I. Introduction and Key Findings

I.

Introduction and Key Findings

New federal child health funds and Medicaid outreach and enrollment options provide California with an historic opportunity to lower substantially the number of uninsured children. By establishing the Healthy Families program and expanding Medi-Cal eligibility in legislation passed in August 1997, California became one of the first states in the nation to take advantage of the new federal funding to expand

health insurance coverage for children. California’s child health programs offer the promise of coverage to more than 60 percent of all uninsured children in the state.

At the same time that California is moving forward to offer coverage to more children, there is broad

recognition that the offer of coverage will not by itself produce the results California is seeking. A large share of California’s uninsured children already is eligible for Medi-Cal. According to recent estimates, some 660,000 children — 38 percent of all

uninsured children in California — are eligible for Medi-Cal but are not enrolled. Almost 80 percent of these children have parents who are working but whose earnings are low enough to qualify the children for Medi-Cal. As the CalWORKS welfare caseload continues to decline, an even larger portion of the children who are eligible for Medi-Cal will be from low-income working families. This will mean that fewer children will be enrolled in Medi-Cal through the

More Than 60 Percent of Uninsured Children in California are Eligible for

Medi-Cal or Healthy Families

Source: UCLA Center for Health Policy Research, “Adjusted Estimates of Uninsured Children & Program eligibility, California 1996”

Healthy Families Eligible 23% Inligible 39% Medi-Cal Eligible 38%

cash assistance system, and, in the absence of new enrollment strategies, the number of Medi-Cal-eligible children who are missing out on health care coverage is likely to grow.

A simple, family-friendly application process is at the core of an effective enrollment strategy. For years, states relied on lengthy and complex Medicaid applications and required interviews at welfare offices. Recently, however, something of a revolution has taken place in Medicaid programs throughout the country. Complicated applications have been replaced with shorter forms; mail-in applications have made welfare office interviews unnecessary, at least for pregnant women and children; and an increasing number of states have begun to rely on self-declarations and computerized data exchanges in lieu of applicant-supplied verification of eligibility.

California has taken some important steps to revamp its Medi-Cal enrollment process. Pregnant women and children no longer have to meet a resource requirement for Medi-Cal, and they can submit their applications by mail. In addition, when it enacted the Healthy Families program, the California Legislature required a joint application to be developed for pregnant women and children so that families would not have to sort their way through two enrollment systems to determine which health program covered their child. In record time, the Department of Health Services (DHS) and the Managed Risk Medical Insurance Board (MRMIB), with

substantial public input, created a new mail-in packet through which families and pregnant women can apply for either Medi-Cal or Healthy Families. The state also has made funds available to community-based organizations to help applicants complete the required forms.

Despite these efforts, families are having difficulty making their way through the process, and enrollment is lagging far behind expectations. Even allowing more time for transition to the new mail-in enrollment system, there is widespread agreement that further steps are needed to simplify the process. DHS and MRMIB plan to revise the new 28-page mail-in packet and have assembled a working group to solicit feedback on how the application process is working and suggestions on the changes that need to be made. In addition, members of the Legislature continue to be attentive to the issue, interested in learning whether decisions made by the Legislature and by the

Administration have promoted or hindered the goal of providing coverage to uninsured California children.

This report is intended to make a contribution to these efforts by identifying options available to California to streamline the new mail-in application and procedures, simplify the questions that are asked in the Medi-Cal forms, and reduce the paperwork requirements imposed on applicants without compromising program integrity. This analysis examines key aspects of the new mail-in packet, as well as the MC210 Medi-Cal application and related forms, as they relate to pregnant women and children applying for Medi-Cal. It relies on the chart included in Appendix A that sets forth the policy and legal basis for all of the relevant Medi-Cal questions asked in these two applications, and it offers suggestions based on the forms developed by other states. While this report draws on examples from other state applications, the analysis provided and the suggestions offered are mindful of the unique features of Medi-Cal and the new Healthy Families program.

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This report does not directly address the draft shortened mail-in application form that was developed by DHS and MRMIB and distributed at the application workgroup meeting in early October. Some of the options outlined in this report, such as those relating to the layout of the form, have been incorporated into the newest draft application. Most of the issues and options discussed in this report, however, continue to be relevant to the revision process, and, hopefully, this report will provide helpful guidance as that process moves forward.

Key Findings

California has the flexibility under federal and state law to simplify its Medi-Cal applications and to streamline the mail-in process to make it easier for eligible children and pregnant women to enroll.

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Neither federal nor state Medi-Cal rules require the state to have a lengthy, cumbersome mail-in application. Some 34 states have Medicaid applications for pregnant women and children that are shorter than four pages. States that have

developed joint applications (for Medicaid and for their separate child health program) have been able to design forms that are much more streamlined than California’s application; several of these new joint forms are six pages or less (including

instructions). The “model” joint application form developed by the federal agency that oversees Medicaid is two pages.1

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The mail-in application’s length and confusing format is due largely to the design of the joint application process, and specifically to the decision to require families — rather than the reviewing agencies — to determine, at least initially, if their children are eligible for Medi-Cal or Healthy Families. This screening process accounts for four pages in the application packet (not counting the related instruction pages). It requires applicants to sort through financial eligibility rules and to make complicated

calculations in order to decide which other forms within the packet they must complete and which documents (verifying the information provided on the forms) they must submit. The process can be difficult, and errors have been commonplace.

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No other state that administers a separate child health program alongside its Medicaid program and that has created a joint application for both programs requires families to figure out the program for which they are likely to be eligible. Other states ask families to report their income and other relevant information on a common application that covers both programs. The form (sometimes along with supplemental forms) is sent to

1 _{Comparisons of applications that are measured by number of pages can be misleading depending on whether} instruction pages are counted and whether supplemental forms are required and taken into account. The California mail-in form is 28 pages, including instructions, but two additional forms that are not included in the packet (relating to medical support) are required for many families. The joint child health forms developed by other states generally range in length from four to ten pages, including instructions. In most, but not all cases, supplemental forms are not required.

a reviewing agency which performs the screening function. States similar to California — that is, states with a county-based Medicaid system and a child health program that is administered by a different agency than the agency that administers Medicaid — have developed workable systems for processing their joint applications that could be adapted to California’s administrative structure.

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Further simplification could be accomplished by eliminating unnecessary questions and by limiting the number of additional documents that pregnant women and families must submit along with their applications. Initial data collected on Medi-Cal mail-in applications processed by Los Angeles County through the end of August, 1998 show that the most common reason for an application error was that the required documents were not included with the mail-in form; this problem accounted for nearly one-third (32 percent) of the application errors.2_{Recent federal guidance has encouraged states} to take advantage of the flexibility accorded them under federal law to eliminate verification requirements that can be barriers to care.

