Department of Health and Human Services 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
 
S U E L
TATE  SE OF  XPRESS  ANE 
 
 
E M
LIGIBILITY FOR  EDICAID 
 
 
CHIP E  
AND    NROLLMENT
 
 
Suzanne Murrin 
Deputy Inspector General 
 
October 2016 
OEI-06-15-00410   
   
EXECUTIVE SUMMARY:  STATE USE OF EXPRESS LANE ELIGIBILITY FOR 
MEDICAID AND CHIP ENROLLMENT 
OEI-06-15-00410 
 
WHY WE DID THIS STUDY 
Medicaid and the Childrens Health Insurance Program (CHIP) provide health insurance 
coverage for certain low-income children, yet millions of eligible children are still 
uninsured.  To increase enrollment of eligible children, Congress authorized States to 
adopt the Express Lane Eligibility (ELE) option, which allows States to expedite and 
simplify enrollment in Medicaid and CHIP by relying on findings from other agencies 
eligibility determinations.  Congress will determine whether to reauthorize the ELE 
option in 2017.  We conducted this study in response to a Congressional request that the 
U.S. Department of Health and Human Services, Office of Inspector General (OIG) 
examine the benefits and barriers to State use and expansion of ELE.  This report is being 
issued concurrently with two OIG audits that fulfill a Congressional mandate to assess 
whether State agencies met Federal requirements in making eligibility determinations 
using ELE and developing eligibility error rates.   
HOW WE DID THIS STUDY 
We administered questionnaires and conducted telephone interviews with Medicaid and 
CHIP officials from the 14 States that adopted ELE.  Where available, we supplemented 
this information with enrollment and cost savings data collected from the States.   
WHAT WE FOUND 
States that used ELE adopted variations of three models, with more than half adopting an 
automated model that requires minimal action from staff and beneficiaries.  All 14 States 
that used ELE reported benefits, including reduced administrative burden and cost 
savings, and some States reported that they rely heavily on ELE.  Eleven States reported 
that they encountered barriers when they implemented ELE, such as problems sharing 
information across agencies, but reported that they overcame these barriers through 
strong partnerships and integrated eligibility systems.  Despite largely positive 
experiences using ELE, 5 of the 14 States that adopted ELE discontinued its use, mainly 
because of competing priorities, system changes, and short-term agreements with partner 
agencies.  None of the 9 States still using ELE plan to expand its use.   
WHAT WE CONCLUDE 
Although State use of ELE is not widespread, ELE appears to meet the intended objective 
of easing the eligibility and enrollment process.  Implementation of ELE is consistent 
with the goals of the Patient Protection and Affordable Care Act provisions to streamline 
enrollment processes for Medicaid and CHIP.  Based on this review of State experiences 
with ELE, OIG did not identify any significant impediments to continuing to allow 
voluntary use of ELE, once States and CMS have corrected process problems and gaps in 
oversight identified by OIG audits of ELE enrollments.  Reauthorization of the ELE 
option would allow States that rely on ELE to continue its use and give other States the 
opportunity to adopt ELE and likely experience similar benefits.   
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................5 
Findings........................................................................................................7 
States that used ELE adopted variations of three models, with  
more than half adopting an automated model that requires   
minimal action from staff and beneficiaries ....................................7 
All 14 States that used ELE reported benefits, including reduced 
administrative burden and cost savings, and some States rely 
heavily on ELE  ...............................................................................8 
Most States that used ELE encountered barriers but reported that 
they overcame these barriers through strong partnerships and 
integrated eligibility systems ...........................................................9 
Despite largely positive experiences using ELE, 5 of the 14    
States discontinued use, and none of the 9 States still using ELE 
plan to expand its use ..................................................................... 11 
Conclusion .................................................................................................13 
Appendix ....................................................................................................14 
Express Lane Eligibility Models by State ......................................14 
Acknowledgments......................................................................................15 
 
 
 
 
 
 
 
