incomes above the Medicaid eligibility thresholds
based on the CPS definition of family (which treats
related subfamilies living together as one unit)
could be eligible if only the resources of their
subfamily are counted by the caseworker. The
amount of latitude caseworkers employ probably
varies across states and possibly even among
counties within a state.

+ Period of Medicaid Certification for
Pregnant/Postpartum Women and Infants.
Federal eligibility criteria mandate that
pregnant/postpartum women and infants who
initially qualify for Medicaid must be permitted to
remain in the program even if their incomes rise
above the eligibility threshold. The rules regarding
eligibility redetermination are complex. In
practice, though, the rules are usually interpreted
so that an eligible pregnant woman is deemed
eligible throughout her pregnancy and postpartum
period regardless of any changes in family
income.‘ An infant is deemed eligible for one year
following birth, regardless of any changes in family
income. These policies could be a significant
factor in explaining why some persons with higher
incomes are enrolled in Medicaid and thus in WIC.

¢ Eligibility Redetermination. Medicaid enrollees
are required to report changes in income to the
-Medicaid program so that eligibility can be
redetermined. However, researchers believe that
many changes in income go unreported.
Therefore, Medicaid enrollees are in effect
guaranteed enrollment until a routine eligibility
redetermination is required, which is typically done
on an annual basis. Like the guaranteed
certification for pregnant/postpartum women and
infants, this could also be a significant factor in
explaining why some persons with higher incomes
are enrolled in Medicaid and thus in WIC. The
extent to which this factor affects eligibility
probably varies by state.

‘The postpartum period is defined as 60 days after giving birth plus
the remaining days in the month in which the 60th day falls,

7



The following criteria were used:

* Size of the infant population enrolled in Medicaid

¢ Level of state's poverty-related income threshold for
infants relative to the WIC poverty level threshold of 185
percent. (Note that states often employ the same poverty
level threshold for pregnant/postpartum women and
infants, but a different, usually lower, threshold for
children.)

¢ Extent of Medicaid coverage for pregnant women and
children (in particular, the presence of a Medicaid
medically needy program)

* The preliminary ratio of infants ever enrolled in Medicaid
according to unadjusted 2082 data to the CPS estimates
of infants eligible for WIC'

* Geographic diversity
* Substantial urban or rural populations

¢ Substantial undocumented noncitizen population?

Beginning with size, preference was given to states with at least
15,000 infants enrolled in Medicaid according to unadjusted 2082
data. States were selected to reflect a range of Medicaid income
thresholds for infants (above, at the same level, and below the WIC
185 percent threshold). At least one state had restrictive coverage
policies (no medically needy program). The selected states include
both those with more and fewer Medicaid infants than WIC eligible
infants according to unadjusted 2082 data. The selected states reflect

geographic diversity (the South, the Northeast, the Midwest and the
West) and have both urban and rural populations. States with large

undocumented noncitizen populations were also included.

‘Only a preliminary estimate of this ratio was available initially because
Medicaid 2082 administrative data for infants and WIC estimates are
not fully comparable without adjustments.

?Undocumented noncitizens are generally eligible only for Medicaid
emergency services.

28



TABLE I1.3

MSIS PARTICIPATION AND SMRF FILE STATUS, BY STATE

State MSIS Status Start-Up Year SMRF Availability*
Alabama Yes 1986 1987, 1993-1995
Alaska Testing 1989 -
Arizona Testing - -
Arkansas Yes 1986 1992-1995
California Yes 1987 1980-1995
Colorado Yes 1994 1994-1995
Connecticut No - -
Delaware Yes 1986 1992-1995
District of Columbia No - -
Florida Testing 1994 1994-1995
Georgia Yes 1988 1980-1992, 1994-1995
Hawaii Yes 1987 1992-1993
Idaho Testing 1995 1995
Illinois No - -
Indiana Yes 1988 1992-1995
Towa Yes 1986 1992-1994
Kansas Yes 1986 1987, 1993-1995
Kentucky Yes 1986 1987, 1992-1995
Louisiana No - -

Maine Yes 1987 1992-1995
Maryland No - -
Massachusetts No - -
Michigan Yes 1995 1980-1995
Minnesota Yes 1986 1994-1995
Mississippi Yes 1992 1994-1995
Missouri Yes 1986 1992-1995
Montana Yes 1986 1992-1995
Nebraska No - -
Nevada Yes 1991 -

New Hampshire Yes 1987 1994-1995
New Jersey Yes 1986 1993-1995
New Mexico Testing - -

New York No - -

North Carolina No - -

North Dakota Yes 1986 1992-1995
Qhio No - -

24



TABLE IV.3

DISTRIBUTION BY STATE OF INFANTS PARTICIPATING IN WIC,
ESTIMATED TO BE ELIGIBLE FOR WIC, AND ENROLLED
IN MEDICAID
(Average Monthly Number—-1995)

Medicaid Enrollees Medicaid Enrollees as

WIC Participants WIC Eligibles (Adjusted) Percent of WIC Eligibles
Alabama 35,439 29,640 33,609 113
Arkansas 23,937 18,189 16,041 88
California 266,928 269,401 233,040 87
Florida 88,993 93,667 91,460 98
Michigan 51,526 56,301 57,506 102
New Jersey 34,989 24,158 36,080 149
SOURCES: WIC data are from FNS estimates using CPS data; Medicaid data are from
1995 SMRF files.
NOTE: States with Medicaid enrollees in boldface exceed CPS-based estimates of

WIC eligibles. Average monthly enroliment for infants based on January
through September 1995. The following adjustment factors were applied to
counts of Medicaid enrollees to account for the delay in program enrollment of
newboms:

Alabama: 2.1%

Arkansas: 5.6%

California: 5.6%

Florida: 1.9%

Michigan: 1.4%

New Jersey: 2.1%

33



I. INFRODUCTION

The Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) provides supplemental food, nutrition education,
and referrals to health care to eligible pregnant and postpartum
women, infants, and children. To be eligible for WIC, individuals
must be categorically eligible, which means that they must be
pregnant women, breastfeeding women up to 12 months postpartum,
nonbreastfeeding women up to 6 months postpartum, infants up to 12
months of age, or children up to their fifth birthday. Each
categorically eligible individual also must be income eligible (defined
as having family income below 185 percent of the poverty level) and
at nutritional risk.! Those who participate in the Temporary
Assistance for Needy Families Program (TANF), the Food Stamp
Program (FSP), or Medicaid are adjunct eligible (that is,
automatically income eligible) and do not have to show further proof
of income.

The Food and Nutrition Service (FNS) of the U.S. Department of
Agriculture (USDA), which administers WIC, asked Mathematica
Policy Research to examine more closely Medicaid’s role in adjunct
eligibility for WIC. Adjunct eligibility through the AFDC and Food
Stamp programs is not an issue, because these programs have
maximum income standards lower than those used for WIC.
However, Medicaid policies differ more significantly from WIC and
may have expansive effects on the WIC program, allowing persons
whose incomes exceed 185 percent of the federal poverty line to
qualify for the program through Medicaid. This study was motivated,
in part, by apparent discrepancies between FNS’s estimates of WIC
eligibles and the number of WIC participants according to
administrative data. In some states, WIC participants exceed the
estimated eligibles, resulting in an implausible WIC participation rate
of more than 100 percent. Adjunct eligibility through Medicaid may
account for this discrepancy.

‘A competent health professional must assess nutritional risk. The
assessment must include measures of height, weight, blood-iron
status, and dietary status. Common nutritional risks include
overweight, underweight, anemia, or inadequate or inappropriate
dietary intake, as well as a wide range of risks specific to pregnancy
(such as history of pregnancy loss or low-birthweight births).

1



REFERENCES

Bruen, Brian K. and Frank Ullman. “Children’s Health Insurance Programs: Where States Are,
Where They are Headed.” Washington, DC: The Urban Institute, May 1998.

Ellwood, Marilyn and Genevieve Kenney. “Medicaid and Pregnant Women: Who is Being Enrolled
and When.” Health Care Financing Review, vol. 17, no. 2, Winter 1995, pp. 7-28.

Gordon, Anne, Kimball Lewis, and Larry Radbill. Income Variability Among Families with Pregnant
Women, Infants, or Young Children. Alexandria, VA: U.S. Department of Agriculture, Food
and Nutrition Service, January 1997.

Lioyd, Bill. SEPP Quality Profile, 3rd Edition. Washington, DC: U.S. Department of | Commerce,
Bureau of the Census, 1998.

Radbill, Larry. “Analysis of WIC Participants Apparently Ineligible for WIC Based on Annual
Income.” Memorandum to Cindy Long of U.S. Department of Agriculture, Food and Consumer
Service, June 12, 1996.

Schirm, Allen L. and Cindy Long. “Fund Allocation and Small Area Estimation in the WIC
Program.” 1995 Proceedings of the Section on Survey Research Methods. Alexandria, VA:
American Statistical Association, 1995.

Shapiro, G.M., G. Diffendal and D. Cantor. “Survey Undercoverage: Major Causes and New
Estimates of Magnitude.” Internal Census Bureau Memorandum, 1993.

U.S. House of Representatives, Committee on Energy and Commerce. Medicaid Source Book:

Background Data and Analysis (A 1993 Update). Washington, DC: Government Printing
Office, January 1993.

43



WIC eligibles.’ This could have larger funding implications for the
WIC program because the national estimate is typically used to
develop the annual budget for the WIC program.

Overall, information on Medicaid enrollment is important information
for estimating the number of persons eligible for WIC each year
because of the close relationship between the WIC and Medicaid
programs. This study demonstrates that Medicaid eligibility policies
may explain discrepancies between estimates of WIC eligibles and
participants and that Medicaid enrollment data is available and may be
used to improve estimates of WIC eligibles.

The Medicaid relationship to WIC may become even more important
in future years. The recently passed State Children’s Health Insurance
Program (CHIP) gives states additional incentives to increase
Medicaid eligibility thresholds for children beyond 185 percent of

_ poverty.” The CHIP legislation, which was part of the Balanced
Budget Act of 1997, provides $20.3 billion in new federal money to
states over the next five years to expand child health coverage. This
money is available at enhanced matching rates of 65 to 85 percent in
comparison to traditional federal matching rates for Medicaid of 50 to
83 percent. Although CHIP funds are generally to be used to provide
coverage only to children with family income below 200 percent of
poverty, states are allowed to go 50 percentage points above their
existing Medicaid income thresholds. Thus, a state using a 185
percent of poverty threshold for infants could go to 235 percent using
CHIP funding. Preliminary information indicates that several states
are using their CHIP funds to expand Medicaid coverage for infants
beyond the 185 percent threshold (Bruen and Ullman, 1998). As
more states extend Medicaid eligibility to children in families with
incomes above 185 percent of poverty, issues are raised about WIC
adjunct eligibility policies.

*For example, Medicaid enrollment counts could be used as a
predictor variable in the regression estimate of WIC eligibles. The
estimate would then be optimally combined with direct CPS-based
estimates of WIC eligibles using the shrinkage technique currently
used to estimate WIC eligibles (Schirm and Long, 1995).

*Under CHIP, states can elect to expand coverage under. their
Medicaid programs, or establish separate state health insurance
programs for CHIP children, or both.