In short, there is nothing inherent in either the Medi-Cal program or in the fact that California administers its two child health programs through separate entities that prevents California from developing a simpler and shorter application and a more seamless mail-in application process for Medi-Cal and Healthy Families. This is good news for California — it means that California has viable options for moving more quickly toward its goal of providing health care coverage to thousands of uninsured California children.

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2 _{Summary data for Medi-Cal/Healthy Families Mail-in Applications, prepared August 31, 1998 by Los Angeles} County. The applications that were “incorrect” because of lack of documents may have had other errors.

II.

What Do We Know About Uninsured Children in California?

What Do the Data Show?

The data available on uninsured children in California show that the state has an extraordinary opportunity to sharply reduce the number of children who lack health care coverage.3

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Nearly one fifth (18 percent) of all children in the state — 1.74 million children — are uninsured.

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Some 61 percent of these 1.74 million uninsured children (1.1 million children) can now be covered through Medi-Cal or Healthy Families. If all children who are eligible for Medi-Cal and Healthy Families participate, the number of uninsured children in California could be reduced from 1.74 million to 672,000.4

3 _{These data were developed by Steven P. Wallace, Hongjian Yu, Carolyn Mendez, and E. Richard Brown; see,} Adjusted Estimates of Uninsured Children & Program Eligibility, California, 1996, UCLA Center for Health Policy Research, May 29, 1998. The CHPR report presents a range of adjusted estimates that vary depending on how many low-income children in California are assumed to be undocumented and are therefore excluded from both regular Medi-Cal and Healthy Families. For purposes of this report, we made conservative estimates of the number of children who could be covered by regular Medi-Cal and Healthy Families by using CHPR’s high-end assumptions of the number of low-income children who are undocumented.

4 _{An estimated 38.6 percent of uninsured children (672,300 children) are ineligible for regular no-cost Medi-Cal} coverage and Healthy Families. A majority of these children (409,000 children) have family incomes in excess of 200 percent of the federal poverty level (some of these children could qualify for “share-of-cost” Medi-Cal). The rest (263,300 children) are ineligible for regular Medi-Cal and the Healthy Families program due to their immigration status (although many are eligible for emergency services under Medi-Cal).

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California’s success in lowering the rate of uninsured children will depend in large part on the proportion of eligible children that actually enroll in the programs. The data show that 38.3 percent of California’s uninsured children (666,300 children) are already eligible for Medi-Cal but are not enrolled.5_{Medi-Cal-eligible children}

comprise almost two-thirds (62 percent) of all uninsured children with incomes below 200 percent of the federal poverty line.

These data suggest that California could decrease the uninsured rate for children from 18 percent to less than 8 percent if it can increase awareness and desirability of these programs and remove unnecessary administrative barriers to enrollment. A simple application process can be an important part of this.

Characteristics of Uninsured Children Who Are Eligible for Medicaid or Healthy Families

There is a considerable degree of similarity between the children who are eligible for Medi-Cal but who are not enrolled and the children who are now eligible for Healthy Families. Most of these uninsured children fall into one or more of the following groups: children living with both parents; children whose parent or parents are employed; Latino children; and children with one or more parents who are not citizens.6

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An estimated 60 percent of uninsured children who are eligible for Medi-Cal live with both parents, as do 75 percent of uninsured children who are eligible for Healthy Families.

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A vast majority (79 percent) of the uninsured Medi-Cal-eligible children live in working families; some 97 percent of uninsured children who are eligible for Healthy Families live in families with earnings.7

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Two-thirds (66 percent) of uninsured Medi-Cal eligible children are Hispanic, as are 61 percent of uninsured children who are eligible for Healthy Families.

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5_{Since the state expanded Medi-Cal to children between the ages of about 14 and 18 effective March,1998, some of} the uninsured children included in the 666,300 figure have only recently become eligible for Medi-Cal.

6_{UCLA Center for Health Policy Research, Data Estimate 98-44, September 17, 1998.}

7 _{A majority of working families with a child eligible for Medi-Cal or Healthy Families include someone who} worked full-time for the entire year (60 percent of working families with a child eligible for Medi-Cal, and 80 percent of such families with a child eligible for Healthy Families).

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Only a small portion of the uninsured children eligible for regular Medi-Cal (seven percent)) and Healthy Families (12 percent) are non-citizens, but about half are members of immigrant families in which one or both parents is not a U.S. citizen (51 percent of uninsured Medi-Cal eligible children and 52 percent of uninsured Healthy Families eligible children).

These data underscore the importance of developing an application process that is welcoming to working families who may have had little previous experience seeking help from public benefit programs. The application process must also accommodate the needs of families with limited proficiency in English. In addition, the characteristics of uninsured children in California suggest that it will be difficult to significantly reduce the number of uninsured children if the applications and application procedures do not help immigrant families feel comfortable seeking health care coverage through both Medi-Cal and Healthy Families.

What Can We Learn from Conversations with Application Assistors and Medi-Cal Eligibility Workers?

To gain a perspective from the front lines on the application process, the Medi-Cal Policy Institute conducted on-site and telephone interviews in 15 counties8_{which use the mail-in} Medi-Cal and Healthy Families forms and the MC210 or SAWS2, MC13 and MC219. During the months of August and September 1998, Institute staff interviewed county Medi-Cal eligibility workers, Medi-Cal program managers, and application assistors at community-based

organizations and clinics. Feedback from these community contacts is interspersed throughout the report. Several noteworthy themes emerged from these interviews.

Complexity of the Mail-In Application

Application assistors and county eligibility workers agree that the mail-in packet is too long and too confusing. Even after attending the state-sponsored application assistance certification training,9_{many assistors felt that it took them a couple of weeks and/or numerous encounters with} applicants to feel comfortable helping families to complete the application — and some assistors continue to have difficulty with certain steps in the application. Several assistors attended the training twice before feeling ready to help applicants. Assistors’ concerns range from confusion in determining an applicant’s countable income to the layout of the application booklet, especially the need to repeatedly turn the booklet and move numbers from one box/page to another.

8 _{Alameda, San Francisco, Tehama, San Diego, Shasta, Orange, Marin, Los Angeles, Tulare, Humboldt, El Dorado,} Contra Costa, Calaveras, Kern, and Imperial counties.

Immigration Issues

Assistors indicated that immigrant parents with potentially eligible children are reluctant to apply for Medi-Cal for fear that their children’s use of the program will negatively affect the parent’s ability to gain legal permanent residence, to naturalize, or to bring other family members into the country. Families’ fears of being labeled a “public charge” stem, in part, from recent accounts that immigrants have been made to repay the government for the lawful use of Medi-Cal benefits before reentering the country. In addition, in one county, the Board of Supervisors has mandated the posting of a notice in the county social services office stating “Federal law now permits confidential information to be released to the Immigration and Naturalization Service (INS) by government agencies providing federal benefits.” One assistor in this county reported, “Undocumented parents are backing away even though their children are eligible. I see this every day with at least one potential applicant who I am helping.” In some communities these concerns were reported only of the Medi-Cal program, but in others, assistors report that applicants were fearful of applying for both Medi-Cal and Healthy Families.

