DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
SHO # 10-003 
CHIPRA # 14 
 
February 4, 2010 
 
Re: Express Lane Eligibility Option 
 
Dear State Health Official: 
 
This letter is one of a series that provides guidance on implementation of the Childrens Health 
Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3.  CHIPRA includes 
many provisions designed to give States the tools they need to effectively enroll eligible children 
in Medicaid and Childrens Health Insurance Program (CHIP) coverage.  One of the key tools that 
CHIPRA offers is the Express Lane Eligibility option.  Section 203 of CHIPRA permits States to 
rely on findings from an Express Lane agency to conduct simplified eligibility determinations and 
facilitate enrollment in Medicaid and CHIP.  This provision was effective upon enactment of 
CHIPRA, February 4, 2009.  This letter and enclosure provide guidance on Express Lane 
eligibility option to enable States to effectively pursue this strategy. 
 
Overview 
 
Section 203 of CHIPRA permits States to rely on findings from an entity designated by the State as 
an Express Lane agency to determine whether a child satisfies one or more factors of eligibility 
for Medicaid or CHIP.  Under this option, Express Lane agencies can provide information that the 
State Medicaid or CHIP agency will use to determine eligibility.  The State Medicaid or CHIP 
agency remains responsible for making the ultimate determination of Medicaid or CHIP eligibility.  
The new option also permits States to automatically enroll and renew eligible children in Medicaid 
or CHIP under the conditions set forth in the statute.  States may use the Express Lane option for 
Medicaid, CHIP, or both programs.  Medicaid programs may apply the Express Lane option to 
children up to age 19, age 20, or age 21.  CHIP may apply the Express Lane option to children up 
to age 19.  The Express Lane option may be used for initial eligibility determinations as well as 
renewals. 
 
The Express Lane option provides States with important new avenues to ensure that children 
eligible for Medicaid or CHIP have a fast and simplified process for having their eligibility 
determined or redetermined.  CHIPRA opens up many possible arrangements for State Medicaid 
and CHIP programs to work with other public agencies to streamline enrollment and renewal -- 
there is no one way to implement the Express Lane option.  We encourage States to consider what 
may be the most promising opportunities given individual State programs, systems issues, and 
other factors, and then to work with CMS to determine how the new option may be utilized to 
further the objectives of the programs.  States may designate multiple Express Lane agencies and  Page 2  State Health Official 
 
establish unique criteria for each agency depending on the type of information that is available 
from that agency. The Appendix provides a few examples of ways States might use the Express 
Lane option.  These examples are intended to help stimulate ideas, not to constrain opportunities. 
 
Express Lane Agencies 
 
As specified by section 203(a) of CHIPRA, Express Lane agencies are entities identified in the 
State plan by the State Medicaid or CHIP agency as being capable of making a finding regarding 
one or more programmatic eligibility requirements, using information the Express Lane agencies 
already collect.  A States Medicaid and CHIP programs may use different Express Lane agencies 
and may select more than one agency. 
 
Express Lane agencies are public agencies, including: 
 
  Agencies that determine eligibility for assistance for any of the following programs or 
under any of the following authorities: 
o  The Temporary Assistance for Needy Families (TANF) program funded under part 
A of title IV of the Social Security Act (the Act); 
o  A State program funded under title IV-D of the Act (Child Support Enforcement); 
o  The State Medicaid or CHIP program; 
o  The Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps); 
o  The Richard B. Russell National School Lunch Act  (School Lunch programs); 
o  The Child Nutrition Act of 1966 (the Special Supplemental Nutrition Program for 
Women, Infants, and Children , or WIC); 
o  The United States Housing Act of 1937; 
o  Head Start; 
o  Child Care under the Child Care and Development Block Grant Act of 1990; 
o  Homeless Assistance under the Stewart B. McKinney Homeless Assistance Act; 
and 
o  The Native American Housing Assistance and Self-Determination Act of 1996; 
  Another State-specified governmental agency that has fiscal liability or legal responsibility 
for the accuracy of the eligibility determination findings relied on by the State; 
  A public agency that is subject to an interagency agreement limiting the disclosure and use 
of information disclosed for purposes of determining eligibility for Medicaid or CHIP. 
 
We note that a public agency may include an agency administered by an Indian tribe 
recognized by the State or federal government that determines assistance for any of the 
programs or under any of the authorities listed above. 
 