41



Legend:

Section A:

Section B:
Section C:

Section D:

Section E:

Section F:
Section G:
Section H:
Section I:
Section J:
Section K:

Section L:

Section M:

CONTENTS OF HCFA FORM 2082 — 1993
Cell entries in bold (e.g., eligibles, recipients)--by column headings and row
headings
Recipients--by type of medical service (TOS) and by Maintenance Assistance Status
/ Basis of Eligibility (MAS/BOE)
Payments--by TOS and by MAS/BOE
Eligibles--by length of eligibility and by MAS/BOE
(1) _ Eligibles--by age and by race/ethnicity and sex
(2) _ Recipients--by age and by race/ethnicity and sex
(3)  Payments--by age and by race/ethnicity and sex
(4) Eligibles--by age and by MAS/BOE
(5)  Recipients--by age and by MAS/BOE
(6)  Payments--by age and by MAS/BOE

Recipients of inpatient general hospital services--by discharges, days of care, and by
MAS/BOE

Recipients of institutional care—by days of care and by MAS/BOE
Recipients--by age, sex, and race/ethnicity, and by TOS

Payments--by age, sex, and race/ethnicity, and by TOS

Recipients of institutional care--by TOS and by MAS/BOE

Payments for recipients of institutional care--by TOS and by MAS/BOE
Eligibles enrolled in managed care and premiums paid--by MAS/BOE

Recipients and payments--by relationships of payment of Title XVIII deductibles
and coinsurance, and by TOS

Visits (by selected TOS) and prescriptions—-by MAS/BOE

Al


SMRF data underestimate the number of infants enrolled in Medicaid
due to delay in the processing of Medicaid enrollment following birth.
Prior to enrollment, any Medicaid charges for an infant are made to
the mother’s Medicaid account. Thus infants are covered under
Medicaid from birth, but are not always shown as Medicaid enrollees
from the time of birth. To account for this delay, an adjustment factor
was calculated for each of the six states examined in this study. The
derivation of these adjustment factors is presented here.

A different adjustment factor was derived for each state because of the
varying degree to which states were able to enroll infants in the birth
month. As shown in Table B.1, for the 6 states whose SMRF data we
examined, from 14 to 46 percent of infants were initially enrolled
within a month after their birth month. In Arkansas, for example, 54
percent of infants were initially enrolled during their birth month, 24
percent were initially enrolled in the month after their birth month, and
another 10 percent were initially enrolled in the second month after
their birth. Other states were more successful in immediately enrolling
infants. In Michigan, 86 percent of infants were initially enrolled
during their birth month.

The adjustment factor was based on the assumption that any infants
initially enrolled within three months of their birth were covered by
Medicaid since birth. Likewise, infants enrolled more than three
months after their birth were assumed to be new enrollees--that is, not
covered by Medicaid since birth. The figures in Table B.2 show the
amount by which newborns and infants ages 1 and 2 months are
adjusted upward in each of the six states examined.’ In Alabama, for
example, we adjusted upward the number of newborns by 14.1
percent to account for the 3,382 infants enrolled in months 1, 2, and
3 after birth.” Similarly, we adjusted upward the number of !-month-
olds by 7.8 percent to account for the infants enrolled in months 2 and
3 after birth, Finally, we adjusted upward the number of 2-month-olds
by 3.3 percent to account for the infants enrolled in month 3 after

'These adjustment factors differ markedly from the percentages in
Table B.1 because the denominators over which they are calculated
are different. The percentages in Table B.1 are of total infants
(28,879), whereas the adjustment factors are based on total newborns
(23,910).

*The derivation of the 3,382 infants can be seen from Table B.1,
where 1,399 infants were enrolled at age 1 month, 1,109 infants were
enrolled at age 2 months, and 874 infants were enrolled at age 3
months (1,399 + 1,109 + 874 = 3,382).

Bl


TABLE 1V.6

DISTRIBUTION BY STATE OF INFANTS ENROLLED IN MEDICAID (ADJUSTED 2082 DATA).
ESTIMATES OF WIC ELIGIBLES, AND INFANTS PARTICIPATING IN WIC

Medicaid Infants Ever Enrolied in
Medicaid in 1995 According to
Number of Infants ___ Adjusted 2082 Daa
Estimated ae for of WIC.

State wit, ‘Number Eligible Infants WIC Panicapants, 1995
All States 1,668,766 1,706,952 102 1,759,919
Alabama * 29,640 34,302 6 35,439
Alaska 4,589 3,885 83 4516
Arizona 36,380 39,415 108 34,013
‘Arkansas 18,189 15,054 8 23,937
California * 269,401 232.144 6 266,528
Colorado TM 18,576 18,173 8 15,362
Connecticut 11,683, 13,284 14 13,026
Delaware * 3517 3,606 103 4,307
Disuict of Columbia 4.928 16 ° 5,397
Florida 93,657 92,649 99 88,993
Georgia” 49,087 56,737 116 57,257
Hawaii 8,051 C) 9 6,985
aang 3,3) 5,323 63 7071
Mlinois 76,924 76.149 9 73,229
Indiana * 30,996 30,899 100 36,662
Towa* 13.506 13292 98 13,812,
Kansas * 15.3 12,362 80 13.463
Keatucky * 24,853, 33,143 133 29,198
Louisiana 35,696 39.270 no 40,460
Maine * 4.798 5397 112 5,762
Maryland 20,878 31,003 143 25,372
Massachusetts 22,891 31475 138 27237
Michigan * $6,301 $5,153 98 $1,526
Minnesota * 02} 28,909 143, 21,100
Mississippi * 23,3: 28,498 122 30,342
Missouri * 31,110 31236 100 32,516
Montana * 5,393 4442 qn 4.149
Nebraskt 8,609 7.099 82 9,012
‘Nevada * 8,791 1973 1 8,257
‘New Hampshire * 3,202 3,825 119 4,64)
New Jersey * 24.158 30,872 128 34,989
New Mexico 16,703 8,841 53 12,321
New York 123,146 130,517 106 115,726
North Carolina 45,040 50,149 Mk 30,147
North Dakota * 3,485 2,543 Bn 3,630
Ohio $7,640 63,865 M1 76,674
Oklahoma 24,185 23,176 96 25,869
Oregon 18.035 AGA8 Ey 15,856
Penneylvania # 56,175 57,853 103 57,338
Rhode Island 4,598 4975 108 S78
South Cerolina 26,258 27,774 106 33,096
South Dakora 4,932 4,226 a $211
Tennessee 335 34,165 102 52,402
‘Texas 152; 173,391 114 162,494
Utah * 18,351 14,358 94 12,939
Vermont * 2,1 3,321 120 2,951
Virginia 35,484 31918 a 92,063
‘Washington * 28,207 32,893 17 31,384
‘West Virginia 14,067 20,930 183 12,557
Wisconsin * 23.279 29.279 126 24,155
Wyoming * 3,063 = 3247 106 2Al4

SOURCES: WIC administrative data, FNS estimates of WIC eligibles, HCFA 2082 report.

“These are MSIS states whose 2082 report was generated by HCFA.
States with Medicaid enrolice numbers in boldface exceed CPS-based estimates of WIC eligibles.


Presumptive Eligibility for Pregnant Women.
State Medicaid programs have the option of
allowing medical providers to make an interim
determination, on the basis of preliminary
information, that a pregnant woman seeking
treatment appears to be financially eligible for
Medicaid benefits. This is known as “presumptive
eligibility.” The pregnant woman must then make
a formal application for Medicaid by the last day
of the month following the month in which the
determination of presumptive eligibility was made.
If the woman fails to apply for Medicaid, her
presumptive eligibility ends the last day of the
month after the month she is determined
presumptively eligible. If she applies for Medicaid,
her presumptive eligibility continues until the day
on which the state makes the eligibility
determination, Even if the state should determine
that the woman is not eligible, Medicaid will pay
for any services provided during the period of
presumptive eligibility. As of 1992, a total of 26
states had elected the presumptive eligibility
option (Table 1.2).

Transitional Coverage for Working Poor
Families. States are required to provide up to 12
months of extended Medicaid coverage to each
family that received AFDC in at least 3 of the 6
months preceding the month the family lost such
assistance due to either increased hours of
employment, increased income, or the loss of one
of the time-limited earned-income disregards.

Guaranteed Initial Enrollment Periods. States
with managed care programs may guarantee initial
Medicaid enrollment for up to 6 months,
regardless of changes in income. In addition, the
Balanced Budget Act of 1997 contains an option
for all states to guarantee 12 months of coverage
to children enrolled in Medicaid, regardless of
changes in family income. As pointed out above,
though, many states already have a de facto 1-year
guaranteed enrollment period simply because they
usually redetermine eligibility on an annual basis,

11



Table IV.1 includes information related to these criteria for the states
with a 1995 SMRF file (sorted by the size of the Medicaid infant
population in each state according to unadjusted 2082 data). This
information formed the basis for selecting six states for this study:
California, Florida, Michigan, Alabama, New Jersey, and Arkansas.
The attributes of the selected states are described below and in Table
IV.2:

* California, California has, by far, the most infants
enrolled in Medicaid nationwide. In addition, California
has relatively generous Medicaid eligibility policies (the
poverty level threshold for infants is 200 percent and the
state has a medically needy program), and California’s
population is mostly urban. California also has a very
large noncitizen population. In fact, in 1991, 45 percent
of the infants whose births were covered by Medicaid had
a noncitizen mother (Ellwood and Kenney, 1995).

¢ Florida, Like California, Florida has many infants
enrolled in Medicaid, a primarily urban population, many
noncitizens, and relatively generous Medicaid eligibility
policies (the poverty level threshold for infants is 185
percent and the state has a medically needy program).
Florida had the highest ratio of Medicaid infants to WIC-
eligible infants (156 percent), using the unadjusted 2082
data..

* Michigan. Michigan has eligibility policies similar to
those of California and Florida, but it has a mix of urban
and rural populations and is located in the Midwest.

* New Jersey. New Jersey has essentially the same
eligibility policies as Michigan, but it is located in the
Northeast and has a slightly higher concentration of urban
residents. New Jersey had a higher ratio of Medicaid
infants to WIC-eligible infants than Michigan (134
percent versus 103 percent, respectively), based on
unadjusted 2082 data.

* Alabama. Alabama is a key state to examine because it
has a large Medicaid infant population, but fairly
restrictive Medicaid eligibility policies (the poverty level
threshold for infants is 133 percent and the state does not
have a medically needy program). Alabama also has a
large rural population--40 percent of the population
resides in rural areas.

29





STATE MEDICAID
RESEARCH FILES
(SMRF)

Medicaid files until their second or third month of life. As
a result, infants born during the last few months of the fiscal
year who are covered by Medicaid may not be counted as
enrolled in the 2082 data for that year. This can occur in
both MSIS and non-MSIS states.

* A few states have some obvious problems with their 2082
data related to infants. For example, the District of Columbia
reports only 26 infants, and Hawaii does not report the ages
of any of its enrollees.

These problems make it difficult to form valid comparisons of the
number of WIC infants and Medicaid infants using HCFA 2082 data
for non-MSIS states. It is difficult to tell from the 2082 and WIC
administrative data whether state-to-state differences represent true
differences in the states, or simply differences in the way that states
report their data.

SMREF are person-based Medicaid enrollment and claims files that
are designed for research. The files are created from the MSIS files
that states submit in licu of a 2082 report, but they contain some
additional variables, go through additional quality checks, and are
based on the calendar year rather than the fiscal year.

