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CHAPTER 3: APPLYING FOR BENEFITS: WHAT FAMILIES MUST DO

Applying for TANF, food stamps, Medicaid, or SCHIP can be a relatively simple and straightforward process or it can be a more complex process involving numerous steps, multiple visits, or visits to multiple offices. Any difficulties faced by individuals attempting to navigate the application process are compounded for non-citizens and limited English speakers. To fully appreciate the application experiences of non-citizens and other limited English speakers who face unique eligibility rules and language issues, it is important to understand the application process facing all individuals, regardless of their English proficiency or immigration status.

The type of assistance sought and the way in which the process is designed and implemented at the local level largely dictates the particular steps and procedures that make up the application process. Individuals applying for cash assistance, or TANF, typically apply for a full package of benefits, including food and medical assistance (i.e., food stamps and Medicaid). This is the traditional welfare package (referred to here as TANF/FSP/Medicaid), and the integrated application process associated with obtaining this package has, until recently, been the primary path to accessing any of these programs.

The establishment of SCHIP and Medicaid-expansion programs spurred the development of different application pathways to coverage under these programs that may have much, little or nothing in common with the traditional TANF/FSP/Medicaid application process. Under federal law, the SCHIP program provides states with the flexibility either to use the pre-existing Medicaid infrastructure or to adopt a stand-alone program for enrolling recipients, or a combination of the two. Among the study sites, one state (Missouri) chose to expand their existing Medicaid program; three states (North Carolina, Virginia, and Washington) chose to create a separate SCHIP program; and two states (New York and Texas) chose to combine both approaches. States may also accept electronic, mail-in, or telephone SCHIP applications and rely on private contractors to facilitate application and eligibility determination. The degree to which states have chosen to combine SCHIP and Medicaid-expansion programs, including providing an integrated application process, varies. In addition, there can be separate Medicaid-only and/or food stamp-only application processes that have their own distinct features.

Overall, there is considerable variation in program application processes across the study sites (and even across offices within sites) as well as across programs.1 For the applicant, the SCHIP application process is typically the most simple and least burdensome to complete and the same is often, but not always, true of Medicaid-only application processes.2 By contrast, the integrated TANF/FSP/Medicaid application process is the most complicated with respect to the number of steps, activities and (sometimes) trips required. Among our sites, the TANF/FSP/Medicaid application process is the simplest in Seattle and the most complicated in New York City.

This chapter describes benefit application procedures from the point at which a person initiates the application process to the point at which the application is ready to be reviewed and verified for eligibility determination purposes. First, an overview of initial points of entry to the application process is provided. A typical application process is then described, focusing primarily on: (1) where application activities take place, and (2) what the process entails. This is followed by a more in-depth description of how these two key dimensions of the application process play out in each of the study sites.

Gaining Access to Program Benefits: Various Initial Points of Entry

The traditional welfare application process (i.e., TANF/FSP/Medicaid) contains a single point of entry—the welfare agency. Alternative points of entry are sometimes available to families interested in obtaining assistance that does not include TANF benefits. This section reviews the major organizational entry points for the four benefit programs considered in this study as of mid-2001 (see Exhibits 3-1 and 3-2).

Accessing the Traditional Welfare Package—TANF/FSP/Medicaid

The number of welfare offices within a given local jurisdiction depends in large part on the geographic and population size of a local jurisdiction. There may be only one centralized office or there may be several welfare offices located throughout the area where families can gain access to the full package of TANF/FSP/Medicaid benefits.

Exhibit 3-1:

Office Structure for Program Application and Eligibility Determination
(Study Sites, 2001)

Site	Integrated Office (TANF, FSP, Medicaid/ SCHIP)	Specialized Program Unit Within Office *	Specialized Office by Program			Specialized Refugee/ Immigrant Office
			TANF (with FSP/ Medicaid)	Medicaid/ SCHIP-Only	Food Stamp-Only
Arlington, VA
Dallas, TX						**
New York, NY
Raleigh, NC
Seattle, WA
Sedalia, MO

* These offices have separate eligibility staff dedicated to TANF/FSP/Medicaid applicants and to non-TANF applicants (i.e., food stamps and Medicaid/SCHIP). ** The state of Texas centralized all refugee eligibility determination at a call center in Austin in September 2001. At the time of our visit, however, refugee eligibility determination took place within specialized units in each region.

In addition to welfare offices that offer access to multiple benefit programs, some places also have specialized offices or units to serve special populations. In New York City, for example, all refugees and non-citizens from across the city must apply for and receive ongoing assistance and services at one of two specialized Job Centers located in lower Manhattan and Brooklyn.3 At the time of our visit (July 2001), refugees in Dallas applied for benefits through specialized refugee units co-located in two welfare offices—one in downtown Dallas and one in nearby Fort Worth. Shortly after our visit, however, state administrators consolidated the application process for refugee public benefits, statewide, in a single call-center based in Austin.

Additional Entry Points to Medicaid/SCHIP and Food Stamps

Some have recently suggested that providing access to non-cash programs through separate offices may help de-stigmatize these programs and distinguish them from traditional “welfare”, thereby improving the capacity of Medicaid, SCHIP, and food stamps to be effective supports for working families (Dion and Pavetti 2000). Among our six sites, only New York City has such specialized offices. Some offices only accept Medicaid/SCHIP applications, and other offices only process applications for food stamps. Applicants who come to these offices and appear to need additional forms of assistance or services, notably TANF cash assistance, are supposed to be referred to one of the TANF welfare offices (which also provide Medicaid and food stamp eligibility determination services for TANF cases).4 Efforts have also been made in New York to provide access to Medicaid for families that applied for TANF but either were not qualified or withdrew their applications by co-locating a Medicaid worker within each TANF office. These workers review applications that have been rejected or withdrawn from TANF for Medicaid eligibility and then transfer the cases to the appropriate specialized office.

While there are not separate specialized Medicaid or food stamp offices in Raleigh and Arlington, these sites have adopted the same approach as New York, albeit on a smaller scale. TANF and non-TANF units are physically separated and have different reception and waiting areas for applicants. In order to streamline casework, workers in the TANF unit also handle food stamps and Medicaid for TANF families.