A State may also obtain and use information directly from State income tax records or returns.  Page 3  State Health Official 
 
Express Lane agencies may not include: 
 
  Private, for-profit organizations; or, 
  Agencies that only determine eligibility for programs under the title XX Social Services 
Block Grant. 
 
Consultation Matters Affecting Indians 
 
In accordance with section 5006(e) of the American Recovery and Reinvestment Act (Public Law 
111-5), effective July 1, 2009, certain States are required to utilize a process for the State to seek 
advice on a regular, ongoing basis from designees of the Indian Health Service (IHS) and Urban 
Indian Organizations concerning Medicaid and CHIP matters likely to have a direct effect on 
Indians, IHS, or Urban Indian Organizations.  States considering Express Lane agencies that are 
likely to serve Indian populations must ensure that this consultation takes place in the earliest 
stages of Express Lane development. 
 
Use of Information 
 
The Medicaid or CHIP agency and the Express Lane agency must have procedures in place, 
including an interagency agreement, to limit disclosure and use of information.  The State may use 
a single interagency agreement with the Express Lane agency, if the State administers Medicaid 
and CHIP through the same State agency, exercises the Express Lane option for both programs, 
and intends to use the same Express Lane agencys findings for both programs. 
 
An Express Lane agency must agree to notify the childs family: 1) about the information that will 
be disclosed to the Medicaid or CHIP agency; and 2) that the purpose of the disclosure will be 
solely for the purposes of determining or renewing eligibility for Medicaid or CHIP.  The Express 
Lane agency must also provide the family the option of not having their information disclosed. 
 
Financial Eligibility Determinations 
 
A State may use a finding from an Express Lane agency made within a reasonable period of time 
(as defined by the State), for any Medicaid or CHIP eligibility factor without regard to differences 
in budget unit, income disregards, deeming, or other differences in methodology between the 
Express Lane agency and Medicaid or CHIP.  For example, a State may use an income finding 
from an Express Lane agency that uses either gross or adjusted gross income obtained from State 
income tax records or returns.  (As noted above, a State may also obtain this information directly 
from State income tax records or returns.) 
 
Since the Express Lane agencys methods of calculating income may result in a determination that 
the familys income is higher than it might be using regular Medicaid or CHIP methods, States 
using the Express Lane option will need to meet the following requirements: 
 
  If a child is found ineligible for Medicaid and CHIP using an Express Lane finding, the 
State is required to conduct a full eligibility determination to ensure that the child is not  Page 4  State Health Official 
 
eligible under regular program rules.  Families in these situations must be informed if 
additional information is required and be given the opportunity to provide it. 
 
  For children who are subject to premiums, the State must provide notice that the child may 
qualify for lower premiums or cost sharing if evaluated for eligibility by the State using its 
regular procedures. 
 
  If a child is found ineligible for Medicaid but eligible for CHIP, the child can be enrolled in 
CHIP.  However, the State must notify the family that the child may qualify for reduced or 
no premiums and cost sharing under Medicaid, as well as a different benefit package, if the 
State were to conduct the full eligibility determination. 
 
Citizenship Status 
 
States using the Express Lane option must ensure that those individuals declaring to be citizens or 
nationals of the United States have established that status, in accordance with the applicable 
documentation requirements.  However, consistent with the changes adopted in section 211 of 
CHIPRA, individuals must be given a reasonable period of time to provide documentation after 
initial eligibility has been established, and, if otherwise eligible for medical assistance, individuals 
must be enrolled in coverage pending the documentation of citizenship/nationality.  In addition, 
section 211 of CHIPRA extended the citizenship verification requirements to CHIP effective 
January 1, 2010, along with a new option for States to meet such requirements through a data 
match with the Social Security Administration.  For more information, see CMS SHO #11, 
December 28, 2009, available at 
http://www.insurekidsnow.gov/professionals/CHIPRA/chipracitizenshipdocumentation.pdf. 
 
Automatic Enrollment 
 
In some cases, States will have all of the information they need from the findings of the Express 
Lane agency, State tax returns, and other sources, to make an eligibility determination (or to renew 
coverage).  In these and other circumstances, a State may choose the automatic enrollment option, 
which allows the State to initiate and determine eligibility for Medicaid or CHIP without a signed 
Medicaid or CHIP program application, as long as the family or child consents to be enrolled in 
Medicaid or CHIP.  This consent can be in writing, by phone, orally, by electronic signature, by 
signature on an Express Lane agency application, or by other means approved by CMS.  The 
parent, guardian, or custodial relative of the child must be informed about: 1) the services available 
for the child; 2) how to utilize services; 3) the applicable premiums or cost sharing; 4) any medical 
support obligations created by enrollment of the child that would apply; and 5) how to maintain 
enrollment and renew coverage. 
 