Stigma Associated With Medi-Cal

The stigma associated with the Medi-Cal program was reported to be a deterrent to enrollment in many counties. Although perceptions of the Medi-Cal program vary in different communities (reflecting the diverse cultures and regions of the state), assistors consistently cited a few main reasons why people may not want to apply for Medi-Cal, including:

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Past unpleasant experiences with eligibility workers;

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Complicated paperwork and cumbersome verification requirements; and

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Quarterly reporting requirements.

III.

Streamlining the Mail-in Application and Application

Process

One challenge facing California is the need to coordinate enrollment between Healthy

Families and Medi-Cal (and between Medi-Cal and AIM) so that there is as seamless a system as possible for families and pregnant women seeking coverage. A coordinated enrollment strategy is particularly important, because, as the data noted above suggest, the uninsured children who are eligible for Medicaid and the children who are eligible for Healthy Families have very similar characteristics — there is no sharp line that can be drawn between the two groups of children for purposes of marketing coverage or for designing enrollment strategies. A unified outreach message helps California to reach all of its low-income uninsured children and pregnant women, and a coordinated enrollment system assures that while there are two programs for covering

children and pregnant women, there is one system for accessing coverage.

This section of the report considers changes in California’s mail-in application procedures that might promote a more coordinated and efficient system for enrolling children and pregnant

women and at the same time help California to simplify its new mail-in application packet.

Federal Law

The federal law that established the new child health block grant funds (Title XXI of the Social Security Act) requires states to coordinate enrollment between any new child health

program funded with the block grant funds and Medicaid. The law requires California to establish procedures to screen children applying for health insurance coverage to assure that Medi-Cal eligible children are identified and enrolled in Medi-Cal rather than in Healthy Families.

This “screen and enroll” requirement is intended to make sure that the new block grant funds cover only the newly eligible children and do not substitute for coverage already available under

Medi-Cal. It also is intended to assure that children do not fall through the cracks and remain uninsured if their families happen to apply for the “wrong” program. If a Medi-Cal eligible child applies for Healthy Families, the state cannot simply deny the child coverage or refer the child to Medi-Cal. Under federal law, California must have an effective system in place to assure that all children who apply for coverage are enrolled in the appropriate program.

California’s Approach

California took the first step toward coordinating enrollment between Healthy Families and Medi-Cal by enacting legislation that called for a joint application. A joint application can be an effective and efficient method for meeting the federal “screen and enroll” requirement and for coordinating enrollment between two programs.

California’s current approach, however, falls far short of creating a seamless enrollment system in which pregnant women and children are assured that they will be screened and enrolled into the proper program. The mail-in packet does not create a “joint application”; it binds together a set of forms, some of which are used to apply for Medi-Cal and some of which are used to apply for Healthy Families. The mail-in packet does not offer families a single integrated application that can be used to apply for either program.

California’s mail-in process requires families or pregnant women to determine the program for which they should apply and which forms they must complete. The initial screening function required by federal law is performed by families, not by the reviewing agencies. Families perform this screening function by completing three “Steps” which are set out on pages 7 through 10 in the mail-in packet (with instructions on page 6):

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Step 1. Applicants must identify which family members’ income should be counted (pursuant to instructions on page 6), list the income for such family members, and then calculate their monthly income by converting the income received to monthly amounts.

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Step 2. Applicants total the monthly income for the family, identify and calculate the

expenses allowed as deductions in the Medi-Cal program, and reduce the total family income by subtracting these deductions.

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Step 3. Applicants are then instructed to group members of the family together depending on the age of the children and whether anyone applying for coverage is pregnant. Next, they must compare the family’s net monthly income to the income

eligibility guidelines for Medi-Cal and compare the family’s gross monthly income to

the income eligibility guidelines for Healthy Families to determine which, if any, of these family subgroups are eligible for no-cost Medi-Cal, Healthy Families, or share-of-cost Medi-Cal.

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Depending on the outcome of this screening process, the family decides which, if any, of the additional forms included in the mail-in packet it should complete. Some families will have to complete and mail in the Medi-Cal forms as well as the Healthy Family forms because one child in the family may be eligible for one program while another child (or pregnant woman) may be eligible for the other program. Completed Medi-Cal forms are routed to a centralized mail house for distribution to the appropriate county

welfare office. Healthy Families forms are mailed to a different central location for Healthy Families processing.

There are several drawbacks to California’s mail-in process:

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The length of the

application packet can be daunting. The booklet is 28 pages, including several pages of instructions and other information.10 The packet is long principally because of the multi-step screening process and because there are separate forms for Medi-Cal and for Healthy Families instead of consolidated forms

that cover both programs. The minimum number of pages any family must complete is 10. Families in which the children or pregnant women appear to be eligible for

different programs have to fill out both a Healthy Families and a Medi-Cal application (a total of 15 pages), and the six pages that are common to both applications ( Steps 1, 2, and 3 and Part A) must be photocopied and attached to the Healthy Families and the Medi-Cal applications.

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The tasks required by the screening process are complex and sometimes difficult to follow. The screening function is time-consuming and difficult. The instructions that are provided to help families make their way through this process are necessarily complex and often confusing even for trained assistors.

Families Must Enter the Same Information Several Times

One reason why the application packet is so long is that California’s approach to the mail-in application system requires applicants to fill in the same information on multiple forms within the packet.

For example, for families applying for Medi-Cal, the names of the children must be written down five times — in Step 1 (to report income), in Step 2 (to report total monthly income), in Step 3 (to compare total income to the income guideline chart), in Part A, section 4 (to provide basic nonfinancial information), and again in the MC13 (to establish citizenship or immigration status). Applicants must write their name in all of these places (or in four of these places if they are not seeking benefits for themselves) and again in Part A, section 1. Applicants must sign their names three times.

10 _{The 28-page packet does not include two additional forms (the CA.1 and the CA.1(Q)) relating to medical} support. Families in which there is an absent parent or in which both parents are in the home but are unmarried have to get these forms and submit them with the application. See discussion of medical support, in Part F of Chapter IV.

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The requirement that families perform the initial eligibility screening process may lead to errors that will not always be caught. As discussed in more detail below (Chapter IV), it will be difficult for some families, particularly those with

grandparents, stepparents and unrelated individuals in the home, to apply the correct rules on whose income is to be counted. Applicants with irregular sources of income, such as overtime pay, may have problems properly estimating monthly income, and some families may have difficulty doing the computations, especially without the benefit of a calculator. The eligibility charts in Step 3, which families must use to determine which family member is

eligible for which program and to identify if any family member is eligible for “share-of-cost” Medi-Cal, is another source of confusion for families.