Efforts to Facilitate Access to Benefits: Medicaid and SCHIP Lead the Way

In contrast to families applying for TANF/FSP/Medicaid, those applying for SCHIP (and in some places, Medicaid-only) typically do not need to rely on the welfare office as their only point of entry. Instead, there are typically multiple points of entry into the SCHIP program. Exhibit 3-2 demonstrates both the array of places and types of organizations that facilitate application for SCHIP benefits. For example, in Arlington, Raleigh, and Seattle, SCHIP applications are disseminated through the schools, Dallas, New York, and Sedalia rely on community-based organizations to help reach and enroll children in SCHIP through a variety of means including attendance at health fairs and dissemination of materials in health clinics, schools, and throughout the community. As described later, the SCHIP programs in Arlington, Dallas, and Seattle have centralized processing centers that take application requests, determine eligibility and process applications for SCHIP for the entire state.

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In all sites, Medicaid and SCHIP mail-in applications for children are permitted. Two study sites (Sedalia and Seattle) rely on pre-existing office-based Medicaid enrollment processes, but applications may also be sent by fax, by mail, or dropped off in-person. In New York, efforts to coordinate Medicaid and SCHIP led to a streamlined approach that currently includes a single joint application and the use of community-based facilitated enrollers who take applications for both programs.

Interest in improving access to and enrollment in Medicaid has also led to a variety of strategies to increase the points of program entry either by out-stationing workers capable of conducting eligibility screenings or eligibility determinations in locations that are more convenient and accessible to the community. Medicaid programs have used this general outreach approach since the late 1980s when Medicaid first expanded coverage to pregnant women and children. To reach this new population, Medicaid agencies began placing out-stationed eligibility workers at hospitals and federally qualified health centers.5 In the study sites, Medicaid eligibility workers are out-stationed at health clinics in Dallas and Raleigh, and at hospitals in Arlington, Dallas, New York, Raleigh, and Seattle.

This trend is much more pronounced since the implementation of SCHIP. In many places, the SCHIP application and eligibility determination process has been deliberately moved away from the traditional welfare agency setting and placed where eligible individuals are likely to be, namely in their local neighborhoods and communities. Efforts to increase the points of access for the SCHIP program has also led to the use of non-welfare agency staff to accept applications.

Overall, there have been extensive outreach efforts to increase awareness and enrollment in Medicaid/SCHIP. Outreach efforts may be designed to reach the entire community, or may target specific neighborhoods, ethnic groups, or other segments of the population. The study sites provide many examples of the wide array of Medicaid/SCHIP outreach efforts taking place through community-based organizations (CBOs), schools, health care providers (including hospitals, public health clinics, and Medicaid managed care plans), and media campaigns (see box, “Reaching Out to Potential Medicaid/SCHIP Applicants: Examples of Outreach in Six Study Sites”). The most effective outreach efforts were typically identified as those conducted through public schools, pediatricians’ offices and health clinics. In addition to conducting outreach, we identified CBOs in all study sites that provided one-on-one assistance to families with some aspect of the application process—usually for Medicaid/SCHIP applications but also, to a lesser extent, for food stamp and TANF applications (see box, below).

Reaching Out to Potential Medicaid/SCHIP Applicants: Examples of Outreach in Six Study Sites Community-Based Organizations. CBOs provide outreach (including application assistance) in many of the sites in our study and are considered particularly effective with reaching out to immigrant and non-English speaking communities, especially when they employ staff that speak the same language and share similar cultural backgrounds as their clients. In Sedalia, a community-based organization, the Pettis County Community Partnership (PCCP), uses VISTA volunteers (some Anglo and some Latino) from the local community to conduct outreach about different programs and services through Head Start, the schools and a local health center. In Seattle, the county public health agency subcontracts with a variety of CBOs to conduct both outreach and application assistance. Schools. School-based outreach is viewed by many as another particularly effective type of outreach. School nurses, school-based health fairs, parent-teacher nights, and school lunch mailings are used in some sites to disseminate information about Medicaid/SCHIP and identify uninsured children. In Raleigh and throughout Missouri, information about SCHIP is provided in the school lunch program application. School nurses in Raleigh have been particularly successful in conducting SCHIP outreach, according to local administrators. School nurses in Arlington, who are actually Department of Human Services employees, also conduct SCHIP outreach. Since 1998, public and private agencies in Washington State have partnered to find ways to increase access to Medicaid/SCHIP through school lunch applications. These ongoing efforts led to a 2001-2002 school year pilot to share students’ school lunch eligibility information with the state Medicaid agency (Papsdorf 2001). Media Campaigns. Many sites are using various forms of media to promote awareness about SCHIP, as well as food stamps and other types of public assistance. Media campaigns have been used in all sites. For example, Texas has a statewide media campaign, including radio and television advertisements, printed media, and the creation of a toll-free hotline and telethons. New York has used Public Service Announcements (PSAs) to create awareness of low-income medical assistance programs. Health Care Providers. Outreach efforts are frequently conducted through community health care clinics, which are considered particularly effective settings to reach immigrant communities. In New York City, the considerable outreach and marketing expertise of private health plans has been used to increase enrollment in publicly funded medical assistance programs. Health plan staff attend health fairs, visit local welfare and health departments, meet with and educate providers, and network with community-based organizations. Public Agencies. More than 20 New York City agencies, including the New York City Housing Authority, are identifying and enrolling uninsured New Yorkers in public health insurance (including Medicaid, SCHIP, and Family Health Plus) through the City’s Health*STAT initiative.

Outreach and application assistance services in the study sites often include a component designed to reach non-citizens and limited English speakers. These targeted efforts typically include disseminating materials about program benefits and eligibility translated in different languages, targeting areas with high concentrations of immigrant families, and using bilingual speakers to provide application assistance. It was often stressed by practitioners that application assistance provided through bilingual staff in community-based settings was a particularly effective means for facilitating immigrant and LEP access to benefits.

