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June 2009 St@teside

Express Lane Eligibility: Some Promising Strategies

To help states address the challenge of reaching uninsured children who qualify for health coverage, Section 203 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) created a new Express Lane Eligibility (ELE) option. ELE’s basic concept is straightforward: if another government agency has already found that a child meets an eligibility requirement for Medicaid or CHIP, a state implementing ELE can rely on that finding to grant health coverage, even if the other agency uses a different methodology for eligibility determination.[1] This article briefly describes how states could apply this new eligibility option in three particularly promising contexts: namely, state income tax forms, food stamps, and the National School Lunch Program (NSLP).   

State income tax forms

CHIPRA specifically permits states to find children income-eligible for Medicaid or CHIP based on gross income or adjusted gross income (AGI) shown on state income tax forms.[2] The remarkable promise of this application of ELE is suggested by recent Urban Institute research[3] finding that, among uninsured children who qualify for Medicaid or CHIP:

  • Nearly 8 in 10 (79.4 percent) live in families who are legally required to file federal income tax returns.[4]
  • Nearly 9 in 10 (89.4 percent) live in families who file such tax returns, either because they are legally required to do so, because they qualify for fully refundable Earned Income Tax Credits, or to obtain a refund of income withheld from their paychecks.

In states with income tax systems, a very high percentage of eligible, uninsured children are likely to live in families who file state income tax returns. States could thus change their income tax forms to give parents an opportunity to identify their uninsured children. Iowa, Maryland, and New Jersey did this for the current year, and hundreds of thousands of such children have been identified. New Jersey is taking the additional step of using ELE to qualify children as income-eligible for Medicaid and CHIP based on their parents’ state income tax returns for the prior year.[5]

Unfortunately, very few children have been enrolled in response to these efforts, because each state requires parents to file an application form separately from the state income tax form. Iowa and New Jersey pursued a direct mail approach, sending parents applications for health coverage. As has been seen with other campaigns that use direct mail to encourage low-income families to take advantage of available benefits,[6] very few parents responded. Maryland sent notices telling parents how to apply for their children’s coverage, and, unfortunately, very few applied.

Given this disappointing response, states could take these initial efforts one step further. Income tax forms could give parents an opportunity, not just to identify their uninsured children, but also to ask the state tax agency share the parents’ income tax information with the state health agency. The purpose of such information transfer, of course, would be to help their uninsured children qualify for health coverage.

When such consent is given, the state could use ELE to establish income-eligibility based on the income tax return. The state could also use the child’s social security number (which, for most children, is shown on the tax form) to document citizenship (and perhaps immigration status). As a result, a large number of uninsured children could be found eligible without requiring their parents to file any forms other than their income tax returns. Children for whom tax information does not establish full eligibility, including many documented immigrant children, could receive targeted follow-up to complete the process, without waiting for parents to complete additional forms unassisted. Some experts believe that, in most states with income tax systems, this may be the single most promising post-CHIPRA approach for identifying and enrolling large numbers of eligible, uninsured children.

Food stamps

Only one-tenth of one percent of uninsured children receiving food stamps are ineligible for Medicaid and CHIP, under normal program rules.[7] This suggests that, when a family has already been found eligible for food stamps, given the extremely high likelihood that their children qualify for Medicaid or CHIP, it is not a good use of the family’s time or the state’s administrative resources to require a full-blown application for health coverage.

Fortunately, CHIPRA lets states short-circuit the traditional application process for these families, as ELE can be applied to food stamp eligibility determinations.[8] Roughly one in eight uninsured children who qualify for Medicaid or CHIP (12.4 percent) live in families who receive food stamps.[9] Accordingly, a state could reach numerous uninsured, eligible children by matching its Medicaid and CHIP eligibility files against its food stamp eligibility files; giving parents a chance to opt-out of having their food stamp files used to determine their children’s eligibility for health coverage; and unless the parents object, automatically qualifying the children as income-eligible for Medicaid based on their receipt of food stamps. As a general rule, food stamp eligibility is limited to families with gross incomes at or below 130 percent of the federal poverty level (FPL) and net incomes below 100 percent.

Immigrant children can likewise qualify as Medicaid-eligible, via ELE, based on the food stamp program’s determination of satisfactory immigration status. However, citizenship is the one element of eligibility to which ELE does not apply. Accordingly, a state would need to verify citizenship using normal procedures before granting Medicaid to citizen children who receive food stamps and have been found income-eligible via ELE.

National School Lunch Program (NSLP)

NSLP is one of the programs listed by CHIPRA as qualifying for ELE.[10] Nearly three out of five (59 percent) uninsured children with incomes below 200 percent FPL live in families who participate in NSLP.[11] However, some of these children are ineligible for Medicaid and CHIP because of immigration status, since children qualify for NSLP based purely on income. 