 
 
   
   
OBJECTIVES 
1.  To describe State use of Express Lane Eligibility (ELE) models to 
enroll beneficiaries in Medicaid and Childrens Health Insurance 
Program (CHIP);  
2.  To identify benefits experienced by States and low-income families 
when using ELE for enrollment; and 
3.  To identify barriers to using ELE and lessons learned by States in 
overcoming those barriers.  
BACKGROUND  
The Medicaid and CHIP programs provide health insurance coverage for 
certain low-income children, yet millions of eligible children are still 
uninsured.1  The ELE option allows States to expedite and simplify 
enrollment in these programs by using eligibility findings of another 
agency or program, such as the Supplemental Nutrition Assistance 
Program (SNAP, formerly food stamps), to qualify children for health 
coverage.  ELE was designed to ease the administrative burden on States 
and beneficiaries, thereby increasing child enrollment and retention in 
Medicaid and CHIP, and reduce State costs.   
With the passage of the Medicare Access and CHIP Reauthorization Act 
of 2015 (MACRA), Congress extended the ELE option for States through 
September 30, 2017. 2  Congress must determine whether to reauthorize 
ELE when this extension expires.  MACRA also mandated that the U.S. 
Department of Health and Human Services (HHS), Office of Inspector 
General (OIG) report on the number of beneficiaries enrolled through 
ELE, the extent to which enrollees met eligibility requirements, and the 
Federal and State expenditures associated with the enrollments, including 
expenditures for those who did not meet eligibility criteria.  Two OIG 
audits conducted concurrently with this study address the MACRA 
requirements, using Medicaid and CHIP case reviews to assess whether 
State agencies met Federal requirements in making eligibility 
                        ____________________________________________________________ 
1 The Henry J Kaiser Family Foundation, Childrens Health Coverage: Medicaid, CHIP 
and the ACA, March 26, 2014.  Access at http://kff.org/health-reform/issue-
brief/childrens-health-coverage-medicaid-chip-and-the-aca/ on July 13, 2016. 
2 MACRA, P.L. 114-10,  302 and 305 (Apr. 16, 2015).  The MACRA requires the 
Inspector General of HHS to submit a report to Congress not later than 18 months after 
its enactment. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  1   
   
determinations using ELE and developing eligibility error rates.3  This 
study responds to a Congressional request that OIG concurrently examine 
the benefits and barriers to State use and expansion of ELE.   
Medicaid and CHIP 
Medicaid provides health care coverage to low-income and medically 
needy populations, including children up to age 21, pregnant women, 
senior citizens, and people with disabilities.  CHIP covers uninsured 
children up to age 19 with household incomes above the Medicaid income 
eligibility threshold but whose families cannot afford private coverage.4  
States operate and jointly fund Medicaid and CHIP in partnership with the 
HHS Centers for Medicare & Medicaid Services (CMS).5
 