The early data on processed Healthy Families applications show that screening errors are commonplace. Data through October 17, 1998 show that 60 percent of the children found

ineligible for Healthy Families — some 6,400 children — had incomes that made them eligible for Medi-Cal. Finding and correcting errors requires close agency oversight and considerable time.11_{Some of these errors, moreover, will never be caught — if a} family mistakenly determines that no one in the home is eligible for coverage the family will not send in its forms and, as a result, eligible children and pregnant women may remain uninsured.

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The “routing procedure” may cause children and pregnant women to lose out on coverage. Under California’s mail-in approach, if a family or pregnant woman makes a mistake in the screening process and applies to the “wrong” program, the application will not be considered for the other program unless the family or pregnant woman has specifically given permission for one program to forward the application forms to the other program.12

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11 _{The data does not report how many of these children had their applications referred to Medi-Cal and how many} were simply denied coverage because they applied for the “wrong” program.

12 _{The question and answer section on page four of the mail-in packet (Q2) explains that the application will be} forwarded to the correct program if permission is granted. Permission is granted by checking one of the boxes on the top of p.11 (Part A). Families applying for Healthy Families are asked: “If you or your child(ren) are not eligible for Healthy Families, do you want this application forwarded to the Medi-Cal Program?” (continued) Families applying for Medi-Cal are asked: “If we find your income gives your child(ren) under 19 share-of-cost Medi-Cal, do you want this application forwarded to the Healthy Families Program?

Assistors are confused by having to figure out an applicant’s monthly income: some assistors average three pay stubs, some use two and some are unsure what a “one month period” is — the most recent month or most recent 30-day period

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This step is an important step in California’s enrollment process. If the permission box allowing the agencies to share the forms is not checked, children or pregnant women who are eligible for one program but who send their forms to the other program by mistake will remain uninsured. Yet, it may not be entirely clear to families that they do not have a choice about which program they apply for and that if they fail to check the box granting permission to forward the application to the other program their children (or any pregnant women in household) will get no coverage at all.13

This routing procedure increases the possibility that eligible children and pregnant women may fall through the cracks and remain uninsured. Permission boxes are not needed in an enrollment system that relies on a joint form which allows families to apply for both programs at the same time and then leaves it to the reviewing agency or agencies to determine the program for which the family members are eligible.

Options for Simplification

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Create a consolidated application that would apply to both programs and revise the process so that families and pregnant women do not have to figure out the program for which they are eligible.

The mail-in forms could be consolidated into one basic application form that all families would complete regardless of the program for which they qualified. A common form (or set of common forms) that applied both to Medi-Cal and to Healthy Families and that eliminated the screening steps would be simpler for families to complete and would allow the state to reduce the size of the application packet. Since most of the rules are common to both programs, almost all questions asked are relevant to both programs. Extraneous questions could be kept to a

minimum.14

13_{Interviews in the community revealed that some immigrant families may not be checking the “permission” box to} forward an application to Medi-Cal because they are concerned that Medi-Cal receipt will prevent them from

adjusting their immigration status at a later point. They may feel that there is less risk if they enroll their children in the new Healthy Families program. Pending further federal clarification, the so-called public charge issues are as real for Healthy Families as they are for Medi-Cal. While some of these issues can only be addressed by the federal government, there are steps California can take to help make immigrant families with eligible children and pregnant women more comfortable applying for Medi-Cal (see discussion of immigrant issues).

14 _{Although Healthy Families uses a gross income standard, the Medi-Cal questions about deductible expenses are} relevant to the Healthy Families eligibility determination, since that determination requires that a finding first be made that the children applying for coverage are not eligible for Medi-Cal. In addition, the deductions are used in the Healthy Families program for purposes of determining premium payments. Some of the Healthy Families questions about health insurance coverage are not necessary for Medi-Cal.

Under this approach, the application process would be restructured so that all applications would be sent to the same entity for initial review. Eligibility screening would be performed by trained eligibility workers and would no longer be the responsibility of families. Errors would be minimized, and the occasions when eligible children and pregnant women fall through the cracks and remain uninsured because they mistakenly applied to the wrong program or mistakenly determined that they were not eligible for either program would be eliminated.

Models from other states

As of September 1998, 14 states are using some or all of their child health block grant funds to operate a separate child health insurance program in addition to Medicaid. These states are Alabama, California, Colorado, Connecticut, Florida, Maine, Massachusetts, Michigan, Nevada, New Jersey, New York, Oregon, Pennsylvania and Utah. The nine states, listed in the table below, are using a joint application that enables families to apply for either program using a single form. A number of other states are moving in this direction, including Arizona, Illinois, and North Carolina, which, as of September 1998, had not yet begun to enroll children in their new programs.

In states that are using joint applications, program features vary in a number of ways, such as whether Medicaid and the separate child health insurance program are consolidated under a single name, whether the final eligibility for Medicaid and the separate state child health

insurance program is determined by the same or by different agencies, and whether the separate child health program is administered by a private or public entity. However, the system

developed by all of these states have two characteristics in common — the basic information required for both programs is collected through one form (or one set of forms that apply to both

programs), and all applicants mail their applications to one central location (a “single point of entry”) for screening and/or final eligibility determination.

If California were to consolidate its forms and adopt a single point of entry system, there are several possibilities for how California’s joint application could be handled — and by whom — once it is received. The systems developed by Florida and Connecticut, which are described below, may be particularly instructive to California.

Either system could be adapted to California’s administrative structure without the need to create a new administrative layer and without imposing or shifting major new responsibilities onto MRMIB (or EDS, the Healthy Families enrollment contractor) or the counties. Under California’s current system, both EDS and the counties already must carefully review all

applications received and recalculate the information provided by families in order to determine if an error has been made.

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Moreover, EDS and the counties already have a system in place for passing applications back and forth. In light of the high percentage of applications that appear to have errors, a simpler form and a more straightforward enrollment process may actually ease administrative burdens as well as make the process more accessible for pregnant women and families.

Length of Program Single Point

State Unified Program Name ? Application (pages) Administrators(s) of Entry? Alabama*+ No, ALL Kids and Medicaid 4 + 2 instructions two state agencies Yes Colorado No, Medicaid and Child 5 inc. instructions private contractor and Yes

Health Plan state agency

Connecticut Yes, Healthcare for Uninsured 4 + 2 instructions private contractor and Yes

Kids and Youth (HUSKY) state agency

Florida No, Healthy Kids and Medicaid 2 + 2 instructions private entity created by Yes statute and state agency Maine+ Yes, Health Insurance 2 inc. instructions single state agency Yes Massachusetts No, MassHealth and Children’s 8 + 2 instructions two state agencies Yes

Medical Security Plan

Michigan No, MIChild and Healthy Kids 3 + 1 instructions two state agencies Yes Oregon Yes, Oregon Health Plan 4 + 4 instructions single state agency Yes Utah+ No, Medicaid and Children’s 6 + 2 instructions single state agency Yes

Health Insurance Program

* Alabama has a single point of entry, but also allows families to opt out of consideration for either program.