Specific consent from the childs parent, guardian, or custodial relative is not generally necessary 
in order for the Medicaid or CHIP agency to obtain and use an Express Lane agencys findings to 
renew or continue eligibility.  This is true as long as the parent, guardian or custodial relative has 
previously signed a Medicaid or CHIP application on behalf of the child and that application 
includes consent to verify eligibility information from such sources. 
  Page 5  State Health Official 
 
Coordination between Medicaid and CHIP can be enhanced if both programs rely on the same 
Express Lane agencies.  If a State chooses the Express Lane option for only the Medicaid or for 
only the CHIP program, and the child is not eligible for that program, the State shall assure that the 
child is evaluated by the other program for a full eligibility determination in accordance with 
longstanding Medicaid and CHIP coordination requirements.  The program receiving the 
information must conduct the eligibility determination according to its usual procedures, and may 
not base its determination on findings from an Express Lane agency unless there is another basis 
for obtaining and relying upon those findings. 
 
Screen and Enroll Requirements 
 
The Express Lane option offers States the following two methods for using income findings from 
Express Lane agencies to satisfy the screen and enroll requirements of section 2102(b)(3) of the 
Act.  These approaches are described below. 
 
Option 1:  Establishing a Screening Threshold 
 
  Since the Express Lane agency determinations may not take into account Medicaid 
income-related deductions, a State may establish a screening threshold set as a percentage 
of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold 
applicable to a child by a minimum of 30 percentage points.  A State may also set this 
threshold higher than 30 percentage points to account for any differences between the 
income calculation methodologies used by the Express Lane agency and those used by the 
State for its Medicaid program.  If the State chooses to set its threshold higher than 30 
percentage points, it should describe this threshold choice in its State plan.  The State may 
set one screening threshold for all children based on the highest Medicaid income threshold 
for children, or it may set more than one screening threshold based on its existing, age-
related Medicaid income thresholds (if applicable). 
  Children with income at or below the established threshold are considered to meet the 
income test for Medicaid eligibility for the purposes of the States compliance with the 
screen and enroll requirement of section 2102(b)(3) of the Act. 
  Children with income above the established threshold for Medicaid are considered to have 
income above the Medicaid applicable income level and to satisfy the requirement that 
CHIP Federal matching funds may be used only for children not eligible for Medicaid.  
Such children should be evaluated for whether they meet the income test for CHIP 
eligibility, based on the Express Lane agency finding if the State elects to use Express Lane 
for CHIP eligibility. 
o  These children are not subject to further testing of income eligibility, but all other 
CHIP eligibility factors must be evaluated. 
o  For children who are determined eligible and enrolled in CHIP using this option, 
the State must provide notice to the parent, guardian, or custodial relative that the 
child may be eligible for Medicaid if evaluated using the States regular eligibility 
determination procedures.  The notice must specify the process for requesting such 
an evaluation and the differences between Medicaid and CHIP, including 
differences in benefits and cost sharing. 
  Page 6  State Health Official 
 
Option 2:  Temporary Enrollment in CHIP Pending Screen and Enroll 
 
  The State may temporarily enroll the child in the CHIP program if he or she appears to be 
eligible using Express Lane agency income findings. 
  During this temporary enrollment period, the State must promptly conduct a full eligibility 
determination, testing all eligibility factors, to establish the childs eligibility for either 
Medicaid or CHIP. 
  In conducting the full eligibility determination, the State must use simplified procedures 
that, to the maximum extent feasible, minimize the burden on the family.  The State may 
not require the parent, guardian, or custodial relative to submit or verify information that 
has already been provided to the State agency by the Express Lane agency, or is available 
to the State from another source, unless the State has reason to believe that the information 
is erroneous. 
  Title XXI matching funds may be claimed for children enrolled in CHIP during the 
temporary enrollment period, even for children who are ultimately determined eligible for 
Medicaid. 
 