The files include a person-summary file and four types of claims files.
The person-summary file, which is the most likely to be used for WIC
eligibility analyses, contains summary information on eligibility,
utilization, and expenditures for each person ever enrolled during the
calendar year. The person-summary file also contains basic
demographic data. Of particular interest for WIC research, the
demographic data identify pregnant women (based on inpatient claims
for delivery) and contain a set of uniform cligibility codes that classify
Medicaid enrollees into the key eligibility groups of interest for most
types of research. However, like the 2082 data, SMRF data contain
no information on family income or assets. SMRF files are checked
for quality, and a detailed set of tables indicating states’ data problems
is produced. The data quality documentation allows researchers to
tell whether a file can be used for a particular research purpose.

‘Prior to enrollment, any Medicaid charges for an infant can be made
to the mother’s Medicaid account. Thus, infants are covered under
Medicaid from birth but are not always shown as Medicaid enrollees
from the time of birth.

22



* Poverty-Related Eligibility Expansions and
Medicaid Waiver Programs. The Medicaid
program requires states to cover pregnant women,
infants, and children up to age 6 with family
incomes below 133 percent of poverty. States
also have the option to set an income standard up
to 185 percent of poverty for pregnant women and
infants, In addition, under the section 1902(r)(2)
provision of the Medicaid law, states can structure
their resource and income disregard policies to
qualify pregnant women and infants in families
with incomes above 185 percent of poverty-that is
above the WIC eligibility level. States may also
Teceive section 1115 waivers from HCFA that
permit them more flexibility in designing their
Medicaid programs, including qualifying pregnant
women and infants in families with incomes above
185 percent of poverty. According to National
Governor's Association data, seven states currently
qualify infants in families with incomes above 185
percent of poverty: California, Minnesota,
Vermont, and Washington under the 1902(r)(2)
provision, and Hawaii, Rhode Island, and
Tennessee under section 1115 waivers (Table
11.2).

* Medically Needy Programs. Thirty-seven states
have medically needy programs that cover persons
who are in one of the groups covered by Medicaid

. (that is, families with dependent children, pregnant
women, categorically eligible children, the aged,
the blind, and the disabled) but who do not meet
the income or resources standards for categorically
needy coverage (Table 11.2). These individuals are
eligible for medically needy coverage if their
income and resources, after deduction of incurred
medical expenses, fall below the state's medically
needy standards. The process of deducting
incurred medical expenses to reduce income to the
medically needy standard is known as
“spenddown.” Through spenddown, it is possible
for individuals in families at any income level to
qualify for Medicaid. Unfortunately, no data are
available on the income levels of medically needy
enrollees.



WIC Certification
Period of 6 to 12 Months

Nonresponse Bias
and Undercoverage
of the Population

The CPS-based estimates of WIC eligibles includes only those
eligible on the basis of their annual income because the CPS data only
report annual income. However, eligibility for WIC is generally
determined using monthly income with a certification period of 6 to
12 months.’ The 6 to 12 month certification period can lead to
discrepancies between estimates of WIC eligibles and WIC program
participants because, in any month, WIC program participants include
those with incomes below the eligibility threshold in that month, along
with those who were certified during the prior 6 to 12 months but
whose incomes are not below the threshold in that month.” Therefore,
during the year the program accumulates new mothers and children as
they become eligible, but it drops persons who become income
ineligible only after a delay of up to 12 months. Therefore, estimates
of those income eligible for WIC in any month of the reference
calendar year may mirror program practice more closely than other
measures. This could be a significant factor in the discrepancy of
eligibles because about 25 to 30 percent more infants and children live
in families that experience at least one month of WIC income
eligibility over the course of a year than live in such families in an
average month or on the basis of annual income. Indeed, research by
Gordon et al. (1997) suggests that a substantial number of WIC
participants appear of eligible for the program based on their annual
incomes (but probably were eligible in the month they were
certified).!°

The CPS is the source of the Federal government’ s official estimates
of poverty in the U.S. and is generally regarded as the best available
annual data source on the economic and demographic characteristics
of households in the U.S. The data are used regularly by
policymakers and researchers for planning and evaluating many
government programs.

"Infants are certified up to their first birthday and children are certified
for periods of up to six months,

Gordon et al. (1997) found that the discrepancies in estimates of WIC
eligibles are probably not attributable to the CPS reporting annual
income instead of monthly income, which is generally used as the basis
for WIC eligibility. Using SIPP data, they found that estimates of
eligibility based on annual income were not significantly different from
average monthly estimates.

"Using the SIPP data, Gordon et al. found that 8 percent of all WIC
Participants are not eligible based on their annual incomes but are
eligible during at least one month of the year.

14



Table Il.2 (continued)

Oregon 133 v

‘Pennsylvania 185 v v
Rhode Island 250 v v

South Carolina 185

South Dakota 133

Tennessee 185+ v v v
Texas 185 v v
Utah 133 v v
‘Vermont 225 v v

Virginia 133 Y

Washington 200 v v

West Virginia 150 v

Wisconsin 185 4 v
‘Wyoming 133 Y
Totals 7 35 31

Source: *“MCH Update: State Medicaid Coverage of Pregnant Women and Children-Summer 1996.”
National Governors' Association, September 1996.

»“MCH Update: State Medicaid Coverage of Pregnant Women and Children-Winter 1996.”
National Governors’ Association, March 1996.

10



USING SMRF FILES
TO IMPROVE
ESTIMATES OF
WIC ELIGIBLES

The main strengths of SMRF data are that they present detailed
person-level data (including pregnancy status and uniform eligibility
codes) that have been checked for quality. Although the SMRF files
are the best available source of data on Medicaid enrollment and
utilization, they do have some limitations. The first limitation is that
only about 30 states have SMRF files, and only for the past few years
for most states.’ * Table III.3 shows the states and years for which
SMRF files are available. The second limitation is that the quality of
SMRF files is ultimately dependent on the quality of states’ MSIS
files. These files, although improving each year, have had some
problems in the past. Finally, the third limitation is that SMRF files
are not as timely as 2082 data--there is currently a 2- to 3-year lag in
the release of SMRF files.

Like the 2082 data, the SMRF person-summary files can be used to
improve estimates of WIC eligibles. The SMRF data, however, are
generally better suited to this task than the 2082 because the SMRF
data can be used to calculate the average monthly Medicaid
enrollment of infants as well as children ages 1 to 4 in SMRF states.
Average monthly numbers are more comparable to WIC
administrative data and estimates of WIC eligibles than the annual
ever enrolled numbers shown in the 2082 data. SMRF data also
include a delivery indicator that identifies pregnant women on the
basis of claims data. However, there are concerns about the quality
of the data identifying pregnant women in some states. As mentioned
earlier, though, analyses in this report will focus on infants only,

The SMRF data can be used to adjust for several problems with the
2082 data. The monthly enrollment data available through SMRF
allow the determination of which states have delays in processing the
initial enrollment of infants. This is done by comparing the birth
month with the month of initial Medicaid enrollment and then, when
appropriate, using this information to make adjustments to the
calculation of average monthly enrollment figures. In addition, based
on the relationship between those ever enrolled and average monthly
enrollment in states with SMRF files, an adjustment factor can be

S5SMRF files should eventually be available for all states because the
Balanced Budget Act of 1997 mandates that all states participate in
MSIS by fiscal year 1999.

‘SMRF-like files created for an earlier project known as Tape-to-Tape
are available for 1980 to 1991 for California, Georgia, Michigan, and
Tennessee.

23



TABLE IL}

WIC ELIGIBLE INFANTS AND PARTICIPATING INFANTS IN 1995, BY STATE

WIC Eligible infamts*

“Approx. 90% WIC Participating Participation
Number Confidence Interval Infants** Rate

State (@) Lower Bound Upper Bound (b) (by(a)x100
All States 1,668,766 : - 1,816,872 109
Alabama 29,640 26,806 32,474 35,439 120
Alaska 4,589 3,911 5,267 4,516 98
Arizona 36,380 33,462 39,298 34,013 93
Arkansas 18,189 16,356 20,022 23,937 132
California 269,401 251,074 287,728 266,928 99
Colorado 18,576 16,463, 20,689 15,362 3
‘Connecticut 11,693 9,160 14,226 13,026 lll
Delaware 3,517 3,061 3973 4,307 122
District of Columbia 4,925 4,513 $337 5397 110
Florida 93,667 87,611 99,723 88,993 95
Georgia 49,047 43,754 54,340 57,257 7
Hawaii 8,031 7,035 9,027 6,985 87
Idaho 8.386 7371 9.395 7071 84
Mlinois 16,924 70,518 83,330 73,229 95
Indiana 30,996 27,023 34,969 36,662 18
Towa 13,506 12,167 14,845 13,812 102
Kansas 15,377 13,885, 16,869 13,463 88
Kentucky 24,853 2979 26,727 29,198 7
Louisiana 35,696 31,435 39,957 40,460 U3
Maine 4,798 4238 5,358 5,762 120
Maryland 20,878 18,229, 23,527 (25,372 122
Massachusetts 22,891 19,185 26,597 27,237 us
Michigan 56,301 50,093 62,509 51,526 2
Minnesota 20,211 17,021 23,401 21,100 104
Mississippi 23,354 20,712 25,996 30,342 130
Missouri 31,110 24s 34,505 32,516 105
Montana 5,393 4g15 son 4149 a
Nebraska 8,609 7411 9,747 9,012 105
Nevada 8,791 7,371 10,011 8,257 94
New Hampshire 3,202 2,451 3,953 4,641 145
New Jersey 24,158 22,126 26,190 34,989 M45
‘New Mexico 16,705 15,416 17,994 12,321 4
New York 123,146 114971 131,321 115,726 4
North Carolina 45,040 40,741 49,339 50,147 ut
North Dakota 3,485 3,096 3,874 3,630 104
Ohio 57,640 52,821 62,459 76,674 133
Oklahoma (24,185 21,997 26,373 25,869 107
Oregon 18,025 16,145 19,905 15,816 88
Pennsylvania 56,175 50,773 61,577 57,338 102
Rhode Island 4,598 3,876 5320 5,178 113
‘South Carolina 26,288 (24,107 28,469 33,096 126
South Dakota 4952 4,430 5474 $211 105
33,502 29,885 37,119 52,402 156
152,705 143,649 161,761 162,494 106
15,351 13,625 17,077 12,939 84
2,760 2,400 3,120 2,951 107
35,484 31,563 39,405 32,663 2
28,227 25,139 31315 31,384 m1.
11,067 10,157 11,977 12,557 13
23,279 19,952 26,606 24,155 104
3,063 2,808 3318 2,414 D

“CPS estimates based on annual income.
**Calendar year 1995 average monthly estimates generated from WIC National Data Bank Version 5 Preload System, July 9, 1998.



APPENDIX B

DERIVATION OF ADJUSTMENT FACTORS FOR THE DELAY
IN PROCESSING OF MEDICAID ENROLLMENT FOLLOWING BIRTH



MEDICAID
POLICIES
AND WIC
ELIGIBILITY

EXECUTIVE SUMMARY

The Food and Nutrition Service (FNS), which administers the Special
Supplemental Nutrition Program for Women, Infants, and Children
(WIC), asked Mathematica Policy Research to examine more closely
Medicaid’s role in adjunct eligibility (that is, automatic income
eligibility) for WIC. Individuals who participate in Medicaid are
adjunct eligible for WIC and do not have to show further proof of
income to qualify. FNS wanted to explore whether Medicaid may
have expansive effects on the WIC program by allowing persons who
have incomes above 185 percent of the federal poverty line (the
income eligibility standard for WIC) to qualify for WIC through
Medicaid. This study was motivated, in part, by apparent
discrepancies between FNS’s estimates of WIC eligibles based on data
from the Current Population Survey (CPS) and the number of WIC
participants according to administrative data. In some states, WIC
participants exceed the estimated eligibles, resulting in an implausible
WIC participation rate of more than 100 percent.