In 2015, children accounted for almost half of the average monthly 
Medicaid enrollments (29.6 million of 68.9 million enrollees).6  An 
additional monthly average of 5.8 million children were enrolled in CHIP.7  
Although enrollments have increased in recent years, in 2015 an estimated 
2.8 million children were eligible for Medicaid or CHIP coverage but not 
enrolled.8   
Many children enrolled in these programs drop from the rolls and later re-
apply and re-enroll, which can be costly for States and may prevent 
children from receiving appropriate care.  According to CMS, 
administrative barriers, such as complicated renewal requirements, and 
beneficiaries and their families lack of familiarity with the qualifying 
                        ____________________________________________________________ 
3 HHS OIG, Medicaid Enrollment Using the Express Lane Eligibility Option                
(A-04-15-08043) and CHIP Enrollment Using the Express Lane Eligibility Option       
(A-04-15-08045), projected September 2016.   
4 Titles XIX and XXI of the Social Security Act (SSA). 
5 CMS, Brief Summaries of Medicare and Medicaid, November 1, 2014. Accessed at  
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/MedicareProgramRatesStats/SummaryMedicareMedicaid.html on July 13, 2016.   
6 CMS, 2014 Actuarial Report on the Financial Outlook for Medicaid, p. 17.  Accessed at 
https://www.cms.gov/Research-Statistics-Data-and-
Systems/Research/ActuarialStudies/Downloads/MedicaidReport2014.pdf on               
July 13, 2016.    
7 CMS, 2015 CMS Statistics, p. 15.  Accessed at https://www.cms.gov/Research-
Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Statistics-Reference-
Booklet/Downloads/2015CMSStatistics.pdf on September 13, 2016. 
8 Kenney, Genevieve M., Jennifer Haley, Clare Pan, Victoria Lynch, and Matthew 
Buettgens, Childrens Coverage Climb Continues:  Uninsurance and Medicaid/CHIP 
Eligibility and Participation Under the ACA, May 2016, p. 3.  Accessed at 
http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000787-Childrens-
Coverage-Climb-Continues-Uninsurance-and-Medicaid-CHIP-Eligibility-and-
Participation-Under-the-ACA.pdf on September 12, 2016. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  2   
   
criteria and application process contribute to children not being enrolled or 
re-enrolled in the programs.9 
Efforts to Increase Child Retention and Enrollment in Medicaid 
and CHIP  
To increase the number of eligible children who are enrolled in Medicaid 
and CHIP, the Childrens Health Insurance Program Reauthorization Act 
of 2009 (CHIPRA) provided States with effective new tools and 
incentives.10  One of the key tools available to States is ELE, which allows 
States to use eligibility findings from other agencies for purposes of 
determining an individuals eligibility for Medicaid and CHIP.11  CHIPRA 
also provided incentives for States to implement ELE by making it one of 
the policies that States could adopt to qualify for performance bonus 
payments.12   
The Patient Protection and Affordable Care Act (ACA) and implementing 
regulations reinforced the ELE principles by requiring States to employ 
data-driven systems that determine eligibility across State coverage 
programs, and streamlining enrollment processes for Medicaid and 
CHIP.13 
Implementation and Use of ELE 
States that wish to adopt ELE must submit and receive CMS approval on a 
State Plan Amendment to their Medicaid and CHIP programs.  States can 
choose to apply ELE to Medicaid, CHIP, or both, and to use it for 
enrollments, renewals, or both.  State Medicaid and CHIP agencies can 
use eligibility findings from partner agencies, as defined in the statute and 
as identified in the State plan.  ELE allows States to disregard technical 
and methodological differences between agencies in determining 
eligibility when using findings from another agency; however, the State 
Medicaid or CHIP agency remains responsible for making the final 
determination of Medicaid and CHIP eligibility.14  Although ELE is 
specifically targeted to children, States may request a waiver to enroll 
                        ____________________________________________________________ 
9 CMS, Medicaid, CHIPRA.  Accessed at 
https://www.medicaid.gov/chip/chipra/chipra.html on July13, 2016.  
10 CHIPRA, P.L. 111-3,  203 (Feb. 4, 2009); Social Security Act (SSA)  1902(e)(13). 
11 CMS, SHO # 10-003: Express Lane Eligibility Option, February 4, 2010.  Accessed at 
http://ccf.georgetown.edu/wp-content/uploads/2012/03/Official-Letter-February-4-2010-
2.pdf on July 13, 2016. 
12 SSA  2105(a)(4). 
13 ACA, P.L. 111-148,  1413 (Mar. 23, 2010), as amended by the Health Care 
Reconciliation Act of 2010, P.L. 111-152 (Mar. 20, 2010), collectively known as ACA.    
14 SSA  1902(e)(13); CMS, SHO#10-003, loc.cit. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  3   
   
