The Application Process For TANF, Food Stamps, Medicaid and SCHIP

This report was prepared by Pamela A. Holcomb, Karen Tumlin, Robin Koralek, Randy Capps and Anita Zuberi of the Urban Institute for the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services under contract number HHS-100-99-0003, Task Order No. 14. The views expressed are those of the authors and should not be attributed to the U.S. Department of Health and Human Services.

The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of public consideration. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS

EXECUTIVE SUMMARY

1 INTRODUCTION

2 STUDY CONTEXT
The Demographic Context: Immigration and Language Diversity
Policy Context: Welfare Reform and Other Key Developments

3 APPLYING FOR BENEFITS: WHAT FAMILIES MUST DO
Gaining Access to Program Benefits: Various Initial Points of Entry
An Overview of Common Steps in the Application Process
Site Specific Application Processes
Special Issues for Non-Citizens and Limited English Speakers

4 APPLICATION FORMS
Application Availability
Integrated Application Forms
Medicaid/SCHIP Program Applications: Streamlined and Simplified

5 ELIGIBILITY DETERMINATION POLICIES AND VERIFICATION
PROCEDURES: SPECIAL ISSUES FOR IMMIGRANTS
Implementing Non-Citizen Eligibility Rules
General Eligibility Documentation and Verification Requirements: Special
Implications for Immigrants

6 THE LANGUAGE DIMENSION OF APPLYING FOR ASSISTANCE:
STRATEGIES TO MEET THE NEEDS OF LIMITED ENGLISH SPEAKERS
Key Language Access Strategies
Multiple Language Access Strategies: Local Level Examples
Responding to Increasing Language Diversity
Developing Language Services in New Immigrant Destinations

APPENDICES
Appendix A Study Methodology
Appendix B Language Spoken at Home, Population Ages 5 and Over
Appendix C Study Program Descriptions

LIST OF EXHIBITS

EXECUTIVE SUMMARY

This report explores one key dimension of access to public benefits—the application and eligibility determination process. Of particular interest is how local-level administrative procedures and operations may generally affect eligible families' access to benefits. Special consideration is given to exploring these issues as they relate to immigrants and limited English speakers.

The four major public benefits programs examined in this study are Temporary Assistance for Needy Families (TANF), food stamps, Medicaid, and the State Children's Health Insurance Program (SCHIP). The findings presented are primarily based on site visits conducted between June 2001 and December 2001 in six different localities: New York City (five counties/NY), Dallas (Dallas and Tarrant Counties/TX), Seattle (King County/WA), Raleigh (Wake County/NC), Arlington (Arlington County/VA), and Sedalia (Pettis County/MO). The sites vary in terms of the overall size of their client base and the diversity of the immigrant population, and the way in which application and eligibility determination processes are structured and implemented.

Background Context

• High levels of immigration over the past decade and increasing dispersal of non-citizens across the country means that more non-citizens now live in areas without an established infrastructure to deliver services in languages other than English, or where such infrastructure is in early stages of development. Even urban centers accustomed to receiving large numbers of immigrants, such as New York City, are faced with the challenge of dealing with an increasingly diverse number of immigrant groups who speak dozens of different languages.
• The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) and subsequent legislative changes include eligibility rules for federally funded public benefits that affect certain classes of legal non-citizens. Further, "mixed-status" immigrant families have to deal with eligibility determination that sometimes may be unclear. According to 1998 figures from the U.S. Current Population Survey (CPS), 85 percent of families with at least one non-citizen parent have at least one citizen child. The vast majority of immigrant families who apply for benefits have both citizens and non-citizens in them and while non-citizen adults are often ineligible for benefits, their children—who are usually citizens—are generally eligible. The mixed-status of many immigrant families and the complicated eligibility rules concerning non-citizens presents challenges for human service agencies as well as immigrant families who may not understand if and how they are affected by the eligibility restrictions.
• In the years following the enactment of PRWORA, human service agencies have been engaged, to varying degrees, in creating new organizational structures, administrative practices and service delivery systems that include undertaking a significant expansion in medical assistance to children and creating a devolved, work-oriented welfare system that provides a variety of supports for working families as well those receiving cash assistance. In particular, the enactment of SCHIP has served as a catalyst for developing simplified and streamlined up- front intake procedures in order to expand health insurance for uninsured children. In addition, efforts to reduce dependency on cash assistance and promote work have increased awareness of the work support role of food stamps and medical assistance.