Findings of Ineligibility 
 
The State must initiate a full eligibility determination for Medicaid and CHIP using its regular 
procedures (including standard screen and enroll procedures), if an Express Lane agency finding 
used by the State would result in a determination that a child is ineligible for both Medicaid and 
CHIP. 
 
Assuring Accurate Payments 
 
A State electing the Express Lane option is expected to have systems and codes in place to 
accurately identify the universe of children who enroll through this option.  Consistent with the 
requirements of CHIPRA, States will be required to ensure the accuracy of Express Lane eligibility 
determinations through eligibility reviews based on a statistically valid sample of the children 
enrolled through Express Lane.  CMS will specify the process for this error rate measurement in 
regulation. 
 
It should be noted that children whose eligibility is determined through use of Express Lane 
agency findings will not be included in the universe from which samples are drawn for either the 
Medicaid Eligibility Quality Control (MEQC) or Payment Error Rate Measurement (PERM) 
reviews. 
 
Additional guidance will be forthcoming regarding the selection of samples, calculation of the 
improper payment rate, and the format and means of reporting the results of the payment reviews.  
According to the statute, if the rate exceeds 3 percent for either of the first two fiscal years the 
Express Lane option is effective, the State must identify the actions it has implemented to reduce 
its rate of improper payments.  A rate in excess of 3 percent will result in a reduction in the amount 
otherwise payable to the State under section 1903(a) of the Act equal to the amount of excess 
payments with respect to children in the sample that are in excess of 3 percent.   
  Page 7  State Health Official 
 
State Plan Amendments and Effective Dates 
 
Medicaid and CHIP State plan amendments must be submitted for each program selecting the 
Express Lane option.  A draft template is attached for State plan amendments under title XIX and a 
guidance document is attached for completion of the title XXI State plan for States electing to use 
Express Lane eligibility for CHIP.  The amendments must identify each Express Lane agency, the 
findings that will be utilized, whether the option will be used for applications, redeterminations, or 
both, and which screen and enroll process will be used.  CMS will continue to work with States 
interested in submitting State plan amendments to implement Express Lane eligibility. 
 
The Express Lane option is effective as of February 4, 2009 through the entire timeframe that 
CHIP has been reauthorized, until September 30, 2013. 
 
Enclosures 
 
Enclosed you will find a summary of  State Express Lane policy choices, a draft Medicaid State 
plan preprint, CHIP State Plan guidance, and three examples of how Express Lane eligibility could 
be implemented. 
 
If you have questions regarding this guidance, please email them to 
CHIPRAquestions@cms.hhs.gov or contact Ms. Victoria Wachino, Director, Family and 
Childrens Health Programs Group, who may be reached at (410) 786-5647. 
 
Sincerely, 
 
/s/ 
 
Cindy Mann 
Director 
Center for Medicaid and State Operations 
 
cc: 
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health 
 
Ann C. Kohler 
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
  Page 8  State Health Official 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.P.H. 
Director, Government Relations 
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy  Page 9  State Health Official 
 
Enclosure 1 
 
SUMMARY OF STATE POLICY CHOICES FOR IMPLEMENTATION  
OF EXPRESS LANE ELIGIBILITY FOR MEDICAID AND CHIP 
 
States have a number of choices to make when considering how they might take advantage of the 
Express Lane option.  The following list is intended to provide States assistance in considering the 
choices that the new Express Lane Eligibility (ELE) option offers.  In thinking through potential 
ELE proposals, States might consider: 
 
  Whether to implement the option for Medicaid and/or CHIP;  
   Whether to apply the option to all children up to 19 years old or, at the States option, to 
all children up to age 19, age 20, or age 21 for Medicaid-eligible children;   
  Which agencies are viable Express Lane agencies; 
  Whether to use the Express Lane option for eligibility determinations, redeterminations, or 
both; 
  Whether to use information available from State income tax records; 
  Whether to implement the automatic enrollment provision (not requiring a Medicaid or 
CHIP application form); and, 
  Whether to maintain the existing Medicaid/CHIP screen and enroll process or use one of 
the two new screen and enroll processes established by CHIPRA in designing an Express 
Lane strategy.  Page 10  State Health Official 
 
Enclosure 2 
 
Express Lane Eligibility in Medicaid and CHIP  
EXAMPLES 
 
The following examples are provided to illustrate how States may use one or more of the various 
simplified and expedited processes offered by the Express Lane eligibility option to enroll or 
renew children eligible for Medicaid or the Childrens Health Insurance Program (CHIP).  Many 
other approaches can be designed and CMS will be providing ongoing technical support as States 
learn which strategies are most effective.  CMS will also work to help States learn from each other 
as new approaches for successfully implementing the Express Lane option emerge. 
 
