Children's Health Insurance Program Enrollment Using the Express Lane Eligibility Option Did Not Always Meet Federal Requirements

States generally determined Children's Health Insurance Program (CHIP) eligibility using the Express Lane Eligibility (ELE) option in accordance with Federal requirements. Under the ELE option, a State CHIP agency can use findings (e.g., income) from eligibility determinations made by a different agency within the State to facilitate enrollment into CHIP. From our sample of 120 beneficiaries, States correctly determined eligibility for 110 beneficiaries. We found no eligibility errors in four of the eight States reviewed; however, four States did not determine eligibility for seven beneficiaries in accordance with Federal requirements. On the basis of our sample, we estimated that 148,375 beneficiaries were eligible, but 6,998 were potentially ineligible. We also estimated that Federal and State CHIP payments on behalf of eligible beneficiaries totaled $196.9 million, and Federal and State CHIP payments made on behalf of potentially ineligible beneficiaries totaled $10.6 million. We attribute the enrollment of potentially ineligible beneficiaries to State-specific eligibility determination errors.

In addition, States did not develop mandated error rates specific to the ELE population because CMS did not provide States with an error rate methodology. Without a methodology for determining an ELE eligibility error rate, contrary to Federal requirements, some States relied on the Payment Error Rate Measurement program to identify eligibility errors before 2014. In addition, even if CMS had provided a methodology, three States had difficulty identifying their ELE population, which would have limited their ability to produce statistically valid error rates.

We recommended that CMS (1) monitor States that use the ELE option for CHIP eligibility determinations for compliance with Federal requirements; (2) provide technical assistance to States to accurately identify beneficiaries who enroll through the ELE option; (3) issue guidance to States to calculate statutorily required eligibility error rates for those enrolled through the ELE option; and (4) ensure States appropriately redetermine, if necessary, the current eligibility status of the sample applicants who were enrolled on the basis of eligibility determinations that were not made in compliance with Federal requirements. CMS concurred with our recommendations and described steps it was taking to address the findings in this report.