Key Findings

The following are key findings about the application process encountered by all potential applicants and, in particular, by immigrants and limited English speakers. There are important variations—across programs and sites—in the application process:

• It is generally easier to apply for children's medical assistance (i.e., SCHIP and Medicaid) than for cash assistance or food stamps. Overall, across all sites, there is a striking difference between the relative simplicity of the application process for SCHIP (and often Medicaid-only) compared to the complexity of the application process required for obtaining the full traditional welfare package—cash assistance, food stamps, and Medicaid. For example, SCHIP application forms tend to be simplified and user-friendly for applicants and often include features that make them more accessible to immigrants. They are typically shorter, require less information about non-applicants in the household, and are more likely to be translated into Spanish (and sometimes other languages) than integrated applications for the TANF, the Food Stamp Program (FSP) and Medicaid.
• Families can gain access to medical assistance benefits through different points of entry whereas families in need of the traditional package of welfare benefits typically have a single physical point of entry—the welfare agency. Efforts to improve enrollment in Medicaid and SCHIP have led to a variety of strategies to increase the points of program entry. These typically involve moving various aspects of program enrollment (e.g., applications, eligibility screenings, and eligibility determinations) away from the traditional welfare agency setting and making these services available in locations that are more convenient and accessible to eligible families (e.g., health clinics, hospitals, schools, community-based organizations, and through phone or mail).
• The application process for the full welfare package of benefits is more rigorous in some places than others. Among the study sites, the TANF/FSP/Medicaid application process is the simplest in Seattle and the most complicated in New York City. Seattle's application process has no up-front requirements whereas applying for TANF/FSP/Medicaid in other sites includes additional steps, such as up-front job search, application screenings, and work program orientations. Among the sites, New York City's TANF application is the most complex and includes requiring applicants to: attend two eligibility interviews in two different locations, undergo fingerprinting and photographing for fraud prevention purposes, receive a home visit from an eligibility verification investigator, attend a mandatory workforce orientation and attend daily job search classes (five days per week) for the duration of the 30-day eligibility determination period.

Special eligibility and language issues presented by immigrants and limited English speakers are addressed in different ways and to varying degrees at the local-level. Looking across the six sites included in this study, the following key points emerge:

• There is no one-size-fits-all approach for providing language services and there are trade-offs associated with each approach. Because there is no single language-access strategy that is appropriate for every program or each stage in the application process, let alone for all language groups, human service agencies tend to employ more than one (and sometimes several) language assistance strategies simultaneously. The design and implementation of these multiple local language access strategies are driven by a complex interplay of factors related to the size of the total local limited English proficient population, client caseload characteristics (e.g., the number and types of languages spoken by limited English proficient applicants), and agency and community language resources. Developing strategies that take into account these factors is all the more challenging because the size, composition, and distribution of immigrant populations are often moving targets.

• For the most dominant non-English speaking language group, it is often considered optimal to use in-house bilingual staff who can provide interpretation assistance in conjunction with their other job duties (e.g., a bilingual eligibility worker conducts an eligibility interview in the primary language of the applicant). In sites with significant staffing capacity, this approach can include specialized units or offices targeted to immigrants and limited English speakers. However, reliance on in-house bilingual staff may prove inefficient and unmanageable, particularly with respect to less common language groups, when the need for language interpretation for a particular language is relatively infrequent and sporadic. And, because of the continually changing composition of the immigrant population across our sites, simply adding new bilingual staff to match each new immigrant wave may be neither possible nor prudent.
• Providing language services on a contract basis provides a more flexible approach that allows local human service agencies to adjust to the different language needs of applicants on a daily operational basis as well as over time. At the same time, relying on contracted staff for interpretation assistance instead of in-house staff also necessitates additional oversight effort on the part of human service agencies to monitor the overall quality of the language services provided to LEP applicants.
• Relying on friends and family for translation is considered a far less desirable language service strategy but many sites still relied on this alternative, particularly for less common languages and in agencies where there were no, or only few, in-house or contracted bilingual staff available to bridge the language gap. Telephone "language lines" offer extensive language coverage but they are expensive to use and staff tend to use this alternative only as a last resort.