Example #1:  Use of State Income Tax Records and Income Threshold Option for CHIP 
Screen and Enroll 
 
This example is based on an approved Express Lane State plan amendment submitted by New 
Jersey.  It illustrates how a State may implement the Express Lane eligibility option for initial 
eligibility determinations for Medicaid and CHIP by using its State income tax records for the 
income finding.  It also shows how a State may fulfill the CHIP screen and enroll requirements 
using the income threshold option.  Additional simplified procedures are used in order to expedite 
eligibility determinations. 
 
Overview 
 
   State law requires the State income tax return to request the health insurance status for 
dependents, and allows the State Department of Taxation to electronically send the mail file of 
all State residents who have uninsured dependents to the State Medicaid/CHIP program for 
outreach. 
  The State Medicaid/CHIP program sends an application packet to those residents on the 
outreach list.  This packet contains a simplified one-half page application that the family may 
complete to apply for Medicaid/CHIP for children in the household who are younger than 19 
years old.  The application asks for each parents and childs Social Security number (SSN) 
and information about any insurance coverage. 
  Having elected the Express Lane option for both its Medicaid and CHIP programs and 
identified the State Department of Taxation as an Express Lane agency, the State uses the 
Department of Taxations findings for gross income, State residency, family composition, and 
family size.  
  Using the parents Social Security numbers, signed authorization on the application form, and 
an interagency agreement, a match is done with the Taxation database to obtain the familys 
gross annual income from the most recent State income tax return.  This match with the States 
income tax records and the home address provided on the Medicaid/CHIP application is also 
considered to verify State residency, family composition, and family size.  Based on this 
income finding from the State Department of Taxation as an Express Lane agency, the State 
Medicaid/CHIP agency evaluates each childs income eligibility as follows:    Page 11  State Health Official 
 
o  If the familys gross income is at or below the screen and enroll threshold approved for 
Express Lane, which is 30 percentage points above the net Medicaid income eligibility 
level for the childs age group, the child is determined income eligible for Medicaid.  
o  If the familys gross income is above the Express Lane screen and enroll threshold, but 
below the gross CHIP income eligibility level, the child is determined income eligible 
for CHIP. 
  Once income is verified through the Taxation database, the State Medicaid/CHIP agency 
conducts a series of other electronic verifications for a full determination of the childs 
Medicaid or CHIP eligibility. 
o  The State Medicaid/CHIP agency checks MMIS to determine if the child is already 
enrolled in Medicaid or CHIP.   
o  It checks with the Social Security Administration (SSA) to determine if the child is a 
Medicare beneficiary. 
o  The States third party liability contractor checks for whether there is a record in its 
database indicating that the child has private health insurance.  (Coverage does not 
preclude eligibility for Medicaid).   
o  The State conducts a match with its vital records database to determine if a birth 
certificate is on record for the child.  If so, this database match verifies the childs U.S. 
citizenship. 
o  The State uses SVES/SOLQ to verify the childs SSN and identity. 
  If the childs Medicaid or CHIP eligibility cannot be determined based on this process (e.g., a 
birth certificate is not located through the vital records match or the child is over income for 
CHIP using the Express Lane agencys income finding), a full eligibility determination is 
conducted using the regular Medicaid/CHIP processes.  Additional information is requested 
from the family as necessary.   
 
Example #2:  Use of the Express Lane Automatic Enrollment Option 
 
This example illustrates how a State may implement the automatic enrollment Express Lane option 
for eligibility determinations for Medicaid and CHIP by using information collected by the agency 
determining eligibility for the Supplemental Nutrition Assistance Program (SNAP). 
 