The objectives of this study were:

* To assess Medicaid’s role in expanding the WIC program
by reviewing Medicaid policies that make it possible for
persons with incomes above 185 percent of poverty to
qualify for Medicaid, and thus WIC.

* To describe the types of Medicaid administrative data that
are available to examine Medicaid’s role in WIC eligibility.

* To assess the extent to which Medicaid administrative
data may be able to improve CPS-based estimates of
infants eligible for WIC.

Several eligibility rules and practices are used by states that
may enable persons with incomes above 185 percent of
poverty to enroll in Medicaid and thus be eligible for WIC.
State Medicaid programs may use a more flexible definition of the
family unit to establish eligibility or may employ relatively longer
eligibility certification periods for pregnant or postpartum women and
infants. Medicaid eligibility redetermination practices may also differ



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20




THE 2082

I. OVERVIEW OF MEDICAID ADMINISTRATIVE DATA

There is no comprehensive national Medicaid data source. Instead,
program statistics are available through data submitted to HCFA by
states. This chapter describes two principal types of Medicaid
administrative data that are available to examine the issue of
Medicaid’s role in WIC eligibility--HCFA 2082 data and the SMRF
data. These data are used for the exploratory analysis of the effect of
Medicaid on WIC eligibility in Chapter IV. An overview of the HCFA
2082 and SMRF data is presented in Table III.1.

The 2082 data (named after the HCFA form on which the data are
submitted) is a hard-copy report showing yearly aggregate Medicaid
enrollment and claims by state and eligibility group.' Originally, all
states submitted hard copies of the 2082; now, more than 30 states
submit their 2082 data electronically through the voluntary Medicaid
Statistical Information System (MSIS) project. The 2082 data are
timely (the data for a given year are usually available within 12 months
after the end of the year), are easily obtainable, and include all 50
states and the District of Columbia. HCFA does only limited quality
checks on the data—quality assurance for the 2082 is ultimately the
responsibility of the states.

The 2082 is actually a series of tables for each state that report
aggregate data on Medicaid enrollees, recipients, service utilization
and payments for the federal fiscal year. The tables show such
information as the distribution of enrollees and recipients by age, sex,
and race. A list of the tables that make up the 2082 is provided in

'The official name of the 2082 is the Statistical Report on Medicaid
Care: Eligibility, Recipients, Payments and Sources.

?When using these tables, it is important to understand the distinction
between the terms “eligibles” and “recipients” on the 2082. Eligibles
are all those who were ever enrolled in Medicaid during the year
(commonly referred to as “enrollees”), regardless of whether they
used a service. Recipients, in contrast, are the subset of eligibles who
had services paid for during the year.

17


NUMBER OF INFANTS ENROLLED IN MEDICAID
ACCORDING TO SMRF DATA... 2.0... ccc cece cence ees

THE NUMBER OF INFANTS ENROLLED IN MEDICAID

USING ADJUSTED 2082 DATA ......... 0... cece cece eee eee eee

CONCLUSIONS ....... 2... o eect eee ee ne

REFERENCES ....... 20.00. 0c ccc ccc cece ccc tent e ete ences

APPENDIX A: CONTENTS OF HCFA FORM 2082 — 1993

APPENDIX B: DERIVATION OF ADJUSTMENT FACTORS
FOR THE DELAY IN PROCESSING OF MEDICAID
ENROLLMENT FOLLOWING BIRTH



Chapter

Il

CONTENTS

Page

EXECUTIVE SUMMARY ...........0.005 0020 c cece eens ix

INTRODUCTION .... 2.2.2 ene enn eee 1

WIC ELIGIBILITY AND MEDICAID ............... 00. cece eee eee eee 3

ESTIMATES OF WIC ELIGIBLES .............0.. 0.0.20 e cece eee eee 3

DISCREPANCIES IN WIC PARTICIPANTS RELATIVE

TO ELIGIBLES ..... ccc cee eee nena 4

MEDICAID POLICIES AND WIC ELIGIBILITY ......................4. 6

DISCREPANCIES IN ESTIMATES OF WIC ELIGIBLES:

OTHER EXPLANATIONS ....... 2.60.00 cece cece eee ee eee eee 12
WIC Certification Period of 6to 12 months ..................-.0000 08 14
Nonresponse Bias and Undercoverage of the Population ................ 14
Income Reporting Differences ........... 0... c cece eee eee eee eee 15
Family Unit Differences ............ 0.000 ccc c cece cece cee ents 16

OVERVIEW OF MEDICAID ADMINISTRATIVE DATA ................ 17

THE 2082 0.0... cece eee ete n tet ee ee eene 17

USING 2082 DATA TO IMPROVE ESTIMATES OF

WIC ELIGIBLES ...... 0.0... eee cc eee e eee 19

STATE MEDICAID RESEARCH FILES (SMRF) ...............00 20s ee 22

USING SMRF FILES TO IMPROVE ESTIMATES

OF WIC ELIGIBLES .......... 0.0... cece cece cnet e een e acne 23

AN EXPLORATORY COMPARISON OF

MEDICAID ENROLLEES AND ESTIMATES OF

WICELIGIBLES ...... 1. cence tenet en eeae 27

SMRF STATE SELECTION CRITERIA ..... 2.0.0... 0c cece eee eee eens 27


MEDICAID POLICIES
AND WIC
ELIGIBILITY

investigation, they do not necessarily mean that the current estimating
methodology or the funding formula is flawed from a public policy
and program operations perspective. It may be possible, however, to
improve estimates of WIC eligibles by taking into account Medicaid
policies that permit persons with incomes over 185 percent of poverty
to enroll in Medicaid, and thus in WIC. Those policies are described
next.

Medicaid is a complex program--states have numerous options with
regard to eligibility groups they cover, and the financial thresholds for
eligibility vary from state to state.* Further, no single up-to-date
source is available that describes all the Medicaid policies in each
state. Nevertheless, based on various sources, several eligibility rules
and practices can be identified that may enable persons with incomes
above 185 percent of poverty to enroll.’ These areas of policy and
practice include the flexible definition of the family unit for eligibility:
relatively long eligibility certification periods for pregnant or
postpartum women and infants; eligibility redetermination practices;
recent poverty-related eligibility expansions; Medicaid waiver
programs, medically needy programs; presumptive eligibility for
pregnant women; transitional coverage for working poor families; and
guaranteed enrollment periods. Each of these policies is discussed in
more detail below.

¢ Flexible Definition of Family Unit for
Eligibility. Many states allow caseworkers to
exercise latitude in defining the family unit for
- Medicaid income eligibility determinations in order
to maximize the possibility of eligibility.
Therefore, some individuals in families with

‘Medicaid is a joint federal and state program. The federal
government sets broad program guidelines and provides matching
funds for the program, while the states administer the program and
have fairly wide discretion in setting eligibility policies. Medicaid,
therefore, essentially comprises 51 separate programs (one for each
state and the District of Columbia).

‘Most of information presented here on state Medicaid policies comes
from the Medicaid Source Book (U.S. House of Representatives,
1993) and various editions of MCH Update, which present the results
of periodic national surveys of state Medicaid coverage of pregnant
women and children conducted by the National Governors’
Association.



TABLES (continued)

Table Page

IV.6 DISTRIBUTION BY STATE OF INFANTS
ENROLLED IN MEDICAID (ADJUSTED
2082 DATA), ESTIMATES OF WIC ELIGIBLES,
AND INFANTS PARTICIPATING IN WIC .... 00.20 39

Bl DISTRIBUTION OF MEDICAID INFANTS BY
STATE AND MONTH FIRST ENROLLED IN
MEDICAID (RELATIVE TO BIRTH MONTH) ..................0.0.. B3

B2 REPORTED VERSUS ESTIMATED NUMBER OF
INFANTS AGE 0 TO2MONTHS ................ 00.0 .e cece eee eee B.4

B3 ADJUSTED DISTRIBUTION OF AVERAGE
MONTHLY NUMBER OF INFANTS BY AGE IN
MONTHS .... 0.0... cece cece cece etn tenet n ete e eee een es BS


DISCREPANCIES IN
ESTIMATES OF
WIC ELIGIBLES:
OTHER
EXPLANATIONS

The above Medicaid policies make it possible for women, infants, and
children in families above 185 percent of poverty to qualify for
Medicaid. The flexible definition of the family unit for eligibility, the
guaranteed certification period for pregnant/postpartum women and
infants, and the eligibility redetermination policies are likely to be the
most significant factors in explaining why families with income above
185 percent of poverty may be enrolled in Medicaid. Medically needy
programs and recent poverty-related expansions above 185 percent of
poverty may also be significant factors.’

Medicaid adjunct eligibility is only one of several factors that may
explain discrepancies in the estimates of WIC eligibles. In this
section, four other factors are discussed that relate to the CPS data
used for the estimates. First, CPS-based estimates of WIC eligibles
based on annual income alone may lead to discrepancies with reported
WIC program participants because participants are certified for
periods of 6 to 12 months. Second, the CPS data may be affected by
nonresponse bias and undercoverage of the population. Third, income
in the CPS data may be reported differently from the way it is typically
reported to caseworkers. Finally, WIC income eligibility is calculated
based on the CPS definition of family, which includes all related,
subfamilies, whereas eligibility for WIC may sometimes be determined
using subfamilies.

"The poverty-related expansions above 185 percent, though, pertain
only to 7 states. The Medicaid poverty level threshold for infants for
each state and the corresponding estimated WIC participation rate is
presented in Table II.3 (sorted by the poverty level threshold and then
the participation rate). States with Medicaid poverty level thresholds
below 185 percent of poverty are less likely to have the implausible
participation rates of over 100 percent (8 of 22 states; 38 percent)
than states with poverty level thresholds of 185 percent or higher (23
of 29 states; 70 percent). However, except for Tennessee, which has
the highest WIC participation rate of all (154 percent), states with
poverty level thresholds of greater than 185 percent of poverty do not
generally have participation rates any higher than that of states with
poverty level thresholds of exactly 185 percent of poverty.

12



USDA
—

Department of
Agriculture

Food and
Nuuition
Service

Office of
Analysis and
Evaluation

Medicaid Policies and
Eligibility for WIC

ab0/S34/b0SN

WWeStTT 6667 ET 'das


(3) Adjust upward the number of infants in each
state to account for delays in reported
enrollment of newborns.

The results of these steps are shown for all states in Table IV.4. The
first step is to adjust downward the 2082 counts of infants in non-
MSIS states by one-third. This is done because non-MSIS states
count infants ever enrolled in Medicaid who were born during an 18-
month period. This problem does not occur with MSIS states, which
count only infants born during a 1-year period who were ever enrolled
in Medicaid. The effect of the step 1 adjustment on the HCFA 2082
data is shown in the second column of Table IV.4 (the first column
shows the number of infants in each state as reported in the unadjusted
2082).6

The second step is to adjust downward the number of infants in all
states so that the data represent the average monthly number of infants
enrolled during the year, as in the WIC eligibles estimates, rather than
those ever eligible during the year. The adjustment is downward
because the number of infants enrolled in an average month is
somewhat lower than the number born during the year who were ever
enrolled in Medicaid. (There are delays in the initial processing of
enrollment of infants, and some infants do not remain enrolled for the
entire year.) As shown in Table IV.5, according to SMRF data the
average monthly enrollment of infants is from 5 to 12 percent less than
the annual enroliment in the six states examined for this study.” The
median difference between the average monthly number and the

‘For the purposes of this report, non-MSIS states are defined as those
that did not have their 2082 reports created by HCFA using the MSIS
data. In 1995, seven states had MSIS systems that were not yet
approved by HCFA and thus were required to submit a hard-copy
2082 report. As a result, the number of infants in these states need to
be adjusted in step 1 to be equivalent to approved MSIS states.