• Language access strategies used in the administration of public benefit programs must be considered within the context of the application processes for these programs. The more complex and involved the application process, the greater the challenge for providing language assistance at each stage in the process and the greater the likelihood that language difficulties may impede access. Less visible but still critical aspects of the application process, including the provision of translated written material and interpretation services for telephone communication, are often overlooked or inadequately addressed components of language access strategies.
• Within welfare offices, strategies used to address complexities presented by non-citizen eligibility rules—and all eligibility determination rules—may include some combination of specialized front-line workers, automated eligibility determination systems that prompt for all the required eligibility information, and reliance on immigration documents. Some agencies rely on more experienced workers or specialized units to handle non-citizen eligibility or have specialized offices located in areas with large immigrant communities. Workers in these settings typically have more experience and familiarity with non-citizen eligibility rules and immigration documents. The automated eligibility interview programs provide a means to further standardize the eligibility determination process, making it possible for all workers to systematically gather all the information needed to correctly apply eligibility rules, including the complex rules pertaining to non-citizen eligibility. In addition, workers typically rely on checking immigration documents in conjunction with charts that crosswalk program eligibility with these documents. If all these methods are used, the risk for error decreases. The risk for error is greatest when non-citizen applicants present rare or unusual immigration documents or more detailed aspects of non-citizen eligibility rule changes are not accounted for by workers and/or automated eligibility interview programs.
• The combination of providing a simplified application process in a non-welfare setting, supplemented with additional application assistance and language accommodations, appears to increase access to benefits by limited English speakers and/or immigrant families. Participants in this study across the six study sites commonly noted that immigrant families (many of which are mixed status families with citizen children) are more likely to apply for benefits at community health clinics, hospitals, and other nonwelfare settings than initiating an application process for benefits at the welfare office. This may be because the application process for childrens' medical assistance benefits in these community- and health-based settings requires less information and documentation and is typically much easier to complete than the integrated TANF/FSP/Medicaid application process. Also, there are more likely to be bilingual staff available in these settings to help bridge any language gaps, and there is less concern among immigrants that the application will cause immigration-related problems for themselves or their children. In addition, some application procedures used by welfare offices for TANF and/or food stamps may be perceived differently by non-citizens than their citizen counterparts. For example, finger imaging, home visits and rigorous eligibility verification—procedures used routinely in the TANF and/or food stamps application in some study sites—can be particularly daunting for families who closely associate many of these procedures with the Immigration and Naturalization Service.

This report is available in its entirety in the Portable Document Format (PDF).

ACKNOWLEDGEMENTS

This study could not have been completed without the cooperation and assistance of many individuals. Most importantly, our thanks go to all the state and local program staff, staff from community-based and advocacy organizations, and local discussion group participants who contributed to this study. These individuals were tremendously generous with their time and provided us with a wealth of critical information and insights.

The authors wish to thank many current and former staff at the Urban Institute who played an important role in this project. We especially thank Michael Fix and Wendy Zimmerman for their invaluable work in laying the groundwork for this study and providing constructive suggestions throughout the project. Frank Ullman provided much appreciated assistance with completing the site visits and contributing to the final report. We also thank Ian Hill and Corinna Hawkes for sharing valuable information about SCHIP and Medicaid implementation, based on their own work in this area.

Finally, we are indebted to David Nielsen, our ASPE Project Officer, for his commitment to this project and helpful guidance throughout the study.

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