Overview 
 
  The State Medicaid/CHIP agency and the SNAP (formerly known as Food Stamps) agency 
enter into an interagency agreement for the SNAP agency to be an Express Lane agency.   
  If a SNAP application is received for a child younger than 19 years old, information provided 
by the family on that application or otherwise collected for the SNAP eligibility determination 
is used by the State Medicaid/CHIP agency to determine most factors of Medicaid/CHIP 
eligibility.   
  For initial eligibility determinations, the State Medicaid/CHIP agency mails an opt-out letter 
to SNAP applicants advising them that the information provided for the SNAP application will 
be shared with the State Medicaid/CHIP agency for determining the childrens Medicaid/CHIP 
eligibility, unless the individual calls a toll-free number to opt-out.  
  A Medicaid or CHIP application is not required.  Page 12  State Health Official 
 
  The State Medicaid/CHIP agency uses the SNAP agencys income finding, calculated based on 
SNAP eligibility policies (income exclusions, disregards, household composition, deeming, 
etc.) to determine income eligibility for Medicaid/CHIP. 
  The State Medicaid/CHIP agency uses other information collected by the SNAP agency on the 
SNAP application or through its verification processes to determine most other factors of 
Medicaid/CHIP eligibility (e.g., verification of citizenship, State residency).  
  The State Medicaid/CHIP agency checks MMIS to determine if the child is already enrolled in 
Medicaid or CHIP.   
  It checks with the Social Security Administration (SSA) to determine if the child is a Medicare 
beneficiary. 
  The State Medicaid/CHIP agency has its third party liability contractor check for whether there 
is a record in its database indicating that the child has private health insurance (coverage does 
not preclude eligibility for Medicaid).  
  If the child is determined eligible for Medicaid or CHIP, the State must obtain affirmative 
consent from the family and send the information required as to services, cost sharing and 
other obligations, as described  in section 1902(e)(13)(D) before enrolling the child. 
  If the childs Medicaid or CHIP eligibility cannot be determined based on the processes used 
for Express Lane eligibility (e.g., the child is over income for CHIP using the Express Lane 
agencys income finding), a full eligibility determination is conducted using the regular 
Medicaid/CHIP processes.  Additional information is requested from the family as necessary.  
The income finding from the Express Lane agency may not be used, so the State must 
determine income eligibility using its regular policies and procedures. 
 
Example #3:  Use of Automatic Eligibility and Temporary Enrollment Option Pending CHIP 
Screen and Enroll 
 
This example illustrates how a State may implement the automatic enrollment Express Lane option 
for eligibility determinations and redeterminations for Medicaid and CHIP by using information 
collected for free or reduced school lunch eligibility by the School Lunch program as an Express 
Lane agency.  It also shows how a State may fulfill the CHIP screen and enroll requirements using 
the Express Lane option for temporary enrollment in CHIP pending screen and enroll. 
 
Overview 
 
  The State Medicaid/CHIP agency and the State School Lunch program enter into an 
interagency agreement for the State School Lunch program to be an Express Lane agency.   
  If an application for free or reduced school lunches is received for a child younger than 19 
years old, information provided by the family on that application or otherwise collected for the 
school lunch program eligibility determination is used by the State Medicaid/CHIP agency for 
an income finding of Medicaid/CHIP eligibility. 
  The application for the school lunch program advises applicants that the information provided 
for the school lunch application will be shared with the State Medicaid/CHIP agency for 
determining the childrens Medicaid/CHIP eligibility, unless the individual calls a toll-free 
number to opt-out.    Page 13  State Health Official 
 
  The State Medicaid/CHIP agency uses the School Lunch programs income finding, calculated 
based on that programs policies (income exclusions, disregards, household composition, 
deeming, etc.) to determine income eligibility for Medicaid/CHIP. 
  If the familys reported income indicates that the child appears to be income-eligible for 
coverage, the child is enrolled in CHIP temporarily after the State confirms that the child is not 
already enrolled in Medicaid or CHIP.   
  Enhanced match is paid for the childs CHIP benefits from the States title XXI allotment 
during the temporary enrollment period in CHIP. 
  If the familys reported income clearly appears to qualify the child for Medicaid eligibility, the 
child should be enrolled directly into Medicaid.  (This determination would be based on the 
auto-enrollment option, not the screen and enroll option, which would require the child to be 
enrolled in CHIP pending verification. The State must obtain affirmative consent from the 
family and send the information required as to services, cost sharing, and other obligations, as 
described  in section 1902(e)(13)(D) of the Act before enrolling the child.)    
  If the child ultimately is eligible for CHIP, the enhanced matching rate will be available for 
benefits paid during the eligibility verification process. 
  The State Medicaid/CHIP agency conducts a full eligibility determination within 30 days from 
the date of temporary enrollment in CHIP.  The State examines all eligibility factors except 
income, to establish the childs eligibility for either Medicaid or CHIP.   
  The State only requests information from the family that is not already available through other 
means (e.g., documentation of citizenship or immigration status, information about any third 
party health insurance coverage, any information necessary to establish paternity or a medical 
support order).   
  The State may use information provided to the School Lunch program to determine factors of 
Medicaid/CHIP eligibility besides income (e.g., State residency based on the reported 
residential address). 
  The State performs the usual verifications (e.g., SVES/SOLQ to verify the childs Social 
Security number with SSA and to determine whether the child is currently Medicare-eligible or 
SAVE to verify qualified alien status).   
  The State verifies citizenship for Medicaid applicants according to existing processes. 
  Based on the States eligibility determination, the child may be determined:  
  Eligible for Medicaid, and so is moved from CHIP to Medicaid after written, 
advance notice;  
  Ineligible for Medicaid but eligible for CHIP, and so remains in CHIP; or 
  Ineligible for both Medicaid and CHIP, and so is disenrolled from CHIP after 
written, advance notice.   Page 14  State Health Official 
 