States can use ELE to find children income-eligible for Medicaid when they receive free school lunches, for which eligibility extends to households with gross incomes up to 130 percent FPL.[12] Since that threshold is so far below maximum income-eligibility for CHIP in almost every state, fully 96 percent of recipients of free school lunches are income-eligible for health coverage, under standard program rules.[13]

One approach to immigration status and citizenship would grant presumptive eligibility (PE) to children based on their receipt of free school lunches, since low income is the only eligibility requirement for PE. A state could then follow up with intensive application assistance to help these families transition to ongoing coverage by documenting citizenship or satisfactory immigration status.


The states that are early adopters of ELE have their work cut out for them. When the Centers for Medicare and Medicaid Services announce guidance interpreting the meaning of these statutory provisions, such states may need to change course in the midst of their planning efforts. As with any major innovation, challenges both foreseen and unforeseen will need to be surmounted with creativity and patience. Nevertheless, states have repeatedly shown with other important innovations in children’s health coverage the capacity to overcome such challenges and achieve significant progress improving the lives of America’s low-income children.

If you are interested in learning more about these strategies and consulting with an expert, please email us at

[1] For a detailed analysis of ELE, including both applicable legal requirements and a much more in-depth analysis of the options described in this article, see Stan Dorn, Express Lane Eligibility and Beyond: How Automated Enrollment Can Help Eligible Children Receive Medicaid and CHIP, prepared by the Urban Institute for the Robert Wood Johnson Foundation and the Academy for State Healthy Policy, April 2009.
[2]New Social Security Act § 1902(e)(13)(H) [42 U.S.C. 1396a(e)(13)(H)].
[3] Dorn S et al. Nine in Ten: Using the Tax System to Enroll Eligible, Uninsured Children into Medicaid and SCHIP, prepared by the Urban Institute for First Focus, February 2009.
[4] In 2004, federal income tax filing was required for households with the following amounts of gross income: for taxpayers filing as unmarried, single adults under age 65, $7,950 (or 51 percent and 42 percent of FPL for families of 3 and 4, respectively); married filing jointly, $15,900 (101 percent and 84 percent of FPL); Married, filing separately, $3,100 (20 percent and 16 percent of FPL); head of household, $10,250 (65 percent and 54 percent of FPL).
[5] New Jersey will grant income-eligibility for Medicaid if gross income shown on the tax return is no more than 30 FPL percentage points above that state’s Medicaid income threshold. Income-eligibility for CHIP will be established using a similar approach. The only exception involves self-employment income; in that case, the state will increase gross income by “adding back” deductions taken for such things as meals, entertainment, and depreciation.
[6] For example, a direct mail campaign encouraging low-income women to obtain mammographies, despite many rounds of work tailoring materials to fit the audience, and despite simultaneous outreach to physicians, resulted in fewer than 1 percent of targeted households making phone calls to seek information or make an appointment. Slater, J. et al. “Effect of Direct Mail as a Population-Based Strategy to Increase Mammography Use among Low-Income Underinsured Women Ages 40 to 64 Years,” Cancer Epidemiology, Biomarkers & Prevention 14(10):2346–52, October 2005.
[7] Dorn April 2009, op cit. In states that do not take advantage of this new CHIPRA option, 3.7 percent of uninsured children who receive food stamps will be ineligible for Medicaid and CHIP for immigration-related reasons, since the food stamps program neither excludes newly-arrived, legal immigrant children nor takes into account their immigration sponsors’ income in determining eligibility.
[8] New Social Security Act § 1902(e)(13)(F)(ii)(I)(ee) [42 U.S.C. 1396a(e)(13)(F)(ii)(I)(ee)].
[9] Dorn April 2009, op cit.
[10] New Social Security Act § 1902(e)(13)(F)(ii)(I)(gg) [42 U.S.C. 1396a(e)(13)(F)(ii)(I)(gg)].
[11] Dorn, S. and Kenney, G.  Automatically Enrolling Eligible Children and Families Into Medicaid and CHIP: Opportunities, Obstacles, and Options For Federal Policymakers, prepared by the Economic and Social Research Institute and the Urban Institute for the Commonwealth Fund, June 2006.
[12] CHIPRA gives states the option to find children automatically income-eligible for Medicaid if the other program—in this case, NSLP—finds income up to 30 FPL percentage points above the standard Medicaid income-eligibility threshold. Children with income more than 30 FPL percentage points above the standard threshold can be classified as income-eligible for CHIP, rather than Medicaid, without any need to apply traditional “screen and enroll” methods. New Social Security Act § 1902(e)(13)(C)(ii) [42 U.S.C. 1396a(e)(13)(C)(ii)].
[13] Dorn, S. April 2009, op cit. For children receiving reduced-price lunches, for which eligibility extends to 185 percent of FPL, 13 percent have incomes too high for Medicaid and CHIP eligibility, under normal program rules.