One-on-One Help for Applicants: Examples of Application Assistance in Six Study Sites The Pettis County Community Partnership (PCCP) in Sedalia, funded by the State of Missouri, links low-income communities to needed benefits and services. PCCP provides numerous services to Sedalia’s growing Latino community, including translation, interpretation and application assistance for health and social services. PCCP employs a full-time, state-funded interpreter and houses a part-time interpreter who is paid by a local church. These interpreters take applications at PCCP and accompany applicants to the welfare office in Sedalia. According to PCCP staff, Latinos usually feel more comfortable applying for Medicaid/SCHIP benefits at PCCP because the welfare office cannot provide assistance with interpretation. The interpreters at PCCP complete Medicaid/SCHIP forms; mail them to the DFS office; and then follow-up on applications with welfare office eligibility workers. The PCCP interpreter and other staff members also educate the Latino community about benefit eligibility and public charge issues, to reduce their fears about applying for Medicaid/SCHIP. Facilitated enrollers in New York City help individuals complete the Medicaid/SCHIP application by walking them through the process and identifying all necessary forms and documentation. Outreach workers from a variety of organizations in Dallas also provide Medicaid/SCHIP application assistance—for example, the Children’s Medical Center in Dallas employs outreach workers to provide hands-on SCHIP application assistance in areas with large numbers of uninsured children. In Arlington, the Pediatric Clinic for low-income families has a part-time Spanish-speaking bilingual case manager who prescreens clients for Medicaid/SCHIP eligibility and provides application assistance to those who appear eligible. The Community Food Resource Center in New York employs pre-screeners who work throughout the City to identify and assist individuals who are potentially eligible for food stamps. Pre-screeners refer applicants to their local food stamp office to apply for benefits, advise them about necessary documentation, and help them complete the food stamp application. In Arlington, the Hispanic Committee provides low-income Hispanic families application assistance for the complete package of TANF/FSP/Medicaid benefits as well as Medicaid/SCHIP benefits.

An Overview of Common Steps in the Application Process

The traditional TANF/FSP/Medicaid integrated application process not only provides a single point of entry; it is typically much longer and more involved than the SCHIP or Medicaid-only application processes. This section provides a generic description of what is involved in each step of the TANF/FSP/Medicaid application process (see Exhibit 3-3) and then describes each site’s application processes in greater detail. The steps that lead up to eligibility determination —reception, screening, up-front requirements, eligibility interview—are most commonly experienced by families applying for TANF/FSP/Medicaid through traditional means, namely the welfare office.

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Reception/Intake

The initial point of contact with the welfare system typically occurs in the reception area of the welfare office. In each of the study sites, the first person new applicants speak with when they enter the welfare office is the receptionist/intake clerk. Receptionists/intake clerks provide blank applications, take completed applications, answer general questions, and sometimes conduct initial reviews of applications to check for missing information. (See Chapter 4 for more details on the written application.) They also frequently schedule eligibility interviews for applicants. Because individuals may not know exactly which benefit programs are available or for which they (or their children) might be eligible, some offices use the receptionist/intake clerk to screen applicants (or their applications) to determine which types of assistance they need, want, and/or for which they might be eligible. In some offices, the reception/intake staff may also review the application to see if the family appears eligible for expedited food stamps or other emergency services.6

Eligibility-Related Screening

Screenings that occur prior to the eligibility determination can serve many purposes, including:

• Simplifying and shortening the eligibility interview;

• Determining the need for expedited food stamps or other immediate services;

• Conducting an up-front needs assessment for the purpose of diverting applicants from TANF to financial lump-sum assistance or referrals to other programs and/or resources;

• Informing applicants about the types of documentation they will need to submit;

• Determining whether or not individuals appear to be eligible for Medicaid because applicants must be determined ineligible for Medicaid before being enrolled in SCHIP; and

• Identifying potential barriers to participation in the TANF work program.

It is common for screenings to be used to identify clients in need of immediate assistance, such as emergency Medicaid or expedited food stamps. In some places (e.g., Raleigh), screenings are intended to identify whether applicants should receive short-term lump sum payments rather than regular TANF while other sites (e.g., Arlington and Seattle) use them as a tool to improve customer service and administrative efficiency.

Eligibility-related screenings may be incorporated into initial reception/intake responsibilities or may constitute a completely separate and distinct step in the application process. For example, reception/intake staff in Sedalia and Raleigh routinely conduct a preliminary screening to assess applicants’ need for expedited or emergency services. At this time they may also refer applicants to other programs or organizations in the community for assistance. This type of screening also provides staff with enough information so they can provide the correct application form and tell applicants which types of additional documentation they will need to submit.

Up-Front Requirements

Many offices have adopted a “work first” policy that stresses the temporary nature of cash assistance and the expectation that clients will go to work. TANF programs across the country have imposed non-income requirements that applicants must meet as a condition of being determined eligible to receive assistance.7

Under welfare reform, many states require TANF applicants to attend a mandatory orientation or conduct a job search prior to approving an application for assistance. These requirements generally reflect efforts to alter the culture of welfare so that it is clearly associated with work and self-reliance (Holcomb and Martinson 2002; Lurie 2001). In some places, these requirements must be met prior to the eligibility interview, while in others they must be met after the interview, but before the application can be approved. According to federal regulations, these “up-front” eligibility requirements under the TANF program cannot be used to delay applications or deny eligibility for Medicaid and FSP.8

Local sites included in this study have implemented several up-front requirements for applicants that must be met while the application for TANF benefits is pending. These up-front requirements include orientations, work-related activities—such as job search or registration with the workforce agency—finger imaging, photographing, and home visits (Exhibit 3-4). New York City has an added requirement of pre-eligibility verification (described in more detail later in this chapter).

Orientation. Among our study sites, it is common to require TANF applicants to attend a separate group orientation to learn about the program rules and expectations regarding work activities, sanctions, and other program requirements. In Arlington, Dallas, and New York City, TANF applicants are required to attend a group orientation prior to being determined eligible to receive benefits.9 Eligibility determination is contingent upon orientation attendance. In Raleigh, participation in a group TANF orientation is not required as part of the application process, but is strongly encouraged. Applicants in Sedalia and Seattle receive a one-on-one orientation about the TANF program as part of the eligibility interview process.10 Staff in Arlington also instruct food stamp and Medicaid applicants to attend an orientation immediately prior to their eligibility determination interview, but the primary purpose of this orientation is to provide additional screening to facilitate the eligibility interview by making sure the applicant has assembled the proper documentation.