+ Alabama-Applicants are asked to complete an additional form (a “Pediatric Health Diary”), but this form is not required for the eligibility determination.

Maine-Applicants may be asked to complete an additional form to provide information about absent parents. Utah-Applicants may be asked to complete additional forms to provide information about third party insurance and absent parents.

Florida

Florida recently has adopted a joint application that can be used to apply for Medicaid and Florida Healthy Kids, the state’s CHIP-funded child health program.15 _{Families receive the} two-page “Florida KidCare” application (plus instructions) at their child’s school, at other

organizations in their communities, or by calling a toll-free number. All families fill out the same application and mail it to the Healthy Kids program office in Tallahassee. Healthy Kids then screens each application for possible Medicaid eligibility.

Applications for children who appear to be Medicaid-eligible are transferred to Medicaid eligibility workers who are co-located in the Healthy Kids program office, which functions as a

Medicaid outstation. Florida has centralized the eligibility determination process even though Florida, like California, has a county-administered Medicaid program. These co-located Medicaid workers contact families to obtain documents not solicited through the joint form that may be needed to make a formal Medicaid eligibility determination, such as evidence of a child’s immigration status. The co-located Medicaid eligibility worker makes the final Medicaid

eligibility determination. Florida Healthy Kids officials report the Medicaid determination process takes between one and seven days. The relatively short processing time is attributed to the

suspension of the requirements for most written verification.

Connecticut

Connecticut’s Medicaid program and its new CHIP-funded child health program are now consolidated under one name: HUSKY (Healthcare for Uninsured Kids and Youth). Husky “A” is the Medicaid program, and HUSKY “B” is the non-Medicaid program funded with child health block grant funds.16_{Applicants fill out one application (for HUSKY) . They either mail that form} to a central location for review.

All applications are received by the private entity that administers Husky B and are screened by that entity for Medicaid eligibility. The contractor sends applications for children who appear to qualify for HUSKY A (Medicaid) to a regional Department of Social Services office for a Medicaid eligibility determination. Applications for children who qualify for HUSKY B are processed by the private contractor.

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14 _{Healthy Kids generally covers school-age children in families with income above Medicaid income limits.} Families with incomes below 185 percent of the poverty line receive subsidized coverage. An (continued) additional CHIP-funded program, Medikids, will soon cover children under age five in families with incomes above Medicaid standards but below 185 percent of the poverty line.

15 _{Children with family incomes below 185 percent of the federal poverty line are eligible for HUSKY A; these} children receive the full range of Medicaid services at no cost to the family. Children with family incomes at or above 185 percent but below 300 percent of the federal poverty line are eligible for HUSKY B. Children enrolled in HUSKY B receive a more restricted package of benefits with some co-pays, and families with incomes above 235 percent of the federal poverty line pay a premium.

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After eligibility is determined, all families are mailed the appropriate “new members packet.” While all packets welcome families to the HUSKY program, they contain somewhat different information related to covered services and how to enroll in a managed care plan, depending on whether the child is enrolled in HUSKY A or HUSKY B.

The application systems for Florida, Connecticut and California are depicted in the following flow charts.

18

Florida

Applications Potentially Eligible

for Medicaid

Not Eligible for MC, but may qualify for HK Medicaid Eligibility Workers Co-located in HK Office Applications Potentially Eligible for

Healthy Kids

Not Eligible

To apply for coverage in Florida, families fill out a two-page joint application (plus in-structions) and mail it to the Healthy Kids (CHIP) program office where all applica-tions are screened. Applicaapplica-tions for children who appear to be eligible for Medicaid are forwarded to Medicaid eligibility workers, co-located in the Healthy Kids office, for follow-up and final eligibility determination. Forms for those who are found inel-igible for Medicaid, but who may still qualify for Florida Healthy Kids, are returned to the Healthy Kids staff for a final determination.

KIDCARE APPLICATION

Florida Healthy Kids Central Office Screens For Medicaid

19

Connecticut

Applications Potentially Eligible for HUSKY A Applications Potentially Eligible for HUSKY B Regional Department of Social Services Not Eligible

Connecticut applicants for the HUSKY program fill out a four-page joint form (plus instructions) and mail it to a central location staffed by the HUSKY B private con-tractor. After an initial screening, applications for children who appear to be eligible for HUSKY A (Medicaid) are forwarded to a regional Department of Social Services office for final eligibility determination. Forms for those who are found ineligible for HUSKY A, but who may still be eligible for HUSKY B (CHIP), are returned to the cen-tral office for a final determination.

HUSKY APPLICATION

HUSKY Central Office Screens for HUSKY A

Eligible

Not Eligible Eligible

Not Eligible for HUSKY A but may qualify for

HUSKY B

forwarded to HUSKY B

California

Possible that family has incorrectly screened and child

may be eligible for HF or MC Family decides child is not

eligible for either program Family decides it should

com-plete the Medi-Cal forms*

(family must give permission for application to be forwarded to HF if found

ineli-gible for MC)

Family decides it should complete the Healthy Families

forms*

(family must give permission for application to be forwarded to MC

if found ineligible for HF)

Not Eligible Medi-Cal central mail house Healthy Families (EDS) Eligible for MC

Not eligible for MC, no

per-mission to forward to HF

Not eligible for MC, permission to forward to HF

Not Eligible

Potentially eligible for HF, but application

not forwarded

Potentially eligible for MC, but application

not forwarded

*Because Medi-Cal eligibility standards vary by age, a family may determine that one child is eligible for HF while another child is eligible

for Medi-Cal. In this situation the family follows both paths.

In California, families use the 28-page Healthy Families/Medi-Cal mail-in application packet to apply for Healthy Families or Medi-Cal. Families complete the screening forms to determine which program they should apply for and which set of applica-tion forms they should fill out. Families with children who are eligible for different programs need to fill out two sets of forms. Completed Medi-Cal applications are mailed to a centralized mail house for distribution to the appropriate county welfare office, while Healthy Families forms are mailed to a central Healthy Families office. If a screening error is made and the family mails the application to the wrong pro-gram, it will not be forwarded to the other program for eligibility determination un-less the family checked a box giving permission for this to occur.