adults (e.g., parents of eligible children, pregnant women) in Medicaid 
using streamlined eligibility and enrollment processes similar to ELE.15 
Prior Research about ELE 
Several other organizations, including the Kaiser Family Foundation, the 
Government Accountability Office (GAO), and Mathematica Policy 
Research, have examined the implementation and use of ELE, with most 
finding that ELE generally was an effective means of increasing and 
retaining child enrollment in Medicaid and CHIP.  In 2009, shortly after 
CHIPRA went into effect, the Kaiser Family Foundation outlined a 
number of possible benefits of ELE, including increased coverage rates, 
improved access to care, reduced burdens for low-income families and 
States, program savings for Medicaid and CHIP, and greater coordination 
across programs.16  In 2012, GAO identified similar benefits, but noted 
that budgetary restrictions and competing priorities may have limited the 
number of States that ultimately chose to adopt ELE.17  In 2013, 
Mathematica Policy Research, together with the Urban Institute and 
Health Management Associates, conducted a comprehensive evaluation of 
ELE.  They found that States adopted different ELE models and that the 
automatic processing model offered a promising approach for increasing 
enrollment and reducing States administrative costs.18   
OIG Audits of ELE Enrollments  
This report is being issued concurrently with two OIG audit reports on 
ELE enrollment, as MACRA requires: Medicaid Enrollment Using the 
Express Lane Eligibility Option Did Not Always Meet Federal 
Requirements (A-04-15-08043), and CHIP Enrollment Using the Express 
Lane Eligibility Option Did Not Always Meet Federal Requirements  
(A-04-15-08045).  The OIG audits found that States using ELE generally 
made eligibility determinations in accordance with Federal requirements at 
the time of enrollment and re-enrollment in Medicaid and CHIP, but that 
States did not always adhere to income and citizenship verification 
requirements or follow the approved State plan.  OIG also found that 
States did not develop statistically valid eligibility error rates specific to 
ELE enrollees in accordance with Federal requirements.  This occurred 
because CMS had not finalized the methodology for States to use in 
                        ____________________________________________________________ 
15 SSA  1115(a)(2) 
16 The Henry J Kaiser Foundation, Why Express Lane Eligibility Makes Sense For States 
and Low-Income Families, October 2, 2009.  Accessed at http://kff.org/medicaid/issue-
brief/why-express-lane-eligibility-makes-sense-for/ on July 13, 2016. 
17 GAO, Medicaid and CHIP: Considerations for Express Lane Eligibility               
(GAO-13-178R), December 5, 2012, p.1. 
18 Mathematica Policy Research, op. cit., pp. xiii, 120-121.  The evaluation was mandated 
in CHIPRA  203(b)(1).    
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  4   
   
identifying error rates, and because States had difficulty identifying the 
ELE population.  OIG recommended that CMS: 1) monitor States use of 
ELE for compliance with Federal requirements, 2) provide technical 
assistance to States to accurately identify beneficiaries enrolled through 
ELE, 3) issue guidance to States for calculating eligibility error rates for 
beneficiaries enrolled through ELE, and 4) ensure that if necessary, States 
redetermine the current eligibility status of sample applicants who were 
enrolled on the basis of eligibility determinations that were not in 
compliance with Federal requirements.  CMS concurred with all 
recommendations in both reports. 
METHODOLOGY 
Scope 
This review focused on all States that had used ELE at any time, as of the 
end of our data collection in March 2016.  The 14 States that had used 
ELE were Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, 
Massachusetts, New Jersey, New York, Oregon, Pennsylvania, South 
Carolina, South Dakota, and Utah.19  In fiscal year (FY) 2015, the latest 
year for which data is available, these States collectively covered more 
than a quarter (12.8 of the 45.2 million) of all children participating in 
Medicaid and CHIP.20   
Data Collection and Analysis 
We based our report findings on qualitative data collected through 
questionnaires and telephone interviews with Medicaid and CHIP officials 
from the 14 ELE States conducted between January and March 2016.  We 
asked about State ELE models, partner agencies, expansion plans, lessons 
learned, and time and cost savings associated with ELE enrollments and 
renewals.  We reviewed States supporting documentation, such as 
enrollment and cost savings data, where available.  We also interviewed 
staff from CMS, Mathematica Policy Research, and the National Academy 
for State Health Policy for additional insights regarding State Medicaid 
agency use of ELE. 
 