Exhibit 3-4:
Up-Front Eligibility Requirements

(Study Sites, 2001)

Site	Orientation	Work Activities *	Finger Imaging/ Photographing	Home Visits	Pre-Eligibility Verification
Arlington, VA
Dallas, TX			**
New York, NY			**
Raleigh, NC
Seattle, WA	***
Sedalia, MO

*     Work activities include work registration and job search **   For both TANF and food stamps *** Following our visit, the Seattle/Kent office added an orientation requirement

Work Activities. Many sites require TANF applicants to participate in some form of work activity while their application is pending. Activities include job search (New York and Sedalia11) and registration for work with the Employment Service (Raleigh and Sedalia). In Raleigh and Sedalia, a representative from the Employment Service is co-located in the welfare office. Applicants for cash assistance in New York City are required to attend an orientation with an employment services provider as well as participate in an up-front job search during the 30-day eligibility determination period.12

Finger Imaging and Photographing. Two sites (New York and Dallas) require applicants for cash assistance and food stamps to have their fingerprints and photographs taken as part of the application process. These procedures are viewed as fraud prevention measures because they allow eligibility workers to compare applicants’ fingerprints and photographs to those of clients receiving benefits.

Pre-Eligibility Verification. While all sites’ application processes include verification of certain information for TANF eligibility determination purposes, New York City is the only site that requires an additional pre-eligibility verification step. Applicants for cash assistance from all five boroughs of the city must go to the Eligibility Verification Review (EVR) office in Brooklyn as part of the application process. According to administrators, EVR’s independent review of applicants’ documents is designed to detect altered or forged documents and identify genuine documents. The fingerprints and photographs of applicants are stored on a computer and used to verify identity as part of the applicant eligibility verification review. However, EVR investigators do not receive copies of documentation and case notes from the welfare offices (called Job Centers) where applicants initiate the process, so applicants must bring the same documents to both interviews.13 They may also ask for additional information that was not already requested by Job Center staff.

Home Visits. In New York City, all applicants for cash assistance receive a home visit as part of the eligibility verification review described above. Home visits allow EVR staff to confirm and gather additional information about household members, residence, and income that may not have been evident during the office interview. No other sites in this study require a home visit as part of the application process.

Eligibility Interview

The eligibility determination interview is a standard feature of the TANF/FSP/Medicaid and food stamp-only application processes and typically (although not always) requires applicants to make an additional trip to the welfare office. During eligibility interviews, workers review applications with clients, fill in missing information, and assemble supporting documentation (see Chapter 5). The eligibility interview also provides an opportunity for workers to complete any section of the application left blank due to lack of understanding or preparation on the part of applicants. As most welfare offices do not offer extended hours, meeting this requirement may pose difficulties for employed individuals. If they cannot get time off from work to complete this interview, they may not be determined eligible for assistance.

In contrast to TANF and FSP, many states do not require a face-to-face eligibility interview for Medicaid/SCHIP. Many simply did not include this requirement when creating their SCHIP application processes. Some states also opted to eliminate the historic requirement for a face-to-face interview for Medicaid for children or pregnant women. This is one important way states have simplified the Medicaid and SCHIP application process.

At the time of our site visits (June-December 2001), Arlington, Raleigh, Seattle, and Sedalia did not require face-to-face eligibility interviews for Medicaid-only or SCHIP applicants. Texas ended the face-to-face requirement for children applying for Medicaid/SCHIP as of January 2002. New York City requires a face-to-face eligibility interview, which may be conducted at Medicaid-only welfare offices or by community-based facilitated enrollers in non-welfare settings.

Site Specific Application Processes

This section provides a fairly in-depth, site-by-site description of the integrated TANF/FSP/Medicaid application process and then highlights how Medicaid/SCHIP or food stamp only application processes differ from the integrated application process. (As noted earlier, families applying for TANF typically are also simultaneously applying for food stamps and medical assistance.)

Exhibit 3-5 outlines the steps involved in the application process for families applying for TANF/FSP/Medicaid benefits in each of our sites as they were as of June – December 2001. In Exhibit 3-5, steps specific to the TANF/FSP/Medicaid process that are not required for individuals applying only for food stamps and/or Medicaid/SCHIP are shaded. As Exhibit 3-5 shows, the Medicaid, and particularly the SCHIP, application processes are often more streamlined. In addition, there tend to be multiple ways to access and apply for these programs (e.g., through health clinics and CBOs).

Among our study sites, the two offices visited in Seattle have the simplest TANF/FSP/Medicaid application process—it is made up of three basic steps (reception, eligibility interview, and eligibility determination) and there are no additional up-front requirements. The other sites have additional steps that either facilitate the application process or stress the work first nature of the TANF program.

Of all our sites, New York has the most complicated and lengthy process for TANF applicants, requiring applicants to attend two eligibility interviews in two different locations, receive a home visit, and participate in up-front work activities. Finger imaging is completed during the first eligibility interview. However, depending on the Job Center, photographing the applicant may require an additional visit to a separate office.

The steps involved in applying for benefits may take more or less time for applicants depending on what procedures they must follow and the order in which they must be completed. In some cases, there may be several steps but they all occur within one location and within a single day. For example, in Raleigh, Sedalia, and the Seattle/Kent office, applicants typically complete their in-person eligibility interview on the same day that they submit an application. In other locations (Arlington, Dallas, New York, and Seattle/Rainier office), the eligibility interview is scheduled to take place at a later date—often but not always within the same week.

In Dallas, for example, applicants are scheduled for an eligibility interview within two to three weeks of submitting an application.14 TANF applicants in New York must complete interviews in at least two different offices and over a period of several days or longer, before their application process is considered complete. They must also participate in job search activities over the entire time that their application is pending.

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In all locations, regardless of the number of formal steps in the process, there are additional efforts associated with providing required documentation for eligibility determination purposes. Often, these documents can be sent by mail or dropped off with the receptionist. At times, complying with verification procedures can involve trips to banks, former employers, and the department of motor vehicles. Both workers and focus group participants noted that, despite the additional effort required, applicants often prefer to go to the office to drop off their documentation and obtain a receipt from their eligibility worker, thereby ensuring that the documentation is received but also adding an additional step in the process.