DRAFT                    DRAFT 
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 
State:                                          Medical Assistance Program 
                          Page 11b 
    
SECTION 2  COVERAGE AND ELIGIBILITY 
 
Citation(s) 
 
 
2.1  Application, Determination of Eligibility and Furnishing Medicaid 
  (Continued) 
 

1902(e)(13) of    (e)  Express Lane Option.  The Medicaid State agency elects the  
the Act      option to rely on a finding from an Express Lane agency when 
determining whether a child satisfies one or more components of 
Medicaid eligibility.  The Medicaid State agency agrees to meet all 
of the Federal statutory and regulatory requirements for this option.  
This authority may not apply to eligibility determinations made 
before February 4, 2009, or after September 30, 2013.  
 
(1)  The Express Lane option is applied to: 
             
Initial determinations Redeterminations 
 
  Both 
 
      (2)  A child is defined as younger than age: 
           
        19 20    21 
 
      (3)  The following public agencies are approved by the  
Medicaid State agency as Express Lane agencies: 
       
 
 
 
 
 
 
 
 
TN No.:    Approval Date        Effective Date       
                   
Supersedes TN No.:   
DRAFT                    DRAFT  Page 15  State Health Official 
 
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 
State:                                                     Medical Assistance Program 
                          Page 11c 
 
SECTION 2  COVERAGE AND ELIGIBILITY 
 
Citation(s) 
 
 
 
2.1  Application, Determination of Eligibility and Furnishing Medicaid 
  (Continued) 
 
  (4)  The following component/components of Medicaid eligibility are 
determined under the Express Lane option.  Also, specify any 
differences in budget unit, deeming, income exclusions, income 
disregards, or other methodology between Medicaid eligibility 
determinations for such children and the determination under the 
Express Lane option. 
 
 
 
 
 
 
  (5)  Check off and describe the option used to satisfy the Screen    
    and Enroll requirement before a child may be enrolled under title  
    XXI. 

     (a)  Screening threshold established by the Medicaid agency as: 
       
(i) percentage of the Federal poverty level which 
exceeds the highest Medicaid income threshold applicable to 
a child by a minimum of 30 percentage points: specify                 
       ; or 
 
(ii)    percentage of the FPL (describe how this reflects 
the value of any differences between income methodologies 
of Medicaid and the Express Lane agency:  
 
); or 
 
     
(b)  Temporary enrollment pending screen and enroll. 
         
TN No.:    Approval Date        Effective Date       
                   
Supersedes TN No.:    Page 16  State Health Official 
 
DRAFT 
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 
State:                                                     Medical Assistance Program 
                          Page 11d 
    
SECTION 2  COVERAGE AND ELIGIBILITY 
 
 
Citation(s) 
 
 
  2.1  Application, Determination of Eligibility and Furnishing Medicaid 
  (Continued) 
 
     
(c)  States regular screen and enroll process for CHIP. 
 
  
 (6)  Check off if the State elects the option for automatic enrollment  
without a Medicaid application, based on data obtained from other 
sources and with the childs or familys affirmative consent to the 
childs Medicaid enrollment. 
 