7Average monthly enrollment was calculated by tabulating the number
of persons under age 1 in each month of the year, and then averaging
the monthly estimates over all 12 months. The number of infants ever
enrolled was calculated by tabulating the number of persons under age
1 in the last month of the year who were ever enrolled during the year.
Overall, the difference between average monthly enrollment and the
number ever enrolled for infants is generally smaller than for older
persons because infants are usually certified for a full year. For
children ages 1 through 4, average monthly enrollment is from 19 to
34 percent less than the number ever enrolled.

35



AN EXPLORATORY
COMPARISON OF
MEDICAID
ENROLLEES AND
ESTIMATES OF WIC
ELIGIBLES

CONCLUSIONS

SMRF files for 6 states were used to estimate lags in the Medicaid
enrollment of infants and to compute average monthly Medicaid
enrollment numbers for infants. On the basis of these SMRF data,
steps were then developed to adjust the HCFA 2082 data, which are
more timely than SMRF and available for all states, to average
monthly estimates that are comparable to estimates of WIC eligibles.
After adjustments, the 1995 2082 data showed that over half the
states had more infants enrolled in Medicaid than were estimated to
be eligible for WIC using CPS data. For 9 states (Kentucky,
Maryland, Massachusetts, Minnesota, Mississippi, New Jersey,
Vermont, West Virginia and Wisconsin) the number of Medicaid
infants exceeded the estimates of WIC eligibles by 20 percent or more.
Many of these states have relatively generous Medicaid eligibility
policies which might explain why Medicaid enrollment was
substantially greater. However, these results should be interpreted
cautiously because the adjustment factors for the 2082 data were
based on a small group of states that were not necessarily
Tepresentative of all states.

Study results confirm that Medicaid eligibility policies make it possible
for persons with income greater than 185 percent of poverty to qualify
for WIC through adjunct eligibility. Further, adjusted 1995 Medicaid
administrative data indicate that a majority of states report more
infants enrolled in the Medicaid program than were estimated to be
eligible for WIC based on CPS data. These results suggest that
Medicaid administrative data may be useful to FNS in improving the
estimates of WIC eligibles. However, MPR recommends that the
adjustment factors for the 2082 data should be re-estimated using a
broader group of states than were used for this study.

The number of Medicaid infants could be useful as a lower-bound
estimate of WIC eligibles in states where the number of Medicaid
enrollees exceeds the CPS-based estimates of WIC eligibles. Revised
state estimates could also be usefull to adjust the CPS-based national
estimate of WIC eligibles.

With the passage of the State Children's Health Insurance Program
(CHIP), state Medicaid programs have even more incentives to
expand public health coverage for children. Several states are now
extending Medicaid to children in families with income beyond 185
percent of poverty. This will make it even more important in the
future for FNS to take Medicaid adjunct eligibility into account in its
estimates of WIC eligibles. Further, as more states begin to use
income thresholds of 250 to 300 percent of poverty for Medicaid,



DISCREPANCIES IN
ESTIMATES OF WIC
ELIGIBLES: OTHER
EXPLANATIONS

MEDICAID
ADMINISTRATIVE
DATA

considerably from those used by the WIC program. Finally, state
medically needy programs and recent poverty-related expansions to
income thresholds above 185 percent of poverty in some states may
be significant factors as well.

Several factors that relate to the Current Population Survey
(CPS) data used for estimates of WIC eligibles may also help
explain discrepancies in estimates of WIC eligibles. First, CPS
estimates of WIC eligibles based on annual income alone may lead to
discrepancies with reported WIC program participants because WIC
participants are certified for periods of up to 6 to 12 months. Asa
result, the WIC program accumulates new participants as they become
eligible, but drops persons who become income ineligible only after a
delay of up to 12 months. Second, the CPS, like most surveys, has
some degree of nonresponse and undercoverage of the population.
This could affect estimates of WIC eligibles if nonrespondents or
those missed by the survey are more likely to be eligible for WIC.
Third, income reported in a survey such as the CPS may differ from
the way that it is reported to an eligibility caseworker when applying
for benefits. Finally, differences in how a WIC caseworker and the
CPS define a family unit for eligibility may also explain discrepancies
in estimates of WIC eligibles.

There is no single source of data on Medicaid enrollees that is
comparable to estimates of WIC eligibles. However, two sources of
Medicaid administrative data, when analyzed together, can be used to
make comparisons with estimates of WIC eligibles. Those two
sources are the HCFA 2082 report and State Medicaid Research Files
(SMRF). The 2082 is a hard-copy report submitted by states showing
yearly aggregate data on Medicaid enrollees, recipients, service
utilization, and payments for the federal fiscal year. The data are
timely, easily obtainable, and include all 50 states and the District of
Columbia. The SMRF files are person-based data on Medicaid
enrollees derived from electronic files submitted to HCFA by many
states in lieu of a hard copy 2082 report. SMRF files, which are
currently available for about 30 states, include information on
eligibility, utilization, expenditures, and demographics for each person
ever enrolled during a calendar year.





TABLE IV.2
CHARACTERISTICS OF STATES SELECTED FOR ANALYSIS

Infants Ever Enrolled in Medicaid in FY
1995 According to Unadjusted HCFA
2082 Data Poverty- | Medically
% of WIC-Eligible Level Needy
State Number Infants Cutoff Program Region Other Attributes
ee Mostly urban, many
California 244,220 a1 200 v West nonciti
. Mostly urban, many
Florida 146,203 156 185 v Southeast tg
cope ‘ Mix of urban and
Michigan 58,022 103 185 v Midwest rural ations
Mix of urban and
Alabama 36,086 122 133 South rural lations
New Jersey 32,478 134 185 v Northeast | Mostly urban state
‘Mix of urban and
Arkansas 15,837 87 133 v South nual ations

31



USING 2082 DATA TO
IMPROVE ESTIMATES
OF WIC ELIGIBLES

Appendix A. An example of 2082 data can be found’in Table III.2,
which shows the distribution of Medicaid enrollees by state and age?

The 2082 contains no information on pregnancy status, family income,
or assets. In addition, the 2082 provides only limited information on
how enrollees qualified for Medicaid. HCFA uses only two data
elements to classify the eligibility status of enrollees~maintenance
assistance status (MAS) and basis of eligibility (BOE). The MAS
refers to whether the enrollee qualified for Medicaid under the AFDC
or Supplemental Security Income (SSI) cash programs, a medically
needy program, or some other route; the BOE refers to whether the
enrollee qualified as (1) aged, (2) blind, (3) disabled, (4) a child, or (5)
an adult caretaker or pregnant woman.

The specific MAS categories are as follows:

1. Categorically needy, receiving cash assistance

2. Categorically needy, not receiving cash assistance
3. Medically needy

4. Other coverage groups prior to 1988

5. Other coverage groups 1988 and later

A major drawback to the current MAS categories is that they are too
broad for analyzing certain Medicaid populations. For instance, the
poverty-related expansion groups, which are of interest to this WIC
study, cannot be uniquely identified using MAS codes because these
groups can fall under MAS categories 4 and 5. However, HCFA is
changing the MAS classification, beginning with the fiscal year 1997
2082 data, so that enrollees in the poverty-related expansion groups
will be identifiable in future years.

Estimates of WIC eligibles may be improved by using the Medicaid
2082 data to determine the number of infants enrolled in Medicaid in
each state for the following reasons. As stated earlier, because of
adjunct eligibility, all Medicaid enrollees are automatically income-
eligible for WIC. Therefore, the number of Medicaid enrollees in each

3Although this is not actually a 2082 table, it was created by HCFA
from 2082 data.

19



TABLE IV.4

1995 HCFA 2082 DATA ADJUSTMENTS FOR INFANTS TO OBTAIN COUNTS COMPARABLE TO.
WIC ADMINISTRATIVE DATA AND ESTIMATES OF WIC ELIGIBLES

‘Non-MSIS States Adjusted All States Adjusted All States Adjusted Tiperard
Downward 33% for Infant Downward 6.9 % for 2.1% for Delay in Processing
Unadjusted ‘Accounting Differences ‘Average Monthly Estimate of Infants
State HCFA 2082 (Step 1) {Step 2) {Step 3)
All States 2,278,492 1,795,750 1,672,843 1,706,952
Alabama ¢ 36,086 36,086 33,596 34,302
Alaska 6,130 4,087 3,805 3,85
Arizona 62,198 41,465 38,604 39,415
‘Arkansas * 15,837 15,837 14,744 15,054
California * 244,220 244,220 27,369 232,144
Colorado * 19,118 19,118 17,799 18,173
Connecticut 20,963 13,975 13,011 13,284
3,794 3,794 3,532 3,606
26 7 16 16
146,203 97,469 90,743 92,649
59,689 59,689 55,570 56,737
0 0 0 0
8,400 5,600 $214 5323
120,168 80,110 74,582 76,149
32,506 32,506 30,263 30,899
13,983 13,983 13,018 13,292
13,005 13,005 12,108 12,362
34,867 34,867 32,461 33,143
61,969 41,313 38,462 39,270
5,678 5,678 5,286 $397
48,924 32,616 30,365 31,003
49,669 33,113 30,828 31,475
58,022 58,022 $4,018 $5,153
30,413 30,413 28,315 28,909
29,981 29,981 27,912 28,498
32,861 32,861 30,594 31,236
4,357 4,357 4,056 4,142
11,202 7,468 6,953 7,099
8,388 8,388 7,809 1973
4,024 4,024 3,746 3,825
32,478 32,478 30,237 30,872
13,952 9,301 8,660 8841
205,960 137,307 127,833 130,517
79,137 52,758 49,118 50,149
2,675 2,675 2,490 2,543
100,781 67,187 62,551 63,865
36,572 24,381 22.699 23,176
7,334 4,889 4,552 4,648
60,863 60,863 56,663 57,853
7,850 5,233, 4872 4,975
43,828 29,219 27,203 274
6,669 4446 4,139 4,226
53,913 35,942 33,462 34,165
273,616 182,411 169,824 173,391
15,105 15,105 14,063 14,388
3,494 3,494 3,253 3,321
49,737 33,158 30,870 31,518
34,604 34,604 32,216 32,893
33,028 22,019 20,499 20,930
30,802 30,802 28,677 29,219
3,416 3,416 3,180 3,247

SOURCE: 1995 HCFA 2082 report.

“*These are MSIS states whose 2082 report was generated by HCFA. Alaska, Arizona, Florida, Idaho, New Mexico, Rhode Island, and Tennessee also

submitted MSIS data to HCFA in 1995. However, these states were still re

quired to submit a hard-copy 2082 report in 1995 because their MSIS systems

had not yet been approved by HCFA. As. result, the number of infants in these states need to be adjusted in step 1 to be equivaleat to approved MSIS.

states,

36



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IV.5

TABLES

WIC ELIGIBLE INFANTS AND PARTICIPATING

INFANTS IN 1995, BY STATE ........................