While the diagrams in Exhibit 3-5 appear very linear, applicants often view the steps they must follow as confusing and complicated. This is because the steps often do not occur in the exact sequence shown in the diagrams (e.g., appointments get rescheduled for various reasons). For example, there may be variations within offices when an applicant has limited English proficiency and requires language assistance. Variations due to applicants’ language needs or citizenship status are noted within the site-specific discussions that follow.

Seattle, Washington

TANF/FSP/Medicaid. As of July 2001, the application process in the Seattle/Kent office was the most straightforward of all the study sites. In a single day, English proficient applicants could submit an application for benefits and complete an eligibility interview.15 The same day eligibility appointment was not an option for limited English speakers requiring interpretation assistance because scheduling the off-site interpreters contracted for this purpose requires a few days’ advance notice. Subsequent to our visit, the Seattle/Kent office has shifted to scheduling eligibility interviews on the day following application submission and adopted an enhanced intake process similar to the one used in the Seattle/Rainier office (described below).

The Seattle/Rainier office offers an enhanced screening at initial reception/intake, designed to increase administrative efficiency and decrease client burden. Experienced eligibility workers are assigned to provide screenings and customer assistance. These “information referral specialists” work alongside receptionist/intake clerks at the front desk. They handle many tasks normally requiring the attention of an eligibility worker but that can be dispensed with quickly and do not actually require a formal appointment or a full eligibility interview. For example, the information referral specialists handle all Medicaid applications for pregnant women and screen applications for expedited food stamps. They also answer questions, inform applicants about additional programs they might be eligible for, and handle a variety of smaller issues such as documenting changes of address. Additionally, the information referral specialists provide applicants with necessary application paperwork, schedule eligibility interviews, and inform applicants about the documents they should bring to the eligibility interview. Since the July 2001 site visit, the Seattle/Kent office added a similar enhanced intake component to their application process.

Both offices visited in Seattle further streamlined the TANF/FSP/Medicaid application process by the absence of a separate group orientation.16 The same types of information about TANF work program rules, participation requirements, sanctions and the availability of support services provided in the larger group orientations in other sites (e.g., Arlington, Dallas, and Raleigh), as well as an initial assessment of work history and employment barriers, are covered one-on-one during the eligibility determination interview.

Medicaid/SCHIP. The state of Washington has a single integrated application process for both Medicaid and SCHIP. Individuals may apply on-line and submit applications directly to the Department of Social and Health Services. Completed applications may also be mailed to the centralized Medical Eligibility Determination Services office that serves the entire state or dropped off in person at the local welfare office. A toll-free number within the state is available to assist with filling out the application or to answer questions. If determined eligible for Medicaid, applicants are required to enroll in a managed care plan. If applicants’ income is too high, their applications are then screened for SCHIP eligibility. If the income falls within the SCHIP range, applicants are sent a letter stating that they are not eligible for Medicaid but may be eligible for SCHIP. A form requesting information about private medical insurance, and information about the monthly premium and co-pays accompanies the letter. Applicants must complete and sign this form and return it to the centralized Medical Eligibility Determination Services office. Medicaid and SCHIP application assistance is available in public health centers and community health centers throughout the Seattle area.

Arlington, Virginia

TANF/FSP/Medicaid. The application process in Arlington is somewhat more complicated than Seattle in that it includes two additional steps—a screening and an orientation. Both steps occur prior to the eligibility interview and are intended to facilitate the application process. Applicant screenings are typically conducted the same day that the applicant initially comes to the welfare office and makes contact with an intake/reception worker (see box, “Pre-Eligibility Determination Screening in Arlington”). After the screening, applicants receive an appointment for an orientation and eligibility interview that they attend on the same day. The appointment letter states when and where the orientation session and interview will be held and what documents to bring for verification. During the orientation, case aides help applicants review, complete, and sign the application and other necessary forms. This group orientation includes a review of TANF eligibility rules and expectations.

Food Stamps and Medicaid/SCHIP. Individuals applying only for food stamps (or food stamps and Medicaid) follow a process that is similar to the integrated application process. One key difference is that the “group” orientation is more individualized than the TANF orientation. Although applicants are instructed to show up at the same time and sit together in one room, case aides see them on an individual basis and go over their application and paperwork to make sure it is in order. Following the orientation, applicants meet individually with an eligibility worker for their eligibility determination interview.

The application process for individuals applying only for Medicaid or SCHIP is greatly simplified. These individuals may mail in their application to the welfare office. Medicaid applicants do not need to go through the screening or orientation processes, but they still must come to the welfare office for a face-to-face eligibility interview. SCHIP applicants are also encouraged to come to the welfare office for assistance with the application and verification process. Recent changes in Virginia’s SCHIP program transferred responsibility for processing SCHIP applications from local welfare offices to a centralized private enrollment broker.17 The enrollment broker (BENOVA) determines eligibility via phone and mail for SCHIP applications across the state.

Applicants are screened over the phone, first for Medicaid and then for SCHIP. If eligible for Medicaid-only, the enrollment broker is supposed to send the application to the welfare office where it is treated like other Medicaid-only applications. If eligible for SCHIP, the application is completed over the phone and mailed to the applicant for signature. The Arlington welfare office will accept SCHIP applications (with income documentation) and send it on behalf of applicants to the enrollment broker’s central processing unit. The same process is used if families applying for Medicaid at the welfare office are determined ineligible because they are over income. The Medicaid-only application process can also be completed at a local public hospital, which houses an out-stationed Medicaid eligibility worker.

Raleigh, North Carolina

TANF/FSP/Medicaid. Raleigh, like Arlington, requires applicants to participate in an up-front screening process prior to the eligibility interview. The primary purpose of the screening is to determine if applicants qualify for a one-time lump sum payment (called “Benefit Diversion”) in lieu of going on cash assistance. Applicants are also screened for a county-funded program for working families whose income is below 150 percent of poverty and a TANF-funded program for those with income below 200 percent of poverty. Spanish-speaking TANF applicants, however, do not have to go through the screening process unless one of the two bilingual screeners is on duty. If no bilingual screener is available, Spanish-speakers meet with an interpreter who prepares the information needed by the case manager to complete the application and verification process.