Not eligible for HF, no

per-mission to forward to MC Not eligible for

HF, permission to forward to MC

Healthy Families/ Medi-Cal Mail-In Packet

A family self screens to determine which program child is eligible for

County Welfare Office

Shaded boxes indicate points in the process where applicants who may be eligible for HF or MC do not receive health coverage.

Not Eligible Eligible for

IV. Simplifying the Medi-Cal Application Forms

This section of the report analyzes the questions asked on the Medi-Cal applications (the “MC210” and related forms, and the forms included in the “mail-in” packet) and offers

suggestions on how the applications could be shortened and made more understandable, consistent with the federal and state rules that govern the program. Some 34 states have Medicaid

applications for pregnant women and children that are shorter than four pages, and other states are planning similar reforms. Short, simple forms can remove enrollment barriers and streamline the application process in ways that would benefit families, applicant assistors and reviewing agencies alike.

While there is a value in limiting the number of questions asked, it is important also to assure that program rules are followed and that the application forms gather the information necessary to properly determine eligibility for Medi-Cal. Throughout this analysis, the tension between needing accurate and precise information and shortening the form is evident. There is no “right” way to resolve this tension; the objective here is to identify the options available to California so that a reasonable balance can be achieved and eligible pregnant women and children are able to enroll in the appropriate program without difficulty.

At various points in this analysis, some ambiguities in the questions or instructions on the application forms are noted. This report intentionally does not take into account provisions in the

regulations or the Application and Certifications Reference Manual (the manual used to train

community-based application assistors) that might resolve certain of these ambiguities on the assumption that a goal of a simplified application process is to permit families and pregnant women to successfully complete the forms on their own. While assistance from community organizations and providers can be invaluable, not all applicants will have such assistance. Data gathered since June, 1998 show that well more than half (60 percent) of the mail-in applications

processed by the Healthy Families program have been unassisted.17_{Assistance is not a substitute} for a simplified application.

Federal Guidance

California’s Medi-Cal program must operate within the limits of federal law, and for many years states felt constrained to maintain a complex application and application process in order to comply with federal requirements. However, In January, 1998, HCFA issued guidance strongly encouraging states to simplify their forms and to eliminate verification requirements that can prevent eligible uninsured children from gaining coverage. Perhaps most significant from a state’s perspective is that the federal guidance assured states that federal rules do not require states to have long, complex applications or burdensome verification requirements. This

guidance pointed to states that have shortened their forms and offered a “model” two-page joint application for states, like California, that use a joint application for its Medicaid program and its separate child health insurance program.18_{In September, 1998, HCFA issued additional guidance} and more encouragement for states to simplify and streamline application procedures.19

The federal “model” application and examples from other state applications can be

instructive to California as it considers further revisions to its Medi-Cal application forms and process. These applications in effect provide further guidance to state policymakers and administrators about what is and what is not required to be included in a Medi-Cal application under federal law, and they can suggest new ways to solicit information that is required by federal law.

22

16 _{Healthy Families Program Application Statistics posted at MRMIB’s website (www.mrmib.ca.gov)through} October 17, 1998. Statewide data on the number and status of the mail-in forms submitted to Medi-Cal are not currently available.

17 _{Letter from Sally Richardson to State Health Officials, January 23, 1997.} 18 _{Letter from Sally Richardson to State Health Officials, September 10, 1998.}

23

A. Eliminating Questions That Ask About Individuals Whose Information Is Not Necessary to Determine Eligibility

The Medi-Cal applications, and particularly the new mail-in application, can be streamlined if the questions ask only for information about individuals whose information is necessary to determine the eligibility of the persons seeking Medi-Cal. Much of the information currently solicited by the applications is not necessary to determine the eligibility of a child or pregnant woman who is seeking coverage through either Medi-Cal or Healthy Families.

Federal law

The basic rule for determining whose information is relevant and whose income counts in Medi-Cal is straightforward, although sometimes difficult to apply. For children and pregnant women, eligibility is determined by looking at:

•

the income of the child or pregnant woman who is seeking Medi-Cal, and

•

the income of legally responsible relatives in the home, meaning the parent(s) of a minor child applying for benefits and the spouse of a pregnant woman applying for benefits if the parent or the spouse is living with the child or the pregnant woman. The income of unrelated adults who may be living in the home and the income of relatives, such as a grandparent, uncle, or stepparent, who have no legal responsibility to support the child or the pregnant woman applying for Medi-Cal do not count. Similarly, a child’s own income (e.g., child support payments from an absent parent) counts only for that child, not for the other children (or pregnant women) in the family.

California’s Approach

There is no disagreement that these so-called “family composition” rules are the rules that operate in California’s Medi-Cal program. Moreover, these are generally the same rules that apply in the Healthy Families program.20_{The Medi-Cal forms, however, do not always follow} these rules.

20 _{One difference between the Medi-Cal and Healthy Families rules relates to how children’s income is to be} counted. Unlike Medi-Cal, Healthy Families rules do not put children into separate family budget units when they have income of their own.

The mail-in form asks all “applicants” (see box) about a range of matters including their residency, income, marital status, Social Security number, ethnicity, date of birth, and birth name. This information is solicited regardless of

whether the person is seeking Medi-Cal for him or herself or is only submitting the application on behalf of others, and these questions are asked even if the “applicant” has no legal responsibility to support the child or pregnant woman who is seeking coverage.

This same information must be supplied for each child in the home, and for the children’s parent(s) if they are in the home. In addition, depending on how the instructions within the mail-in packet are interpreted, the information also must be supplied for the spouse of the person filling out the application, and potentially even for “other adults” in the home, including

individuals who are not seeking coverage for themselves and who have no legal responsibility for the children or pregnant women on whose behalf the application is being submitted.21_{The MC210}

24

Who Is an Applicant?

The Medi-Cal applications (the “MC 210” and the mail in packet) both use the term “applicant” to refer to the person who is filling out the form. This person may or may not be seeking (Medi-Cal or Healthy Families) coverage for herself. For example, if a mother applies for Medi-Cal on behalf of her children, she is considered the “applicant” on the mail-in form even though she is not “applying” for coverage for herself.

This is a confusing use of the term, as judged by many of the conversations with application assistors, and this report suggests that the forms be revised to use another term to refer to the person who is filling out the form. However, in order to describe what information is asked of different household members on the current forms, this report uses the term “applicant” as it is used in the Medi-Cal forms — to refer to the person filling out the form without regard to whether she is seeking coverage herself

“It is so confusing between applicant, adult and other adult — you don’t know who is who by the end.” — an application assistor

21 _{The instructions in the mail-in packet do not provide clear or consistent directions on whose information must be} reported on each of the various mail-in packet forms. Part A (the “Application for Health Care- Healthy Families and/or Medi-Cal”) and Steps 1 and 2 (the income worksheets for both programs) ask for information about “other adults” in the home. The instructions to Part A (p.12) state that if there is another parent in the home, information about that parent should be included in the “other adult” column in Part A. These instructions, however, do not otherwise define or limit the term “other adult”; for example, it is not clear whether “other adult” also includes the applicant’s spouse, the child’s grandparent, or an unrelated adult living in the home.