 
                        ____________________________________________________________ 
19 One U.S. territory has also adopted ELE.  CMS, Express Lane Eligibility for Medicaid 
and CHIP Coverage, July 9, 2015.  Accessed at https://www.medicaid.gov/medicaid-
chip-program-information/by-topics/outreach-and-enrollment/express-lane-
eligibility.html on July 13, 2016. 
20 CMS, FFY 2015 Number of Children Ever-Enrolled in Medicaid and CHIP.  Accessed 
at https://www.medicaid.gov/chip/downloads/fy-2015-childrens-enrollment-report.pdf on 
September 13, 2016.  
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  5   
   
Limitations 
Although we reviewed supporting documentation where available, the 
benefits and challenges described in this report are State-reported and may 
not reflect all of the benefits and challenges associated with ELE use.  
Moreover, while we collected the perspectives of officials in State 
Medicaid and CHIP agencies, we did not interview frontline staff (e.g., 
eligibility caseworkers) or beneficiaries to gain their perspectives.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  6   
   
FINDINGS 
States that used ELE adopted variations of three 
models, with more than half adopting an automated 
model that requires minimal action from staff and 
beneficiaries 
CMS gives States discretion in establishing ELE processes for Medicaid 
and CHIP, including the type of model used to implement ELE.  The 
14 States that used ELE adopted variations of three models, which the 
Mathematica Policy Research study categorized as:  automated 
processing, simplified procedure, and simplified application.  Most States 
adopted one model, and three States reported using two different ELE 
models at one time.  Of the 14 States that adopted ELE, 7 used ELE for 
initial enrollments, 2 used it for renewals, and 5 used it for both initial 
enrollments and renewals.  (See Appendix for a list of ELE models by 
State.)   
Automatic processing.  Eight States adopted an automatic processing 
model, through which States automatically enroll or renew coverage with 
the familys consent, without an application, by transferring data 
electronically from eligibility findings for children enrolled in ELE partner 
agencies programs.  Typically, when State agencies use an automatic 
processing model to enroll or renew beneficiaries, the eligibility system 
itself, rather than staff, reviews and determines eligibility.  The 
Mathematica Policy Research study of ELE identified the automatic 
processing model as the most promising for increased enrollment and 
retention and decreased administrative costs.21   
Simplified procedure.  Five States adopted a simplified procedure model, 
through which States process traditional applications using prior eligibility 
findings of ELE partner agencies to determine eligibility.  For example, 
one State employed this method of shared eligibility findings to simplify 
eligibility determinations within the Medicaid and CHIP programs.  Prior 
to ELE, applicants had to submit a separate application to CHIP if found 
ineligible for Medicaid.  With an ELE simplified procedure, CHIP staff 
use the eligibility finding already completed by Medicaid.   
Simplified application.  Four States reported adopting a simplified 
application model, through which State Medicaid agencies use eligibility 
findings of ELE partner agencies to identify children who are likely 
eligible for Medicaid or CHIP, but not enrolled.  In these States, Medicaid 
agencies send families shortened applications which are prepopulated with 
                        ____________________________________________________________ 
21 Mathematica Policy Research, loc. cit. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  7   
   