MEDICAID ELIGIBILITY CRITERIA, BY STATE ........

MEDICAID POVERTY LEVEL THRESHOLDS FOR
INFANTS AND WIC INFANT PARTICIPATION

RATES, BY STATE ........0.. 0000... s ccc e eee eee ee

STATE SUMMARY TABLE OF MEDICAID ELIGIBLES

BY AGE FISCAL YEAR 1995 2.0.00... eee eee eee

MSIS PARTICIPATION AND SMRF FILE STATUS,

BY STATE 2.0... e ence ences

MEDICAD ELIGIBILITY CHARACTERISTICS OF
STATES WITH A 1995 SMRF FILE, SORTED BY SIZE OF

MEDICAID INFANT POPULATION .................0.4%

CHARACTERISTICS OF STATES SELECTED FOR

ANALYSIS 22.0.2... ccc cence cence

DISTRIBUTION BY STATE OF INFANTS
PARTICIPATING IN WIC, ESTIMATED TO BE

ELIGIBLE FOR WIC, AND ENROLLED IN MEDICAID ....

1995 HCFA 2082 DATA ADJUSTMENTS FOR INFANTS
TO OBTAIN COUNTS COMPARABLE TO WIC
ADMINISTRATIVE DATA AND ESTIMATES OF

WIC ELIGIBLES .......... 00. e cee e eee

DISTRIBUTION OF INFANTS ENROLLED IN
MEDICAID BY STATE: ANNUAL VERSUS
AVERAGE MONTHLY ENROLLMENT .............

vii



TABLE 11.2

MEDICAID ELIGIBILITY CRITERIA, BY STATE

Expanded Medicaid Coverage of
Infants as of 1996*
Income Presumptive
Threshold > WIC Income | Medically Needy Eligibility for
State (% of poverty) Threshold Program* Pregnant Women?
Alabama 133
Alaska 133
Arizona 140
Arkansas 133 v v
California 200 v v v
Colorado 133 v
Connecticut 185 v v
Delaware 185
District of Columbia 185 v v
Florida 185 v v
Georgia 185 v v
‘Hawaii 300 v v v
Tdaho 133 v
Illinois 133 v v
Indiana 150
Towa 185 v v
Kansas 150 v
Kentucky 185 v
Louisiana 133 v
Maine 185 v v
Maryland 185 v v
Massachusetts 185 v v
Michigan 185 v
Minnesota 275 v v
Mississippi 185
Missouri 185 v
Montana 133 v v
Nebraska 150 v v7
Nevada 133
‘New Hampshire 185 v v
New Jersey 185 v v
‘New Mexico 185 v
New York 185 v v
North Carolina 185 Vv Vv
North Dakota 133 v
Ohio 133 7
Oklahoma 150 v v





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B3



derived to estimate the average monthly enrollment for infants from
reported enrollment in the 2082.

Without linking records at the person-level, SMRF and WIC
administrative data enrollment numbers will not identify the degree of
overlap between the programs. However, these data can be used to
show whether and by how much the average monthly number of
Medicaid enrollees exceeds the average monthly number of WIC
eligibles. In short, becausc of adjunct eligibility, the number of
Medicaid enrollees can be viewed as a lower-bound estimate of the
number of WIC eligibles in the state.

26



SMRF STATE
SELECTION
CRITERIA

IV. AN EXPLORATORY COMPARISON OF MEDICAID
ENROLLEES AND ESTIMATES OF WIC ELIGIBLES

A key objective of this study was to examine whether Medicaid
administrative data might be useful in improving CPS-based estimates
of WIC eligibles. In particular, if the number of Medicaid enrollees in
a state typically exceeds the estimated number of WIC eligibles, then
Medicaid enrollee counts could be useful in adjusting the estimate of
WIC eligibles. In this chapter, 1995 SMRF files for six states are used
to compare the number of infants enrolled in Medicaid to estimates of
WIC eligibles to explore whether Medicaid data do indeed provide a
higher estimate of WIC eligible infants than current CPS estimates.
SMRF files were chosen for this analysis instead of HCFA 2082 data
because the counts of Medicaid enrollees in the 2082, which show
those ever enrolled during the year, are not comparable to the CPS-
based estimates of WIC eligibles, which show those eligible in an
average month. On the basis of the SMRF analysis, though, steps
were developed to adjust HCFA 2082 data, which are more timely
than SMRF data and available for all states, to average monthly
estimates that are comparable to estimates of WIC eligibles. Medicaid
enrollee counts from adjusted 2082 data for all states are then
compared to estimates of WIC eligibles to draw conclusions about the
overall usefulness of Medicaid data for WIC.

This analysis focuses on infants because discrepancies between
estimates of WIC eligibles and participants seem to affect infants
disproportionately. However, this analysis will also be applicable to
women because estimates of women eligible for WIC are derived from
the number of eligible infants.

Project cost and time constraints permitted analysis of 1995 SMRF
data for 6 of the approximately 27 states with 1995 SMRF files
available. Data for 1995 were used because they are the most current
data available. States were selected for this analysis so that a wide
range of Medicaid eligibility policies and demographic characteristics
are represented.

27





Income Reporting
Differences

However, like most national survey data, the CPS has some degree of
nonresponse and undercoverage of the population. Nonresponse
occurs when respondents are unable or unwilling to respond to survey
questions; the nonresponse rate for the CPS is usually about 10 to 15
percent. Undercoverage of the population results from missed
housing units and missed persons within sampled households; the
undercoverage rate for the CPS is estimated by the Census bureau to
be about 8 percent." The Bureau notes that adjustments to the CPS
weights reduce the problems of nonresponse and undercoverage
somewhat, but not totally.” As a result, the CPS data may be biased
to the extent that nonrespondents and those missed by the survey
differ systematically from those that respond to the survey.
Unfortunately, measuring such bias is difficult, and thus the magnitude
of its effect on the on the CPS is unknown. These problems could
lead to underestimates of WIC eligibles if nonrespondents and those
missed by the survey are more likely to be WIC eligibles,

Estimates of WIC eligibles based on the CPS may be affected by
differences in income reporting in the CPS data in comparison to the
way that income is reported to a WIC eligibility caseworker. Radbill
(1996) makes the following points about this issue:

¢ WIC applicants may underreport their incomes to
caseworkers to ensure eligibility for the program. Indeed,
a number of states either require no income documentation
in establishing WIC eligibility or allow local discretion in
establishing documentation rules.”

"The Census Bureau notes that undercoverage varies with age, sex,
and race. Generally, undercoverage is larger for males than for females
and larger for Blacks and other races combined than for Whites.
Census Bureau Web Site. “Source and Accuracy of the Data for the
March 1997 Current Population Survey Microdata File.”
[www.bis.census.gov/cps/ads/1997/ssrcacc.htm]. July 1998.

For a further discussion of this subject, see Shapiro et al. (1993) and
Lloyd (1998). Lloyd discusses this problem in terms of the SIPP;
however, his conclusions are applicable to the CPS as well.

"In 1994, the states that required no income documentation were
Massachusetts, Delaware, Arkansas, Oklahoma, Nebraska, Alaska,
Nevada, Washington, and most Indian Tribal Organizations. The
states that allowed local discretion in determining documentation rules

(continued...)

15



APPENDIX A

CONTENTS OF HCFA FORM 2082 — 1993



TABLE B.2

REPORTED VERSUS ESTIMATED NUMBER OF

INFANTS AGE 0 TO 2 MONTHS
Reported # of Infants Estimated # of Infants
Age 0 to 3 Months Age 0 to 2 Months Monthly Adj. Factor

Age in Months @ () (a/b)
Alabama

Month 0 23,910 27,292 1.141

Month 1 25,309 27,292 1.078

Month 2 26,418 27,292 1.033

Month 3 27,292 - -
Arkansas

Month 0 7,319 12,528 1.712

Month 1 10,575 12,528 1.185

Month 2 11,899 12,528 1,053

Month 3 12,528 - -
California

Month 0 108,746 176,200 1.620

Month 1 144,453 176,200 1.220

Month 2 163,956 176,200 1.075

Month 3 176,200 - -
Florida

Month 0 65,130 - 73,585 1.130

Month 1 68,404 73,585 1.076

Month 2 71,383 73,585 1,031

Month 3 73,585 - -
Michigan

Month 0 40,388 45,123 1117

Month 1 43,445 45,123 1.039

Month 2 44,489 45,123 1.014

Month 3 45,123 - -
New Jersey

Month 0 23,676 27,354 1.155

Month 1 25,245 27,354 1.084

Month 2 26,451 27,354 1.034

Month 3 27,354 : -

B4



ACKNOWLEDGMENTS

‘The authors would like to thank Janet Schiller of the U.S. Department of Agriculture, Food and
Nutrition Service (FNS) for developing the initial plan for this report and for providing guidance
throughout its course. We would also like to thank Jay Hirschman, Cindy Long, and others at FNS
who reviewed initial drafts of this report and provided helpful comments. At Mathematica Policy
Research, we would like to express our gratitude to Anne Gordon, who reviewed numerous drafts
and whose keen insights on the policy implications of using Medicaid enrollment data to enhance
estimates of WIC eligibles were invaluable. Finally, we would like to thank Besaida Rosado for
producing this report.

iti



THE NUMBER

OF INFANTS
ENROLLED IN
MEDICAID USING
ADJUSTED 2082
DATA

that in some states, the number of Medicaid infants for a given year is
greater than the CPS-based estimates of WIC eligible infants.
However, this pattern does not hold true in all states, suggesting that
Medicaid eligibility policies do not explain all the discrepancies
between estimates of WIC eligibles and actual participation.*

Although the SMRF files are a rich source of information on Medicaid
enrollees, it would be preferable to use data that are more timely and
are available for all 50 states. In the next section, SMRF data for the
six study states are used to develop a set of adjustments to 2082 data
that make the 2082 data more comparable to the estimates of WIC
eligibles.

Medicaid 2082 data count infants using a methodology that is
different from the way infants are counted in WIC administrative data
and estimates of WIC eligibles. WIC administrative data and
estimates of WIC eligibles count the average monthly number of
infants, whereas the 2082 data count either the number of infants born
during a 1-year period in approved MSIS states or, in non-MSIS
states, the number of infants born during an 18-month period who
were ever enrolled in Medicaid. Findings from analysis of the SMRF
data, though, make it is possible to adjust the 2082 data for all states
to obtain an estimate of the average monthly number of infants
enrolled in Medicaid in each month. This adjustment takes two or
three steps, depending on whether the state being analyzed is an MSIS
or anon-MSIS state. The adjustments involve the following steps:

(1) _ Adjust downward the counts of infants in non-
MSIS states to be equivalent to the counts in
MSIS states.

(2) Adjust downward the number of infants in all
states so that the data represent average
monthly enrollment.

SThis same analysis on children age | through 4 suggests that using
Medicaid administrative data for children would add little to estimates
of WIC eligibles. For all the states except New Jersey, the number of
CPS eligibles exceeds the number of Medicaid enrollees by 26 to 89
percent. In New Jersey, however, the number of Medicaid enrollees
is about 10 percent higher than the number of CPS eligibles and about
50 percent higher than the number of WIC participants.