Another set of instructions on page 6 lists who is considered a “family member”. These instructions state that the applicant, the applicant’s spouse, and the child’s parent who is living with the applicant are to be considered “adults.” These instructions appear to assume that the applicant is the parent, although that is not always the case. The

instructions also leave open the question of whether other adults (e.g., grandparent) are to be included when the forms ask about “adults”, and it suggests that information about an applicant’s spouse is to be included regardless of whether the applicant or the applicant’s spouse is applying for benefits.

A “note” at the end of these instructions states that if a stepparent is not applying for his or her children, the stepparent’s income is not to be included in Step 1 (the income worksheet), but the note does not address the situation where the stepparent’s spouse (e.g., the applicant) is also applying for Medi-Cal or Healthy Families (for example,

25

solicits a similar range of information with respect to the applicant, the applicant’s spouse or the child’s other parent, and all children, including unborn children.

By limiting questions on the application to apply only to those individuals whose information is necessary to determine the eligibility of the persons seeking coverage and by clarifying the use of the term “applicant”, California could streamline its forms and improve the integrity of its eligibility determination process.

•

Focusing the questions to solicit information only about people whose

information is relevant to determine eligibility could reduce errors. It is important for a mail-in application to be clear on the face of the application about the issue of whose information must be reported and whose income is to be considered since these matters will not be resolved at an eligibility interview with agency staff. Mistakes may cause delay, and, in light of the screening process that families must perform, they can even cause eligible children and pregnant women to lose out on coverage. While trained assistors will in many cases prevent mistakes from occurring, the integrity of the Medi-Cal and Healthy Families mail-in application system should not depend on trained assistors.

•

Unnecessary questions create unnecessary verification requirements. Currently, Medi-Cal applicants must verify (ie., produce written documentation that

substantiates the information provided on the application) the following items: identity, income and expenses, residency, immigration status, and pregnancy. To the extent that the applications require that these items be reported for individuals living in the home whose information is not necessary to determine the eligibility of the pregnant women and children applying for benefits, it also results in families having to search for and provide unnecessary documentation. Documentation requirements — particularly those relating to income — can lead to delays in families applying for coverage and result in families being denied coverage because they were not able to satisfy the paperwork requirements.

because she is pregnant). The note about stepparents, moreover, applies to Step 1 but not to Part A, the main form in the packet that solicits nonfinancial information (such as Social Security numbers) about household members and so it is not clear whether stepparent information should be filled in on that form in all circumstances or only when the stepparent’s child is applying for benefits.

•

Questions about individuals whose information is not necessary could discourage families from applying for health insurance. Depending on how families read the forms and

interpret the various instructions, they may believe

they are required to provide fairly detailed information about persons in the household whose presence in the home has nothing to do with their child’s need for or ability to obtain health insurance coverage. Extensive and unnecessary probing

could perpetuate the stigma sometimes associated with publicly-funded programs and discourage families from pursuing an application for both Medi-Cal and Healthy Families.

•

Questions about the Social Security numbers of individuals who are not applying for coverage could deter eligible children and pregnant women who live with immigrant family members from applying. In general, when someone’s information is reported on either the MC210 or the mail-in application forms, the applicant also must supply that person’s Social Security number (SSN). To the extent that such persons do not have an SSN, this request may deter the family from proceeding with the application on behalf of an eligible child or pregnant woman.

Federal law prohibits states from requiring SSNs from anyone other than the person or persons who are applying for coverage for themselves.22 Thus, at a minimum, requests for Social Security numbers for other persons in the household must be made optional in the Medi-Cal program. (Social Security numbers are optional in the Healthy

Families for all persons, including the children applying for coverage.) While this would improve the California forms substantially, families might feel even more comfortable if questions about SSNs were not even asked with reference to individuals who are not applying for coverage and who have no legal responsibility to support the child or pregnant woman seeking coverage.

Options for Simplification

•

The Medi-Cal applications could be shortened and simplified by soliciting information only for the following categories of individuals:

26

(W)here they were born, race, birth name -why do they want so much information on the parent?” — an application assistor

22 _{The federal law was recently restated by HHS in guidance sent to states. Letter from Sally Richardson to} State Health Officials, September 10, 1998.

27

— The person(s) or persons in the home who is seeking coverage;

— Parents of a minor who is seeking coverage if the parent(s) and the minor live together, and;23

— Other adults living in the home who are married to a person (e.g., a pregnant women) seeking coverage.

•

The forms could be made clearer by no longer using the term “Applicant” to refer to individuals who are filling out the form without regard to whether they are seeking (ie., applying for) coverage. Another term, such as “Head of Household”, could be used to refer to the adult who is filling out the form.

Models from Other Forms

•

South Dakota’s question asking about adults in the home is as follows:24 The South Dakota form further states:

IMPORTANT: Answer the remaining questions for ONLY the following individuals living in the home:

— children wanting medical and their parents. Note: For a child living with someone other than a parent, only list the child’s income

— pregnant woman wanting medical, her spouse, and their children. Note: For a pregnant woman 18 or older, do NOT list her parent’s income

1.A. List the adults in this home starting with the person making the

application. Then ONLY list and provide information on this form for adults who are:

• the parents of children under 19 wanting medical assistance • women who are applying for pregnancy coverage and their spouses

23 _{Since Healthy Families allows children to select their absent parent’s home as their household unit (the term} used in the application is the “children’s unit”), the mail-in packet must solicit the absent parent’s income for purposes of the Healthy Families program when a family chooses this option.

24 _{South Dakota Children’s Health Insurance Program (CHIP) Application, DSS-EA-301M-07/98, South Dakota} Medicaid.

•

With respect to the term “applicant,”

— The model HCFAjoint application (which covers children but not pregnant

women) refers to the person filling out the form as “Person Applying for the Child or Children.”25

— Delaware’s application refers to the person filling out the form as the “Head of Household.”26

B. Simplifying and Clarifying the Income Questions

Since no-cost Medi-Cal (and Healthy Families) is only available to children and pregnant women whose income is below state-established eligibility standards, determination of countable income is central to the application process.

Federal law

The process of ascertaining countable income in Medi-Cal involves three steps:

1. The first step is to determine whose income is to be counted, applying the family

composition principles discussed above.

2. Once it is established whose income is counted, the sources of income that are to be counted must be identified. Although federal law requires most kinds of income to be counted for purposes of determining Medi-Cal eligibility, certain sources of funds are excluded.