information obtained from the ELE partner agency, serving both to 
simplify the process and provide program outreach.    
All 14 States that used ELE reported benefits, 
including reduced administrative burden and cost 
savings, and some States rely heavily on ELE  
Regardless of which model States used to implement ELE, all State 
Medicaid agencies rated their experiences with ELE as positive and 
reported that ELE met its objective of easing the eligibility and enrollment 
processes.  Officials also reported that using ELE helped prepare the State 
for implementing ACA requirements to adopt data-driven eligibility 
systems and procedures across State coverage programs.  The OIG audits 
of State enrollment through ELE, released concurrent with this report, also 
found largely positive results, reporting that State ELE processes were 
generally effective in enrolling and retaining eligible beneficiaries into 
Medicaid and CHIP.   
The most commonly reported benefit from ELE was a reduced 
administrative burden for State agencies and families.  Agency officials 
from 13 of 14 the States reported, and previous research indicated, that 
ELE reduced State agency administrative tasks to determine eligibility and 
enroll beneficiaries.22  In one State, one-fifth of its one million Medicaid 
and CHIP beneficiaries automatically renew through ELE every year 
because they also receive benefits from SNAP, its ELE partner agency.  
According to State officials, this saves the State an average of 20 staff 
minutes per renewal case by reducing the need to mail renewal packets, 
collect verification information, and process case closings, reopenings, 
and appeals.  Officials in another State reported that adoption of an ELE 
automated model dropped the States Medicaid and CHIP application 
processing time from 15-20 days to 10-11 days.  Agency officials also 
reported that the reduced administrative burden assisted beneficiaries and 
their families, providing a simpler and faster application and renewal 
process.   
About half of the States reported that using ELE produced cost savings.  
Medicaid officials in 6 of the 14 States reported cost savings from using 
ELE, mostly due to reduced staff time to complete enrollments and 
renewals.  Agency officials in one State reported that using an automatic 
ELE model reduced State costs for initial enrollments and renewals by 
$7.3 million between 2011 and 2014.  In another State, agency officials 
indicated that the agency saved $25.77 per initial enrollment and $5.15 per 
                        ____________________________________________________________ 
22 Mathematica Policy Research, loc. cit.; The Henry J Kaiser Foundation, loc. cit.  
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  8   
   
renewal form, a cost savings they characterized as significant, given the 
large number of beneficiaries processed through ELE.   
For some States, ELEs simpler enrollment and renewal processes also 
increased enrollment and retention.  States reported that use of ELE 
contributed to increased enrollment (3 of 14 States) and retention  
(6 of 14 States) of beneficiaries.  These States were not able to report data 
to support this view because of difficulties associated with separating the 
effect of ELE from other enrollment and population factors.  State officials 
in several of these States also reported that ELE is useful for outreach to 
low-income families, and that the simplified application process increased 
the likelihood that families would take action to complete applications and 
renewals.   
Some State Medicaid agencies reported that they rely heavily on ELE and 
consider ELE critical to enrollment efforts.  While all States experienced 
benefits, five States reported particularly strong support for ELE and 
believed its use was important to agency operations.  Two of these States 
have expanded the ELE-like process to adult populations in addition to 
children.  One State agency official described ELE as among the most 
beneficial processes that the State had implemented, and stated that 
benefits from ELE extended beyond simplified eligibility and enrollment 
tasks.  The official explained that the State had implemented ELE during a 
recession and indicated that ELE enabled the State to offset staff cutbacks 
without disrupting services. 
Officials in seven States expressed concern about losing ELE if Congress 
does not extend the current ELE authorization by the end of  
FY 2017.  Officials reported that losing ELE would result in having 
wasted the administrative costs of implementation, and increase the cost of 
eligibility and enrollment processes going forward.  One State that was 
particularly reliant on ELE indicated that without ELE, staffing shortages 
would make it difficult to manage high beneficiary caseloads.  This State 
reported that in 2015, it automatically renewed coverage for 45 percent of 
its Medicaid beneficiaries using ELE.   
Most States that used ELE encountered barriers but 
reported that they overcame these barriers through 
strong partnerships and integrated eligibility systems 
Medicaid agency officials in 11 of the 14 States encountered barriers to 
implementing ELE, mostly related to difficulties collaborating with 
partner agencies and sharing information across systems and processes.  
The OIG audits also found that some States using ELE struggled to 
coordinate partners and systems effectively within the provisions of their 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  9   
   