34



NUMBER OF
INFANTS
ENROLLED IN
MEDICAID
ACCORDING TO
SMRF DATA

* Arkansas. Arkansas has demographic characteristics
similar to those of Alabama but somewhat different
Medicaid eligibility policies. Like Alabama, the poverty
level threshold for infants is 133 percent, but Arkansas
has a medically needy program. Arkansas had the lowest
ratio of Medicaid infants to WIC-eligible infants (87
percent), using unadjusted 2082 data.

The average monthly number of infants enrolled in Medicaid in each
of the six study states according to 1995 SMRF data is presented in
Table IV.3, The number of infants enrolled in each state was adjusted
upward somewhat because detailed analyses of SMRF data showed
that states have delays in the processing of Medicaid enrollment
following birth.* After adjustments, the number of infant Medicaid
enrollees exceeded CPS estimates of WIC eligibles in three of the six
states examined: Alabama, Michigan, and New Jersey. In these
states, the number of Medicaid enrollees exceeded the CPS estimate
of WIC eligibles by 13 percent, 2 percent, and 49 percent,
respectively. (In Alabama, though, the number of Medicaid infants
was below the average monthly number of WIC participants.) In the
other three states, the number of Medicaid enrollees was lower than
the CPS estimates of WIC-eligible infants--California by 13 percent,
Arkansas by 12 percent, and Florida by 2 percent.*

To some extent, these results were expected because the six states
were selected to include both states with higher and lower numbers
of Medicaid infants (according to unadjusted 2082 data) relative
to WIC-eligible infants. Nevertheless, these results demonstrate

°As mentioned earlier, prior to enrollment, any Medicaid charges for
an infant are made to the mother’s Medicaid account. Thus, infants
are covered under Medicaid from birth, but they are not always shown
as Medicaid enrollees from the time of birth. The adjustment factor
for each state is shown in a footnote to Table IV.3; the derivation of
the adjustment factors is described in Appendix B.

“It should be noted that the 1995 SMRF data for Florida indicate a
much lower number of Medicaid infants ever enrolled than the state's
unadjusted 2082 data for 1995. In 1995, Florida was not yet fully
approved for the MSIS system. As a result, the state submitted its
own 2082 report in 1995 using an 18 month period for counting
infants, similar to the approach used by other non-MSIS states. As
expected, SMRF data showed about 30 percent fewer infants ever
enrolled in 1995 than the number of infants ever enrolled according to
the 2082 data.

32



v

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and
activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs,
sexual orientation, or marital or family status. Persons with disabilities who require alternative
means for communications of program information (Braille, large print, audiotape, etc.) should
contact USDA's TARGET Center at (202) 720-2600 (voice and TTD).

To file a complaint of discrimination, write USDA Director, Office of Civil Rights, Room 326-W,
Whitten Building, 14th and Independence Avenue, S.W., Washington, D.C. 20250-9410 or call
(202) 720-5964 (voice and TTD). USDA is an equal opportunity provider and employer.



The objectives of this study were:

* To assess Medicaid’s potential role in expanding the WIC
program by reviewing Medicaid policies that make it
possible for persons with incomes above 185 percent of
poverty to qualify for Medicaid, and thus WIC.

* To describe the types of Medicaid administrative data that
are available to examine Medicaid’s role in WIC eligibility.

¢ To assess the extent to which Medicaid administrative
data may be able to improve CPS-based estimates of
infants eligible for WIC by comparing the estimated
number of infants eligible for WIC with the number of
infants enrolled in Medicaid according to administrative
data from the State Medicaid Research Files (SMRF) and
the Health Care Financing Administration’s (HCFA) 2082
Teport.

Chapter II describes the Medicaid eligibility policies that allow
persons with incomes above 185 percent of poverty to qualify for
Medicaid. Chapter II also includes a discussion of issues related to
the Current Population Survey (CPS) data used for FNS’s estimates
that, in conjunction with Medicaid policies, might help to explain why
WIC participation rates exceed 100 percent in some states. Chapter
III presents an overview of the two types of Medicaid administrative
data that are available to examine the effect of Medicaid on WIC
eligibility: the SMRF data and HCFA 2082 data. Chapter IV then
presents the results of an exploratory analysis of Medicaid
administrative data on infants. The analysis focuses on infants because
discrepancies in estimates of WIC eligibles seems to affect infants
disproportionately and because estimates of women cligible for WIC
are based on the number of eligible infants.







DISCREPANCIES IN
WIC PARTICIPANTS
RELATIVE TO
ELIGIBLES

categorically eligible and income-eligible for the program. For
example, a state with one percent of the eligible persons has a fair
share of one percent of total available funds. Remaining funds are
allocated only to below-fair-share states,’

Allocating funds for the WIC program, therefore, requires estimating
the number of WIC eligibles in each state. The primary data source
for these estimates is the March CPS.” Because the CPS sample sizes
in all but the largest states are too small for precise state-level
estimates, the USDA's official number of eligibles per state is
calculated using a Bayesian shrinkage estimator that optimally
averages the CPS direct sample estimates of WIC eligibles and the
predictions of WIC eligibles obtained from a regression model.? In
comparison to a simple CPS estimate of eligibles in a given state, the
shrinkage technique provides a substantially more precise estimate by
“borrowing strength” from CPS data from other states, CPS data from
previous years, and census and program administrative data. In the
1992 estimates of WIC eligibles, the shrinkage confidence interval
was, on average, 61 percent narrower than the corresponding direct
sample confidence interval--about the same gain in precision that
would be obtained from increasing the sample size of the CPS from
fewer than 60,000 households to nearly 400,000 households.
Estimates of WIC eligibles for 1995 are presented in Table II.1. As
shown in the last column of this table, the overall WIC participation
rate in 1995 was 109 percent.

The discrepancy in WIC eligibles does not necessarily affect the
allocation of WIC funds to states because each state's fair share is not
dependent. on the overall estimate of eligibles, but rather on its
relative share of that estimate. Moreover, the funding formula does
not distribute funds exclusively on the basis of the estimate of
eligibles. Although discrepancies are of concern and merit

"This description of the WIC funding formula is drawn from Schirm
and Long (1995).

*Bligibility is defined in terms of categorical eligibility, income
eligibility, and nutritional risk status. However, nutritional eligibility
is considered only for national estimates of WIC eligibles. The
individual states estimates consider only categorical and income
eligibility.

Examples of predictor variables in the regression model are receipt
of public assistance, receipt of food stamps, and receipt of free or
reduced-price school lunch.

4





TABLE II.3 (continued)

State MSIS Status Start-Up Year SMRF Availability’
Oklahoma No - -
Oregon No - -
Pennsylvania Yes 1990 1992-1995
Rhode Island Testing - 1995
South Carolina No - -

South Dakota No - -
Tennessee Testing - 1980-1993
Texas No - -

Utah Yes 1986 1987, 1992-1995
Vermont Yes 1986 1992, 1994-1995
Virginia No - -
Washington Yes 1987 1987, 1992-1995
West Virginia No - -
Wisconsin Yes 1988 1992-1995
Wyoming Yes 1990 1992, 1994-1995
Total States 34 - 30

" SMRF files for before 1992 were created by the Tape-to-Tape project.

25



TABLE 11.3

MEDICAID POVERTY LEVEL THRESHOLDS FOR INFANTS
AND WIC INFANT PARTICIPATION RATES, BY STATE

Income Threshold
for Medicaid Infants
State (eof Poverty) WIC Participation Rate, 1995
All Jurisdictions 109
Montana 133 1
Wyoming 133 0
Colorado 133 83
133 84
133, 84
133 38
133, 2
133 94
133 95
133 98
133 104
133 105
133 13
133 120
133 132
133 133
140 8
150 88
150 105
150 107
150 113
150 118
185 4
185, n
185 94
185 9
Pennsylvania 185 102
Towa . 185 102
Wisconsin 185 104
Missouri 185 105
Texas 185 106
District of Columbia 185 110
North Carolina 185 Ml
Connecticut 185 Ml
Georgia 185 u7
Kentucky 185 117
‘Massachusetts 185 9
Maine 185, 120
Maryland 185 122
Delaware 185 122
South Carolina 185 126
Mississippi 185 130
New Jersey 185 145
New Hampshire 185 145
Tennessee 185 + 156
California 200 99
Washington 200 ul
Vermont 225 107
Rhode Island 250 113
Minnesota 215 104
Hawaii 300 87

13



MPR Reference No.: 8207-810

MEDICAID POLICIES AND
ELIGIBILITY FOR WIC

Authors:

Kimball Lewis

Marilyn Ellwood
Submitted to: Submitted by;
U.S. Department of Agriculture Mathematica Policy Research, Inc.
Food and Nutrition Service 1 Mifflin Place
3101 Park Center Drive 3rd Floor
2nd Floor Cambridge, MA 02138
Alexandria, VA 22302 (617) 491-7900
Project Officer: Project Director:
Janet Schiller Anne Gordon
Task Leader:

Marilyn Ellwood

eve'd 222" ON ayovso4-edsn WWeStTT 6667 ET 'das


TABLE IV.5

DISTRIBUTION OF INFANTS ENROLLED IN MEDICAID BY STATE:
ANNUAL VERSUS AVERAGE MONTHLY ENROLLMENT

Infants
Ever Avg. Monthly
State Enrolled Enrollment (Unadj.)* Pct. Diff.
Alabama 37,165 32,930 -11.4
Arkansas 16,050 15,191 -5.4
California 238,260 220,698 -7.4
Florida 102,201 89,741 -12.2
Michigan 60,537 56,727 -6.3
New Jersey 37,326 35,340 -5.3
Total 491,539 450,626 -8.3

SOURCE: 1995 SMRF data.
NOTES: Infant average monthly enrollment based on January through September
1995.

*The number of Medicaid enrollees in this table is somewhat lower than those in
Table III.4 because these numbers have not been adjusted to account for the delay
in enrollment of newborns.

37



state is a lower-bound estimate of the number of WIC eligibles,
Moreover, the number of Medicaid enrollees may be a good indicator
of WIC eligibility in the regression equations used for the shrinkage
estimates of WIC eligibles described in the previous chapter.

Of the three WIC eligibility groups, HCFA 2082 data can be used only
to obtain counts of infants enrolled in Medicaid because women and
children age 1 to 4 are not specifically identified (the closest child age
cohort is age 1 to 5). This is not a serious limitation, however,
because infant data are used to calculate estimates of eligible women
and because the discrepancies in estimates are greatest among infants.
However, there are some issues with 2082 data on infants that, taken
together, suggest that even the infant data are not completely
comparable to WIC administrative data:

* The HCFA 2082 data and WIC administrative data count
infants differently, yielding numbers that are not fully
comparable. The HCFA 2082 data show the number of
infants born during the federal fiscal year who were ever
enrolled during the year, whereas estimates of WIC eligibles
approximate those eligible in an average month.

* — Some states count infants differently from other states in the
2082 data. For states that do not participate in HCFA's
MSIS system, HCFA 2082 instructions indicate that enrollees
should be classified by their age as of March 31--the midpoint
of the fiscal year. There are no instructions, though, for
classifying infants born between March 31 and the end of the
fiscal year. If they are also classified as infants, which is the
most likely scenario, then the 2082 is in effect counting as
infants all those born during a 11-year period--that is, those
under age 1 as of March 31 and those born during the 6-
month period from March 31 to Scptember 30. In contrast,
MSIS states, for which the 2082 tables are created by HCFA,
count as infants all those bom during the year who were ever
enrolled in Medicaid. As a result, the proportion of infants
reported in MSIS states should be about one-third lower, on
average, than the proportion of infants reported in non-MSIS.
states.