Following the meeting with the screener, applicants participate in an eligibility interview. After the interview, but while their application is pending, applicants must register for work with an on-site representative from the Employment Services Commission. Typically, this happens during the same day as the eligibility interview, but if not, it must occur within ten days of the interview. Applicants are encouraged but not required to attend a work orientation and visit the on-site resource area to start a job search.

Pre-Eligibility Determination Screening in Arlington In Arlington, screenings are conducted for TANF/FSP/Medicaid (as well as food stamp-only or Medicaid-only) after the applicant makes initial contact with the reception/intake clerk—usually on the same day. The county welfare agency implemented screenings to increase the speed and efficiency of the eligibility determination process by ensuring that clients understand what they may apply for, how they should complete the application, and which documents are needed for the eligibility interview. Although these screenings constitute an additional step in the application process, they appear to help offset some of the difficulty applicants would normally encounter with the state’s relatively long and complicated integrated application (available only in English). In order to help applicants determine exactly which parts of the application they need to complete, screeners go through the form, highlighting the parts that the applicant needs to fill out and crossing out the parts they do not need to complete. Tenured eligibility workers with strong knowledge of eligibility rules and documentation requirements fill the screener positions.

Food Stamp-Only. The food stamp-only application process is simpler than the TANF application process. Food stamp-only applicants do not participate in a screening interview and are not subject to any additional up-front requirements that must be met prior to eligibility determination. Instead, they register with the receptionist to start the application process and then meet briefly with a verification clerk who records basic household composition, income, and work history information. After completing an application, applicants are interviewed by an eligibility worker. If food stamp applicants would also like to apply for Medicaid, they may do so at the same time.

Medicaid/SCHIP. In Raleigh, as with the other sites, Medicaid-only and SCHIP individuals may submit applications by mail or apply for either program through out-stationed eligibility workers. At the time of our visit (August 2001), food stamp and Medicaid/SCHIP applications for Spanish-speaking families were only taken two days per week (but subsequent to our site visit were taken five days per week). Raleigh officials noted that even though face-to-face interviews are no longer required for eligibility determination, the Latino population tends to prefer face-to-face interviews to the mail-in option. Administrators said it is rare for Latino applicants to mail in their applications, and they believe that staff encourage this practice because they are able to obtain better information through face-to-face interviews and to address other service needs. Additionally, most staff indicated a preference to take Spanish-language applications in person due to the high volume of mistakes in mail-in forms. Medicaid eligibility workers are also out-stationed at public health clinics and hospitals throughout the county.

Dallas, Texas

TANF/FSP/Medicaid. In Dallas, the receptionists screen the completed applications to determine eligibility for expedited food stamps and emergency Medicaid. If applicants do not appear eligible for expedited services, they receive an eligibility interview appointment for some time in the next two to three weeks. One Dallas office visited for this study holds “group appointments” for eligibility interviews because of staffing shortages and the need to process all applications in a timely manner. Appointment notices mark the date of the interview, instruct applicants to arrive at the office by 8:00 a.m., and state that applicants would be seen on a first come, first served basis. Staff noted that the line starts forming by 7:00 a.m. and all eligibility interviews are typically completed by early afternoon. Those that do not check in by 8:15 a.m. are considered “no-shows” and can either contact the office to reschedule an appointment or could wait until the end of the day to see if an interview slot had opened.

The TANF/FSP/Medicaid application process in Dallas reflects and reinforces the high priority Texas places on fraud prevention and quality control. Both TANF and food stamp applicants must be finger imaged, either before or after the eligibility interview, as part of the application process. Following the eligibility interview, TANF applicants are required to participate in a Workforce Orientation if it appears that they will be required to participate in TANF work activities. The orientation is not held within the welfare office, although applicants have to return to the welfare office with proof of participation before benefits can be authorized. Accommodations are not routinely made for non-English speakers—they must attend orientation if they appear to be work mandatory TANF applicants, even if it is held in English and no interpreter is available.

Medicaid/SCHIP. Medicaid/SCHIP applications are typically handled through a mail-in application process—roughly three-quarters of SCHIP applicants enroll by mail. Similar to Virginia, applications are mailed directly to a private contractor that serves as the state’s SCHIP enrollment broker. Individuals seeking application assistance can utilize the services of local outreach workers, and receive help by phone from the private enrollment broker’s help-line. Completed applications are screened first for Medicaid, and then for SCHIP. If eligible for SCHIP, the family is sent an enrollment packet; if eligible for Medicaid, the application information is forwarded to the local welfare office that, until January 2002, had to arrange face-to-face eligibility interviews for all Medicaid applicants.18 Those who do not use the mail-in application enrollment option can apply for SCHIP at county welfare offices or other sites, primarily hospitals or clinics, where welfare workers are outstationed. If a family applying for Medicaid is determined ineligible due to income, the application is forwarded to the private contractor to determine SCHIP eligibility.

Most Medicaid-only applications taken at the area’s largest public hospital (Parkland Hospital) are for deliveries and other obstetrics, and the majority of these are emergency Medicaid for undocumented women. The welfare agency has Medicaid eligibility workers out-stationed at the hospital but this unit was short-staffed at the time of our visit. Hospital financial counselors conduct an initial financial screening and assist patients that appear Medicaid-eligible with the Medicaid application before referring them to the out-stationed Medicaid unit. Although this division of labor somewhat eases the out-stationed Medicaid unit’s workload, screenings and eligibility determination interviews cannot always be carried out on the same day and, until January 2002, applicants often made an additional trip to the hospital later in the week for their face-to-face eligibility interview.

Sedalia, Missouri

TANF/FSP/Medicaid. Sedalia’s application process involves many steps, but they can all be completed within the welfare office, and often in a single day. Clerical staff at the reception desk conduct preliminary screenings to determine which benefit programs they appear eligible for and give applicants the appropriate program application. After completing the application, applicants typically are seen for an eligibility determination interview that same day, although final determination is delayed pending completion of the TANF work program orientation and job search.