CMS-approved State plans for ELE use.  Still, State officials reported that 
they largely overcame barriers in most cases, and officials identified 
factors that were important to success in implementing ELE.   
States cited the importance of strong relationships with partner agencies, 
and reported partnering most often with SNAP.  States with the most 
positive experiences using ELE emphasized that collaboration with partner 
agencies was critical to their success.  States that reported effective 
collaboration attributed the success to three factors:  (1) long-standing 
relationships with the partner agencies or programs in their States, (2) data 
systems that were either fully integrated or could easily share information, 
and (3) similar agency missions that serve the same low-income 
beneficiaries as Medicaid and CHIP.  States most frequently partnered 
with SNAP (9 of 14 States), sometimes in combination with the 
Temporary Assistance for Needy Families (TANF) program  
(3 of 14 States), to employ ELE.  Both SNAP and TANF serve the same 
or similar populations as Medicaid and CHIP, and use similar eligibility 
criteria.  Agency officials from half of the States (7 of 14) reported 
partnering with more than one agency for ELE.  In addition to SNAP and 
TANF, agencies partnered with tax agencies (3 of 14 States) and school 
lunch programs (3 of 14 States).  (See Appendix for a list of ELE partner 
agencies by State.)   
State agency officials also emphasized the benefits of using integrated 
eligibility systems.  Most States (10 of 14) encountered some barrier 
related to the lack of system integration or other data sharing issues when 
implementing ELE.  State agencies without an integrated system had to 
develop methods for sharing information across program-specific systems, 
and reported that this often caused confusion among staff.  In one State, 
agency officials described their struggle to re-format data from an ELE 
partner agency to match the eligibility system that Medicaid and CHIP 
use.   
Agency officials emphasized the importance of having eligibility systems 
that are integrated with those of ELE partner agencies.  Seven of the  
14 States reported using integrated systems, some of which the States 
developed only recently.  One State agency official noted that an 
advantage of integrating an eligibility system with that of an ELE partner 
agency (e.g., Medicaid, SNAP) is that it allows the agency to use the same 
benefits specialists to process all applications that come through the 
integrated system. 
States that had difficulty collaborating with ELE partner agencies faced 
administrative barriers to establishing processes and sharing information.  
Some State Medicaid agencies had problems collaborating with ELE 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  10   
   
partner agencies because establishing the shared enrollment processes 
required complex administrative agreements.  This was particularly 
challenging when the agreements required action by entities outside the 
agencies.  For example, some agreements required State legislative or 
process changes to allow information sharing between agencies.  For the 
three States that partnered with tax agencies, sharing tax information not 
only required the States to pass legislation, but called for substantial 
revisions of documents and forms.  States that partnered with school lunch 
programs (3 of 14 States) also faced challenges collecting and using data, 
because each school district administered the programs differently and the 
data often were not standardized.  In one State, local school districts 
resisted sharing student and family information, considering the 
information legally protected.   
To overcome barriers to collaboration, agency officials stressed the 
importance of thoroughly discussing with partners the implications of each 
step involved in operationalizing ELE.  The officials suggested that the 
agencies involved should examine each others programs; set out the 
goals, limitations, processes and systems needed to be successful; and 
request input from each other before entering into a partnership.   
Despite largely positive experiences using ELE,  
5 of the 14 States discontinued use, and none of the  
9 States still using ELE plan to expand its use  
Although all States found ELE beneficial, about one third of the small 
number of States that adopted ELE no longer use it for a variety of 
reasons.  As of April 2016, five States had discontinued use of ELE for 
Medicaid and CHIP enrollments and renewals.  A sixth State reported that 
it planned to discontinue use within the next 2 years once its eligibility 
system has the capability to serve all beneficiaries.  (One of the States that 
discontinued use reported that it is considering reactivating ELE in the 
future.)   
Officials in States that stopped using ELE indicated that although they 
experienced the same benefits as States that retained ELE, competing 
priorities (3 of 5 States), system changes (2 of 5 States), and short-term 
agreements with ELE partner agencies (2 of 5 States) caused them to 
discontinue use.  Agency officials in one State explained that a shift in 
priorities to focus on ACA-related tasks not only was resource intensive, 
but resulted in system upgrades that integrated program eligibility and 
enrollment processes, reducing the need for ELE.  Officials in another 
State reported that the State never intended to use ELE long-term.  Rather, 
the State considered ELE a temporary outreach tool to bolster enrollment 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  11   
   
