph 3: In the third sentence, substitute statute for legislation. 
Pg. 12, paragraph 5: The State reports that the number of presumptively eligible women who are 
determined eligible is very low.  This seems at odds with other reports that the vast majority of 
women are found eligible. 
States Application and Enrollment Processes  32  OEI-05-98-00310  APPENDIX A 
Pg. 12, last paragraph: The last sentence does not appear to be correct.  It says that States prefer 
backdating the program eligibility to the date of application because it ensures that eligible 
children get immediate medical care.  If the children are not eligible until determination, this 
would not help them get care in the short run.  They would still have to pay out of pocket for any 
services initially received. 
Pg. 16, second paragraph: Please add at the beginning of the 4th sentence: In a letter to State 
Health Officials on September 10, 1998, HCFA clarified that ... 
Pg. 17, third paragraph: The conflicting positions of HCFA and INS are never specified.  It only 
mentions HCFA policies. 
Pg. 19, first full paragraph: It would make sense if the work group were interagency. 
Simplification Efforts, as continued at top of page 21: The last sentence should be clarified.  Does 
the report mean that HCFA should encourage States to adopt presumptive eligibility in separate 
State CHIP programs?  Does the report mean that States should presume all children who apply 
are eligible until a final CHIP determination?  Does the report mean that anyone taking the CHIP 
applications should determine children presumptively eligible? 
States Application and Enrollment Processes  33  OEI-05-98-00310  APPENDIX B 
Health Resources and Services Administration 

Comments on the Draft Report

TO:  Inspector General 
FROM:  Deputy Administrator 
SUBJECT:	 OIG Draft Report, "THE CHILDREN'S HEATH INSURANCE PROGRAM -
State Application and Enrollment Processes: An Early Report from the Front 
Lines," Issued February 2, 1999 
We have reviewed the subject report and find it to be acceptable.  HRSA has no comments on this 
report. 
States Application and Enrollment Processes  34  OEI-05-98-00310  APPENDIX C 
Assistant Secretary for Management and Budget

Comments on the Draft Report

MEMORANDUM TO:  June Gibbs Brown 
Inspector General 
FROM:	 John J. Callahan 
Assistant Secretary for Management and Budget 
SUBJECT: 	 Comments on OIG Draft Report: The Children's Health 
Insurance Program - State Application and Enrollment 
Processes: An Early Report from the Front Lines 
Thank you for the opportunity to review the draft report entitled The Children's Health Insurance 
Program (CHIP) - State Application and Enrollment Processes: An Early Report from the Front 
Lines (OEI-05-98-00310).  We would like to offer the following comments: 
C	 The use of simplified application forms has been cited by the Department as a form of 
outreach.  Since the Department has no authority to require the states to undertake any of 
the activities described in the report, it should be clearly stated that any state activity 
related to outreach is done at state option. 
C	 On page 1, Background section -The report cites the number of uninsured children, but 
does not cite a source.  Given that there is more than one way to count numbers of 
uninsured children and given that there is more than one set of published numbers, it may 
be useful to cite a source or use a range of numbers rather than a discrete number. 
C	 On page 13, Use of enrollment contractors - The language in the first paragraph which 
describes the use of enrollment contractors in assisting eligible families in choosing a 
health care plan, may not be consistent with department policy.  Policies differ depending 
on if the state is implementing a CHIP Medicaid expansion or if the state is developing a 
separate state plan.  In Medicaid, while enrollment contractors may assist in application 
completion, I understand that they are prohibited from determining eligibility or directing 
beneficiaries to enroll in health plans. 
In separate CHIP plans, assisting enrollment in health plans may be acceptable if these 
contractors are truly independent from the health plans and if there is no financial 
incentive.  While this is implicitly discussed, we believe a more explicit explanation would 
be useful. 
States Application and Enrollment Processes  35  OEI-05-98-00310