+ — Infants may be undercounted in the 2082 data because some

states take a few months to process the enrollment of infants
following birth. In many states, infants do not appear on

21



TABLE IV.1

MEDICAID ELIGIBILITY CHARACTERISTICS OF STATES WITH A 1995 SMRF FILE,
SORTED BY SIZE OF MEDICAID INFANT POPULATION

Infants Ever Enrolled in Expanded Medicaid
Medicaid in 1995 According to | Coverage of Infants as of
Unadjusted HCFA 2082 Data 1996*
Number of % of WIC- >WIC | Medically | Urban/
WIC-Eligible Eligible Level Elig. Needy | Rural

State Infants, 1995 Number Infants | (%of poverty) | Standard | Program | Ratio?
California 269,401 244,220 91 200 v v 93/7
Florida 93,667 146,203 156 185 v 85/15
Pennsylvania 56,175 60,863 108 185 v 69/31
Georgia 49,047 59,689 122 185 v 63/37
Michigan 56,301 58,022 103 185 v 71129
Alabama 29,640 36,086 122 133 60/40
Kentucky 24,853 34,867 140 185 v 52/48
Washington 28,227 34,604 123 200 v v 16/24
Missouri 31,110 32,861 106 185 69/31
Indiana 30,996 32,506 105 150 65/35
New Jersey 24,158 32,478 134 185 v 89/11
Wisconsin 23,279 30,802 132 185 v 66/34
Minnesota 20,211 30,413 150 275 v v 70/30
Mississippi 23,354 29,981 128 185 47153
Colorado 18,576 19,118 103 133 82/18
Arkansas 18,189 15,837 87 133 v 54/46
Utah 15,351 15,105 98 133 v 87/13
Kansas 15,377 13,005 85 150 v 69/31
Idaho 8,386 8,400 100 133 57/43
Rhode Island 4,598 7,850 171 250 v v 86/14
Maine 4,798 5,678 118 185 v 45/55
Montana 5,393 4,357 81 133 v 53/47
New Hamp. 3,202 4,024 126 185 v 51/49
Delaware 3,517 3,794 108 185 73/27
Vermont 2,760 3,494 127 225 v v 32/68
Wyoming 3,063 3,416 112 133 65/45
N. Dakota 3,485 2,675 11 133 v 53/47

““MCH Update: State Medicaid Coverage of Pregnant Women and Children — Summer 1996.” National Governors’
Association, September 1996.

* Based on 1990 Census.

NOTES: Of the 32 states with SMRF files in 1995, only 27 are listed above. The remaining 5 states had data quality problems
that made them unsuitable for analysis.

30



Family Unit
Differences

* Income may be misreported in the CPS. There are two
reasons why this might happen. First, respondents may
simply misreport their income, either intentionally or
unintentionally. Second, the Census Bureau may impute
income incorrectly to respondents who refuse to answer
some (or all) of the income questions in the survey. It is
not known whether misreporting and _ incorrect
imputations tend to lead to over- or under-estimates of
income in the CPS.

* CPS estimates may be counting income from different
sources than those used by program caseworkers.

Differences in how a WIC caseworker defines the family unit for
eligibility and how the family unit is defined in the CPS may also
explain discrepancies in estimates of WIC eligibles. Income eligibility
for WIC is based on family poverty level, which will vary depending
on which members of the household are included in the family unit.
Past research on simulating eligibility in the Food Stamp Program
(FSP) demonstrates that splitting households into smaller units
generally makes eligibility for the FSP more likely.

The CPS definition of family comprises the primary family and all
related subfamilies. This means, for instance, that a teenage mother
residing with her adult parents will be counted together with her
parents when determining income for WIC eligibility. Income of other
related persons, such as adult siblings and elderly grandparents, would
also be included in the family for calculating WIC eligibility. This
methodology is in accordance with the WIC program's definition of
family, which is those who live together and share Tesources, and
which is usually interpreted to mean families plus related subfamilies
(but may vary by locality). In some instances, though, it is likely that
caseworkers may not consider the resources of related subfamilies
when determining eligibility. Such instances are not taken into
account in the estimate of WIC eligibles.

3(...continued)

were Rhode Island, New Jersey, Florida, Mississippi, North Carolina,
Michigan, Louisiana, Colorado, Missouri, Montana, Arizona,
California, and Oregon.

16



issues are raised about WIC adjunct eligibility policies should
necessarily follow suit.



birth. Table B.3 shows the total effect on the average monthly
number of infants of these adjustments. The adjustments increased the
average monthly number of infants by 1.4 to 5.6 percent in the six
states examined. We consider our adjustment factor conservative
because some infants who were initially enrolled more than 3 months
after their birth may also have been covered since birth.

B.2


number ever enrolled in these states was 6.9 percent. Therefore, for
the step 2 adjustment to the 2082 data, the number of infants in each
state after the step 1 adjustment was reduced by 6.9 percent. The
result of this adjustment is shown in the third column of Table IV.4.

The third and most tenuous step is to adjust upward the number of
infants in each state to account for the fact that Medicaid
administrative data underestimate somewhat the number of infants
enrolled in Medicaid because of delays in the processing of Medicaid
enrollment following birth. These adjustment factors, which are based
on the percentage of newborns enrolled in Medicaid after the birth
month, varied from 1.4 to 5.6 percent for the six states in this analysis.
The wide range of adjustment factors makes it difficult to estimate the
amount by which counts of infants in a typical state should be adjusted
without first analyzing SMRF data for more states. For this analysis,
all states are adjusted upward by 2.1 percent, which is the median
adjustment factor of the 6 states examined. The result of this final
adjustment (applied to the number of infants according to the 2082
after the step 2 adjustment) is shown in the final column of Table
IV.4. In all, after adjusting non-MSIS states for their overcount of
infants (step 1), HCFA 2082 data for each state are reduced bya4.8
percent (6.9 percent adjustment from step 2 minus the 2.1 percent
adjustment in step 3) to yield estimates of the average monthly number
of infants enrolled in Medicaid.

Table IV.6 shows the number of Medicaid infants enrolled in an
average month in 1995 by state based on 2082 data, along with the
CPS-based estimates of WIC eligibles and the average monthly
number of WIC participants according to WIC administrative data.
These 2082 data have been adjusted using the factors derived from the
analysis of SMRF data for six states. The number of Medicaid infants
exceeds estimates of WIC eligibles in 28 states (shown in bold in
Table IV.6). In 19 of the 28 states, Medicaid infant enrollment was
greater by at least 10 percent. The difference was at least 20 percent
for 9 states (Kentucky, Maryland, Massachusetts, Minnesota,
Mississippi, New Jersey, Vermont, West Virginia and Wisconsin).
Many of these states have relatively generous Medicaid eligibility
policies which might explain why Medicaid enrollment is substantially
greater than the estimates of WIC eligibles.

These results suggest that, for a majority of states, Medicaid data can
improve estimates of WIC eligibles. In addition, that the number of
Medicaid enrollees exceeds estimates of WIC eligibles in so many
states suggests that Medicaid eligibility policies may indeed play a part
in the discrepancies between estimates of WIC eligibles and actual
participation.

38



CONCLUSIONS

Both SMRF data and HCFA 2082 data are usefiil in examining the
discrepancies in estimates of WIC eligibles for infants and may be used
in the future to improve estimates of infants eligible for WIC. Of
these two data sources, though, the 2082 data are more likely to be
usefiul because they are more timely, are available for all states, and do
not require additional data programming and analysis. However, the
2082 data have one serious limitation: the data for infants show all
those bom during the year who were ever enrolled rather than average
monthly enrollment, which is the basis for the CPS estimates of WIC
eligibles.

This analysis suggests that this limitation of the 2082 data can be
overcome if the numbers are adjusted based on analysis of SMRF
data. The adjustments entail making counts of infants in non-MSIS
and MSIS states comparable and then reducing the reported number
of infants to account for the net effect of (1) the difference between
ever enrolled and average monthly enrollment and (2) the delay in
enrollment of infants.

Based on the SMRF data for six states, MPR has identified some
preliminary adjustment factors for the 2082 data. However, if FNS
decides to use Medicaid data to enhance its estimates of WIC
eligibles, these adjustment factors should be re-estimated for a broader
group of states. Although the six states examined in this analysis are
diverse in terms of population characteristics and Medicaid eligibility
policies, the states are not necessarily representative of all states.

Analysis of all states with a SMRF file for 1995 would be the best
method to confirm the results of this analysis. Currently, about 27
states have usable SMRF data for 1995. If resource constraints limit
the number of files that can be analyzed, focusing on states with large
WIC populations or with the largest discrepancies in estimates of WIC
eligibles would be most useful. FNS may also want to consider
analysis of 1996 SMRF and 2082 data as they become available.
Medicaid 2082 data for 1996 have now been released, but it will
probably be late 1998 or early 1999 before any 1996 SMRF files are
ready.

After additional SMRF files are analyzed, more reliable adjustments
could be made to Medicaid 2082 data for all states. The adjusted
2082 data could be used to improve estimates of WIC eligibles in
several ways. For example, FNS could use the number of Medicaid
infants as a lower-bound estimate of WIC eligibles in states where the
number of Medicaid enrollees exceeds the CPS-based estimates of
WIC eligibles. This might have implications, however, for how WIC
funds are allocated among the states. FNS could also use these
revised state estimates to adjust the CPS-based national estimate of

40



ESTIMATES OF
WIC ELIGIBLES

I. WIC ELIGIBILITY AND MEDICAID

Although most Medicaid enrollees have incomes well below 185
percent of poverty, Medicaid policies in some states make it possible
for individuals in families with incomes above 185 percent of poverty
to qualify for Medicaid. Because of adjunct eligibility, these persons
also qualify for WIC. Therefore, eligibility estimates for WIC based
on survey income information alone may underestimate the true
number of persons that are eligible.

In a recent report for FNS, Gordon et al. (1997) found that many
reported WIC participants in the Survey of Income and Program
Participation (SIPP) appeared to be ineligible for the program on the
basis of their income, but they were enrolled in Medicaid. The
researchers found that of seemingly income-ineligible WIC
participants (5 percent of all WIC participants), 44 percent
participated in Medicaid for 1 or more months during the year.
Gordon et al. point out that these findings should be used with
caution, however, because WIC participation is known to be severely
underreported in the SIPP. Thus, this result alone cannot be used as
evidence of Medicaid’s role in causing seemingly ineligible persons to
be eligible for WIC.

This chapter begins with an overview of the methods used by FNS to
estimate the number of persons eligible for WIC and a discussion of
the frequent discrepancies in the estimates of eligibles in comparison
with WIC administrative data on participants--discrepancies that
motivated much of this research. Next, the Medicaid eligibility
policies that may permit persons with incomes above 185 percent of
poverty to qualify for coverage are presented. The chapter concludes
with a brief discussion of other factors that might also explain the
discrepancies in estimates of WIC eligibles.

Each year, FNS estimates the number of WIC eligibles in order to
determine the program budget request and to allocate program funds
among the states, Funds are allocated to the states based on two
factors: (1) their prior year funding level, plus some adjustment for
inflation; and (2) a growth calculation that attempts to direct funds to
states on the basis of need for the program. Need is determined using
the “fair share” concept, whereby a state's fair share of available funds
is its share of the estimated national population of persons