and renewals.  The State discontinued ELE when the temporary State 
authorization for sharing information with its ELE partner agency ended.   
Further, none of the nine States still using ELE plan to expand its use to 
other types of applications.  Agency officials in these States indicated that 
while they recognized the benefits of using ELE, they did not consider 
expansion of ELE critical to their eligibility and enrollment efforts. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  12   
   
CONCLUSION 
All State Medicaid agencies that used ELE reported associated benefits, 
and some States rely heavily on ELE for Medicaid and CHIP enrollment.  
To the extent that State officials encountered barriers to using ELE, these 
officials reported that they largely overcame those barriers by forming 
strong partnerships and integrating data systems with other agencies.   
Although State use of ELE is not widespread, ELE appears to meet its 
intended objective of easing the eligibility and enrollment processes.  
Implementation of ELE is consistent with the goals of the ACA provisions 
to streamline enrollment processes for Medicaid and CHIP.  Moreover, 
based on this review of State experiences with ELE, OIG did not identify 
any significant impediments to continuing to allow the voluntary use of 
ELE, once States and CMS have corrected process problems and gaps in 
oversight identified by OIG audits.  Reauthorization would allow States 
that rely on ELE to continue its use and also provide other States with the 
opportunity to adopt ELE and likely realize similar benefits.  
OIG is issuing this report directly in final form because it contains no 
recommendations.  If you have comments or questions about this report, 
please provide them within 60 days.  Please refer to report number  
OEI-06-15-00410 in all correspondence. 
 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  13   
   
APPENDIX  
Table A:  Express Lane Eligibility Models by State 
 
State  ELE Model  ELE Partner Agency*  Application 
 
Automatic  Simplified  Simplified  Medicaid/ 
  SNAP  TANF  WIC  NSLP**  Tax  Medicaid  CHIP  Initial  Renewal 
Processing  Procedure  Application  CHIP 
Alabama                           
Colorado                           
Georgia                           
Iowa                           
Louisiana                           
Massachusetts                           
Maryland***                           
New Jersey                           
New York                           
Oregon                           
Pennsylvania                           
South Carolina***                           
South Dakota                           
Utah                           
*All but one of the ELE States used the same ELE partner agencies for their Medicaid and CHIP programs.  Iowa partnered with SNAP for its Medicaid program, but not for its CHIP program.             
**NSLP is the National School Lunch Program.                                                                                                                                                                                                                                     
***Maryland and South Carolina do not have a separate State Plan Amendment to use ELE for CHIP because these States use CHIP funding to cover children in Medicaid.                                                                                                                                                                                                                        
Note: Georgia, Maryland, New Jersey, Oregon, and Utah are no longer using ELE, and New York has plans to discontinue ELE within the next two years.  Alabama, Massachusetts, and New York are 
the only States with waivers that extend ELE to other types of populations (e.g., parents, caretakers). 
Source:  OIG analysis of State Plan Amendments, questionnaires, and interview responses collected from States, 2016. 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  14   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Ruth Ann Dorrill, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office.  
Petra Nealy and Anthony Guerrero-Soto served as the team leaders for this 
study.  Central office staff who provided support include Kevin Farber, 
Kevin Manley, and Joanne Legomsky.  
 
 
 
 
 
 
 
 
 
State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410)  15   
Office of Inspector General
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