TANF/FSP/Medicaid applicants must attend a one-on-one orientation, held once a week at the welfare office that covers program benefits, services, and requirements. Applicants must then meet with a representative from the Employment Security Commission who is co-located at the welfare office. The Employment Security representative registers applicants for work and helps them start a mandatory up-front job search requirement consisting of ten contacts per week for four weeks. If the application for assistance is processed prior to the completion of four weeks of job search, the eligibility worker certifies the applicant for TANF and starts issuing benefits. If an applicant fails to fulfill the up-front job search requirement, the case is still approved, but the adult caretaker’s portion of the cash grant is sanctioned (i.e., removed from the grant).

Food Stamps and Medicaid/SCHIP. The application process is much simpler for food stamps and Medicaid/SCHIP. Individuals may submit an application at the welfare office but do not have to go through any of the steps described above. They may also apply for Medicaid/SCHIP by fax or mail—face-to-face interviews are not required. Medicaid/SCHIP applications are available through a local health center, hospital, and a community-based organization.

New York, New York

Food Stamps. The application process in New York City varies significantly by the type of assistance individuals want to receive. Applicants applying only for food stamps must go to one of the specialized food stamp-only offices to obtain an application. The receptionist pre-screens completed applications and asks applicants additional questions to determine if they need expedited food stamps. Applicants then receive an appointment for an eligibility interview, typically within five days and even sooner if eligible for expedited food stamps.

Special Assistance for Refugees Applying for Benefits Sponsor agencies play a key role in ensuring that refugees quickly access benefits by facilitating the application process. This makes the application process generally easier for refugees to navigate than is true for other non-citizens. Most refugees are sponsored by organizations (rather than the employers or individuals that sponsor other immigrants). These refugee sponsors are often non-profit organizations who have Reception and Placement grants from the U.S. Department of State to aid refugees in resettling in the United States. These agencies either sponsor the refugees themselves or find family members or others to sponsor them in the communities where they resettle. According to welfare agency staff in the six study sites, refugees that apply for benefits are almost always sponsored by agencies as opposed to individuals. Refugees are usually destitute upon arrival and therefore eligible for the full package of benefits: TANF, food stamps, and Medicaid/SCHIP. Single refugees and others not eligible for TANF because of family composition usually receive Refugee Cash Assistance and Refugee Medical Assistance (an insurance program similar to Medicaid) instead during their first eight months in the country. If they still need assistance at the end of their resettlement period, refugees may transition to regular public benefits (i.e., TANF, food stamps, and Medicaid/SCHIP) if they are eligible. Sponsor agencies generally provide initial cash and other assistance immediately upon arrival, and then help refugees and their families apply for public benefits. For example, sponsor agency staff will accompany refugees to the welfare office, help them fill out application forms, show them what documentation needs to be assembled, make sure their paperwork is in order, and provide language interpretation and translation if needed. In New York, for example, representatives from the New York Association for New Americans (NYANA) accompany new refugees to apply for benefits. They assist applicants in completing the application and provide interpretation assistance, when necessary. In Raleigh, an eligibility worker from the welfare office regularly goes to Lutheran Family Services, a resettlement agency, to process refugee benefit applications.

TANF/FSP/Medicaid. In contrast, families applying for TANF/FSP/Medicaid must complete a several steps prior to eligibility determination:

• Individuals give the completed application to the Job Center receptionist who asks preliminary questions.

• A Job Opportunity Specialist (i.e., eligibility worker) screens applicants, explains the programs, and offers alternative services to cash assistance.

• If the applicant would still like to apply for cash assistance, the Job Opportunity Specialist conducts an eligibility interview, prepares an initial assessment and work plan, and refers the applicant to:

  • An eligibility verification review (EVR) performed at a different office location and subsequent home visit,

  • A workforce orientation,

  • Finger imaging and photographing,

  • Mandatory daily job search classes for the duration of the 30-day eligibility determination period, and if necessary,

  • Additional medical and substance abuse reviews at other locations.

Depending upon the particular Job Center, orientation, finger imaging, photographing, orientation, and job search may take place at the Job Center or at other locations. Medical and substance reviews do not take place at the Job Centers.

The EVR represents the high priority New York City places on deterring and controlling fraud. EVR Investigators are responsible for identifying those who are not eligible, and they review documents and verify information provided to staff at the Job Centers (e.g., household composition, income, and city residency).

New York City transitioned its welfare offices to “Job Centers” in July 2001, which resulted in a somewhat less cumbersome application process for families applying for cash assistance and other services. The transition integrated pre-screening, meeting with an employment counselor, and the initial eligibility interviews into a single interview. All TANF applicants must still go through the separate EVR before their applications are approved. As noted earlier, non-Spanish speaking refugees and other non-citizens applying for TANF/FSP/Medicaid are required to go to one of two specialized Job Centers.19 Although the location is different, the application process is very similar to that in the non-specialized Job Centers—applicants must also meet up-front requirements and participate in EVR.

Medicaid/SCHIP. The application process for individuals seeking only Medicaid/SCHIP in New York City is much simpler than the TANF/FSP/Medicaid process. Families may apply for Medicaid/SCHIP through the city’s Medicaid-only offices, directly through a private or non- profit health plan, or through a facilitated enrollment agency (which includes some of the health plans). SCHIP applications may also be mailed, but then require a face-to-face eligibility interview conducted by a Medicaid-only eligibility worker at the welfare office or a facilitated enroller in a non-welfare office setting. Medicaid/SCHIP applicants are not required to go through the EVR and home visit, or be fingerprinted.

Special Issues for Non-Citizens and Limited English Speakers

As the previous discussion makes clear, some application processes are more complicated than others and the level of complexity varies by site and by type of benefit. The TANF/FSP/Medicaid application process typically includes more steps—and generally the more steps involved, the harder the system can be to understand and navigate. By all accounts this complexity probably affects participation, and this effect may be greater for immigrants and limited English speakers whose efforts to navigate the application process are frustrated by their lack of English proficiency, confusion about eligibility rules, and apprehension about the consequences to their immigration status. In particular, some application procedures may present more significant issues for non-citizens than for citizens. Finger imaging, home visits and overly rigorous eligibility verification can be particularly daunting for families who closely associate many of these procedures with the Immigration and Naturalization Service (INS).