  
 (7)   Check off if the State elects the option to rely on a finding from an  
Express Lane agency that includes gross income or adjusted gross 
income shown by State income tax records or returns. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                                                                                                      
TN No.:     Approval Date        Effective Date   
Supersedes  
TN No.:     Page 17  State Health Official 
 
 
DRAFT 
 
CHIP State Plan Guidance for Express Lane Eligibility Option 
 
This is a guide containing information on the specific subsections of the title XXI State plan that 
should be completed when submitting a State plan amendment (SPA) to add the Express Lane 
option for conducting simplified eligibility determinations under CHIP. 
 
Section 1.  General Description and Purpose of the State Child Health Plans and State Child 
Health Plan Requirements 
 
Complete subsection 1.4 providing information related to this SPA.  This includes the SPA 
number, submission date, effective date, and implementation date. 
 
Section 2.  General Background and Description of State Approach to Child Health 
Coverage and Coordination 
 
Within subsection 2.2, regarding current State efforts to provide coverage for uncovered children, 
complete subsection 2.2.1.  The State should include a description of its election of the Express 
Lane eligibility option to provide a simplified eligibility determination process and expedited 
enrollment of eligible children into Medicaid or CHIP. 
 
Section 4.  Eligibility Standards and Methodology 
 
Subsection 4.1 addresses various eligibility standards used by the State in establishing eligibility.  
Within subsection 4.1, check the box for subsection 4.1.9 Other standards.  Identify the Express 
Lane option, and describe how the State intends to implement this option.  Include information on 
the identified Express Lane agency or agencies, and whether the State will be using the Express 
Lane eligibility option for initial eligibility determinations, redeterminations, or both.   
 
Next, within subsection 4.4, complete subsection 4.4.1.  When the State is using an income 
finding from an Express Lane agency, the State must still comply with screen and enroll 
requirements before enrolling children in CHIP.  The State may either continue its current screen 
and enroll process, or elect one of two new options to fulfill these requirements.  The State should 
designate the option it will be using to carry out screen and enroll requirements.  
 
The State will continue to use the screen and enroll procedures required under section 
2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c).  Describe 
this process. 
 
The State is establishing a screening threshold set as a percentage of the Federal poverty 
level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a 
minimum of 30 percentage points.  (NOTE:  The State may set this threshold higher than 30 
percentage points to account for any differences between the income calculation methodologies 
used by the Express Lane agency and those used by the State for its Medicaid program.  The State  Page 18  State Health Official 
 
may set one screening threshold for all children, based on the highest Medicaid income threshold, 
or it may set more than one screening threshold, based on its existing, age-related Medicaid 
eligibility thresholds.)   Include the screening threshold(s) expressed as a percentage of the FPL, 
and provide an explanation of how this was calculated.       
 
The State is temporarily enrolling children in CHIP, based on the income finding from the 
Express Lane agency, pending the completion of the screen and enroll process.    
 
Section 5.  Outreach 
 
Information should be added to this section similar to the information being added in subsection 
2.2.1 regarding the States election of the Express Lane eligibility option to provide a simplified 
eligibility determination process and expedited enrollment of eligible children into Medicaid or 
CHIP.  Include any outreach and enrollment activities that are specifically related to the Express 
Lane eligibility option to rely on findings from an Express Lane agency to conduct simplified 
eligibility determinations. 
 
Section 9.  Strategic Objectives and Performance Goals and Plan Administration 
 
Subsection 9.9 addresses public involvement. 
 
Within this subsection, include information in subsection 9.9.1 describing the States interaction, 
consultation, and coordination with any Indian tribes and organizations in the State regarding 
implementation of the Express Lane eligibility option.   
 
Subsection 9.10 
 
Provide a 1-year projected budget. 
 
Section 12.  Applicant and Enrollee Protections 
 
Complete subsection 12.1 relating to eligibility and enrollment matters, and describe any special 
processes and procedures that are unique to the applicants rights when the State is using the 
Express Lane option when determining eligibility.  See examples below: 
 
Example 1:  If a child is found eligible but subject to premiums, based on an income finding from 
an Express Lane agency, the State must provide notice that the child may qualify for lower 
premiums if evaluated using the States regular eligibility determination procedures, and receive 
information concerning how to request such an evaluation.   
 
Example 2:  Children who are determined eligible and enrolled in CHIP using the screening 
threshold option for screen and enroll, the State must provide notice to the family that the child 
may be eligible for Medicaid if evaluated using the States regular eligibility determination 
procedures.  The notice must specify the process for requesting such an evaluation and the 
differences between Medicaid and CHIP, including differences in benefits and cost sharing.