Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

STATE USE OF EXPRESS LANE 

ELIGIBILITY FOR MEDICAID 

AND CHIP ENROLLMENT

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 Children’s 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
 

State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410) 1

OBJECTIVES

1. To describe State use of Express Lane Eligibility (ELE) models to 

enroll beneficiaries in Medicaid and Children’s 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, Children’s Health Coverage: Medicaid, CHIP 

and the ACA, March 26, 2014. Access at http://kff.org/health-reform/issuebrief/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) 2

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 reapply 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-andReports/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-andSystems/Research/ActuarialStudies/Downloads/MedicaidReport2014.pdf on 

July 13, 2016. 

7

 CMS, 2015 CMS Statistics, p. 15. Accessed at https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Statistics-ReferenceBooklet/Downloads/2015CMSStatistics.pdf on September 13, 2016. 

8 Kenney, Genevieve M., Jennifer Haley, Clare Pan, Victoria Lynch, and Matthew 

Buettgens, Children’s 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-ChildrensCoverage-Climb-Continues-Uninsurance-and-Medicaid-CHIP-Eligibility-andParticipation-Under-the-ACA.pdf on September 12, 2016.
 

State Use of Express Lane Eligibility for Medicaid and CHIP Enrollment (OEI-06-15-00410) 3

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 Children’s 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 individual’s 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) 4

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/issuebrief/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) 5

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/medicaidchip-program-information/by-topics/outreach-and-enrollment/express-laneeligibility.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) 6

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) 7

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 family’s 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) 8

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 State’s 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) 9

renewal form, a cost savings they characterized as significant, given the 

large number of beneficiaries processed through ELE. 

For some States, ELE’s 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) 10

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) 11

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 other’s 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) 12

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) 13

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) 14

APPENDIX 

Table A: Express Lane Eligibility Models by State 

State ELE Model ELE Partner Agency* Application

Automatic 

Processing

Simplified 

Procedure

Simplified 

Application SNAP TANF WIC NSLP** Tax Medicaid/CHIP Medicaid CHIP Initial Renewal

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) 15

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.
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of individuals served by those programs. 

This statutory mission is carried out through a nationwide network of audits, investigations, 

and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and individuals. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.