Disaster Relief Medicaid in New York City: A Simplified Application Process In September 2001, New York implemented a temporary Disaster Relief Medicaid Program in response to the September 11 attacks. (New York also accepted applications for a more limited New York City Disaster Food Stamp Program through October 31, 2001.) This program temporarily replaced both Medicaid and Family Health Plus (the state’s Medicaid expansion program). The application form was limited to a single one-page application that applicants could submit at designated offices throughout the city. The eligibility process sharply reduced documentation and verification requirements—proof of immigration status was not required and income was not verified. Despite lack of public awareness campaigns or other forms of outreach, this greatly simplified eligibility process contributed to an influx of Medicaid applicants. Approximately 300,000 low-income individuals and families were enrolled over four months, greatly taxing Medical Assistance Program staff (P. Coltoff, letter, January 23, 2002). The Washington Post reported that many people applying for Disaster Relief Medicaid would have been eligible for Medicaid, SCHIP, or Family Health Plus prior to September 11, but were taking advantage of the simplified application process (Russakoff 2001). New York City’s experience with this highly simplified application process provides an example of how application procedures and processes can affect the extent to which individuals seek and obtain assistance. Originally intended to be only a temporary measure, Disaster Relief Medicaid enrollment ended on January 31, 2002. However, based on this experience, New York City administrators are negotiating with the State of New York to simplify recertification and documentation requirements, and have implemented various enrollment simplification pilots.

 

At the same time, while immigration status and limited English proficiency are responsible for some differences in the type, sequence, and difficulty of steps that make up the application process, non-citizens and other limited English speakers are not, as a group, subject to different treatment in terms of what they are expected to do or longer waiting periods before benefits are authorized. In fact, newly arriving refugees in many of the study sites appeared to move through the application process more easily than non-refugees due to the additional help they receive from sponsoring agencies (see box).

Administrators, staff, and advocates included in this study commonly noted that non-refugee immigrants and mixed-status families are more likely to apply for benefits in community health clinics, hospitals, and other non-welfare settings. The need for immediate access to health care services makes it more likely that they will come into contact with these types of organizations than the welfare office. Once at the clinic, they may be more receptive to applying for health benefits because the process is typically much easier to complete than the integrated TANF/FSP/Medicaid application process, there are more likely to be bilingual staff available, and they are more likely to trust that the application will not cause immigration-related problems for themselves or their children. In sum, anecdotal evidence indicates that the combination of providing a simplified application process in a non-welfare office setting, supplemented with additional application assistance and language accommodations, results in greater levels of participation by these special populations.

New York’s Facilitated Enrollment Process: Community-Based Access to Medicaid/SCHIP The State of New York implemented a new concept called “facilitated enrollment” through which community-based organizations, with grant support from the state, provide application assistance to families applying for Medicaid/SCHIP. One goal of the process is to enroll hard-to-reach populations. Facilitated enrollers fulfill the face-to-face function required under state Medicaid requirements. Thirty-two organizations in New York are designated as “lead agencies” with more than 100 smaller CBOs throughout the city to facilitate enrollment. The facilitated enrollers walk individuals through the application process and help them organize the necessary documents for verification. They then submit the application to a lead agency for quality control. The lead agencies are responsible for submitting applications to the city’s Medicaid/SCHIP agency for eligibility determination. Working with a facilitated enroller, who is typically located within the community, is potentially easier and less intimidating than having to go to the welfare office. Several facilitated enrollment agencies target their efforts toward specific non-citizen and limited-English speaking communities. For example, the Children’s Aid Society is the lead agency for four other CBOs, three of which target Chinese communities, and one that targets a Latino community.

1 There is also tremendous variation in caseload size and staffing capacity across jurisdictions. These factors may affect how locations organize staff and structure the application process. (back)

2 Although not a focus of this study, the application and eligibility determination process are considerably simplified and shortened for emergency Medicaid and expedited food stamps. (back)

3 The specialized Brooklyn Job Center opened in January 2002. (back)

4 The specialized office must take an application for the initial services requested and then refer the applicant to the generic benefits office to complete the application and eligibility determination steps required for the additional programs. The eligibility determination period for the original benefits applied for begins on the date of the initial application. (back)

5 Medicaid law and regulations require States to provide opportunities for children under age 19 and pregnant women to apply for Medicaid at locations other than local public assistance (i.e., welfare) agencies and in each facility designated as a disproportionate share hospital (DSH) and federally qualified health center, unless there is an approved alternative arrangement. (back)

6 This is usually just a cursory review of the application, not a formal screening or intensive needs assessment. (back)

7 In Dallas and New York City, finger imaging and photographing is required for both TANF and food stamp applicants. (back)

8 7 CFR 273.2 and 42 CFR 435.906 (back)

9 Often applicants that will not be required to participate in ongoing work activities are not required to participate in the orientation. (back)

10 The Seattle/Kent office added a group orientation after the July 2001 site visit. (back)

11 Job search is typically enforced only for two-parent families in Sedalia. (back)

12 TANF eligibility must be determined within 30 days; however, determinations may be made sooner than that. (back)

13 As of December 2001, New York City was in the process of implementing a “paperless” office system and document imaging systems that will allow EVR investigators to electronically access documentation presented at the Job Centers. (back)

14 If the applicant appears eligible for expedited food stamps, the Dallas office typically schedules the eligibility interview for that same day or early the next day. (back)

15 English-speaking applicants who arrived in the office before 9:30 a.m. and completed the first page of the application for benefits were guaranteed a same day appointment; after 9:30 a.m., applicants were given application materials that they could send back via mail or return the next morning for an interview. (back)

16 As noted elsewhere, the Kent/Seattle office has added a mandatory TANF orientation since the site visit. (back)

17 The SCHIP program in Arlington and elsewhere in the State of Virginia was in a period of transition at the time of our site visit in September 2001, which involved shifting from a welfare-office based SCHIP program model to a private insurance SCHIP program model. Thus, we were not able to fully capture either the old or new SCHIP application process or gain a clear picture of the comparative advantages and disadvantages of these different application processes. (back)

18 As of January 2002, the in-person interview for initial Medicaid applicants was waived for children, but not for adults. (back)

19 The majority of Spanish speaking applicants continue to be served in local, non-specialized job centers. (back)

 

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