3. The third step is to actually calculate the countable income. This generally requires converting the reported income to monthly amounts, adding the income received by various household members to arrive at total countable monthly income, and

subtracting allowable expenses (deductions).

28

25 _{HCFA model joint application, revised August 31, 1998 attached as Appendix B.} 26 _{Delaware Family and Community Medical Assistance Application, MAP-4.}

29 California’s Approach

The MC210 and the mail-in packet take two different approaches to steps two and three of this process. The MC210 asks for income from earnings (Q 30), income from self-employment (Q 31), and unearned income (Q32). The unearned income question identifies 15 categories of unearned income, including a catchall

category for “any other unearned income (include gambling/lottery/bingo winnings, lump sum payments, inheritance).” The form asks how often each source of income is received, and the agency — not the applicant — calculates countable monthly income.

In contrast, the mail-in packet collapses the income questions into one worksheet. Step 1 in the mail-in packet (page 7) asks the

applicant to identify countable sources of income (based on instructions provided on page 6), to convert all income received to monthly amounts and to determine total income for each person identified on the form. Step 2 then requires the applicant to add the income for all persons to determine total income for the household and (for Medi-Cal applicants) to subtract applicable deductions.

There is no “right” way to ask about income. The approach taken in the mail-in form of asking about all sources of income in one question/worksheet is reasonable. It could (if the income calculations were dropped) take up less space than the MC210 approach, which asks three separate income questions (along with an additional set of questions about employment; see MC210 questions 13-16), and takes up nearly a page identifying potential sources of unearned income.

Neither form fully informs applicants of the sources of income that should and should not be counted, although this is likely to create more problems in the mail-in system because the applicant, and not the reviewing agency, makes an initial determination of eligibility. For example, bona fide loans that must be repaid are not to be counted as income under federal and state law. The mail-in form income instructions on page 6 do not address the issue of loans, although the MC219 mail-in form (the four-page section on “rights and responsibilities” in the mail-in packet) instructs applicants (at p. 25 of the packet) to report when income, including

loans, decreases, increases or stops.

The most significant problem with the way that income is addressed in the mail-in packet relates to the requirement that applicants calculate their total monthly income. This approach adds considerable length and complication to the form and the application process. The income calculations required by the mail-in form are likely to be very difficult for some unassisted applicants to manage on their own and could result in mistakes and delays in coverage as

Assistors consistently ranked determining countable income as the most confusing part of the application.

families seek help completing the form. The requirement that families calculate income could even keep some families from applying.

These calculations are required because the general approach taken by the mail-in packet is that the applicant, rather than the reviewing agencies, must determine, at least in the first instance, whether the children and pregnant women who are applying for coverage are eligible for Medi-Cal or Healthy Families. The income calculations required by the Step 1 and Step 2 forms in the mail-in packet is central to this process. As discussed more fully mail-in Chapter III, this approach differs significantly from the approach taken by other states that have adopted mail-in forms covering both Medicaid and the state’s separate child health program.

Options for Simplification

The forms could be made shorter and easier to complete by combining the best features of the two Medi-Cal forms:

•

Maintain the mail-in form approach, which asks about all income within one question or worksheet;

•

Eliminate the requirement (which is part of the mail-in packet, but which is not part of the MC210 application) that applicants convert their income to monthly amounts, calculate total monthly income and subtract applicable deductions. These calculations would be done instead by the reviewing agency.

•

Assure that the income question or worksheet includes either clear information about which common sources of income are counted or a cross reference to the page in the application packet where such information appears.

Options for how to shift the responsibility to do the income calculations from families to a reviewing agency are discussed more fully in Chapter III.

31

C. Assuring That Applicants Are Able to Take Available Deductions Federal law

Under federal Medicaid law, certain expenses that reduce the income available to families to purchase health care services and health care coverage are allowed as deductions. In other words, financial eligibility is determined by comparing net income with the Medi-Cal income standards.27

Both the MC210 and the mail-in form solicit information about expenses that are allowable Medi-Cal deductions. While certain differences in how these allowable expenses are described on the forms are noted in Appendix A, the most significant issue relates to the deduction allowed for people whose income is from self-employment.

The MC210 solicits information about business-related expenses for self-employed individuals (Q 34), but the mail-in form does

not include these expenses in the section of the application that identifies allowable

deduc-tions. Applicants may pick up on the fact that such deductions are permitted because the instructions on the mail-in form (page 6) state that “self-employment net profits” and “net rental income” are counted as income. Many applicants, however, may miss the point that business-related expenses are allowed as deductions. This is particularly likely because the instructions to Step 1 (the income

worksheet) state that “monthly gross

income/earnings” (emphasis supplied) are to be listed. Options for Simplification

In order to assure that eligibility is properly determined for children and pregnant women with income from self-employment, the mail-in forms could be revised either

•

By adding business-related expenses to the deduction section in Step 2, or

•

By specifically noting in the income reporting section (Step 1) that self-employment income should be reported after business-related expenses are taken into account.

An assistor explained that many self-employed families in her county have business expenses such as cattle feed and labor costs so that “a monthly salary of $5,000, after business expenses are subtracted, is more like $600.” But the Medi-Cal mail-in application doesn’t have a “space for subtracting” work expenses. “I just hope social services doesn’t look at the check and think the money is all the

applicant’s.”

27 _{The rules for the Healthy Families program are different. In Healthy Families, financial eligibility is determined} by comparing gross income to the Healthy Families income standards. This difference in (continued) program rules adds to the complexity of the mail-in form and is discussed in Chapter VIII, along with the possibility of using gross income standards in Medi-Cal.

D. Residency Federal law

Federal law provides that Medicaid beneficiaries must be residents of the state. The definition of residency is left to the states.

California’s approach

For purposes of Medi-Cal eligibility, state law generally defines residency as having a physical presence in the state with an intent to remain in the state indefinitely.>28_{Residency in the state also} is a requirement for the Healthy Families program.

The mail-in packet, and particularly the MC210, ask multiple questions with respect to residency. Both forms ask the applicant to identify his or her address, and the mail-in form (Part A) also asks for the addresses of the children if they do not live with the applicant. In the model HCFA joint application (and in many other state forms), the question soliciting the applicant(s)’s home address is the only question asked about residency.

The mail-in form, however, asks two additional questions. It asks if the applicant and other family members live and intend to remain in California (Part C “Application for the Medi-Cal Program”, section 1, Q.2), and both applications ask if the applicant or family member has a visa or a border crossing card.29 In our review of state Medicaid applications, we found no other state that asked whether an individual had a visa or border crossing card.

In addition, the MC210 asks five more questions relating to residency (Q10 - Q12):

•

Do you or any family member own, lease or maintain a home outside California?

•

Are you or any family member currently receiving public assistance outside

Califor