2069 Express Lane Eligibility | Medicaid
Georgia Division of Family and Children Services |
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Policy Title: |
Express Lane Eligibility |
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Effective Date: |
June 2025 |
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Chapter: |
2050 |
Policy Number: |
2069 |
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Previous Policy Number(s): |
MT 69 |
Updated or Reviewed in MT: |
MT 74 |
Requirements
Express Lane Eligibility (ELE) is an enrollment strategy which begins with a Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Childcare (CC), Women Infants & Children (WIC), or Refugee Cash Assistance (RCA) case used to make an ELE determination for a child(ren)'s potential Medicaid eligibility and ends with notification to the Assistance Unit (AU) of its eligibility status.
Basic Considerations
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3 includes many provisions designed to give states some tools which may be used to effectively enroll eligible children in Medical Assistance. Section 203 of CHIPRA allows states to rely on the findings from an entity designated by the state as an “Express Lane agency” to determine whether a child satisfies one or more factors of eligibility for Medical Assistance. Such agencies are identified by the state Medicaid agency as being capable of making a finding regarding one or more programmatic eligibility requirements using information the agencies are already collecting. “Express Lane agencies” are public agencies which would include the following:
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Agencies that determine eligibility for assistance for any of the following programs or under any of the following authorities:
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The Temporary Assistance for Needy Families (TANF) program funded under part A of title IV of the Social Security Act
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A State program funded under title IV-D of the Act (Child Support Enforcement)
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The State Medicaid or PCK program
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The Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps)
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The Richard B. Russell National School Lunch Act (School Lunch programs)
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The Child Nutrition Act of 1966 (the Special Supplemental Nutrition Program for Women, Infants, and Children, or “WIC”)
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The United States Housing Act of 1937
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Head Start
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Child Care under the Child Care and Development Block Grant Act of 1990
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Homeless Assistance under the Stewart B. McKinney Homeless Assistance Act
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The Native American Housing Assistance and Self-Determination Act of 1996
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Another State-specified governmental agency that has fiscal liability or legal responsibility for the accuracy of the eligibility determination findings relied on by the State.
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A public agency that is subject to an interagency agreement limiting the disclosure and use of your information disclosed for purposes of determining eligibility for Medical Assistance .
The State Medical Assistance agency remains responsible for making the ultimate determination of eligibility. The Medical Assistance programs may apply the ELE option to children up to age 19.
Initial ELE Determinations
Children (newborn through the month a child turns 19) who are active and receiving benefits on a SNAP, TANF, CC, WIC, or RCA case can have Medical Assistance eligibility determined according to ELE criteria as set forth in the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. The Division of Family and Children Services (DFCS) agency will utilize information collected when an application/renewal/change is completed by SNAP, TANF, CC, WIC, or RCA eligibility workers for services to determine eligibility. This data includes, but is not limited to all demographic data, proof of income, and household size.
If an application/renewal/change is received for a child younger than 19 years old, information provided by the family on that application/renewal/change or otherwise collected for the SNAP, TANF, CC, WIC, or RCA eligibility determination is used by the DFCS agency to determine most factors of Medical Assistance eligibility. During eligibility determinations, the DFCS agency will advise SNAP, TANF, CC, WIC, or RCA applicants/recipients that the information provided for the SNAP, TANF, CC, WIC, or RCA application/renewal/change will be shared with the DFCS agency for determining the children’s Medical Assistance eligibility, unless the individual chooses to opt-out on the initial application/renewal/change document or verbally during the SNAP, TANF, CC, WIC, or RCA interview.
DFCS should ensure that the child is not already enrolled in Medicaid (including SSI), PCK, or Medicare prior to an ELE determination. If a child(ren) under 19 Medical Assistance application is received and there is no active SNAP, TANF, CC, WIC, or RCA case, then an ELE determination cannot be completed.
The DFCS agency will use the SNAP, TANF, CC, WIC, or RCA income findings, calculated based on the specific program’s eligibility policies (income exclusions, disregards, household composition, deeming, etc.) to determine income eligibility for Medical Assistance. DFCS will use other information collected by the SNAP, TANF, CC, WIC, or RCA program on the application/renewal or through its verification processes to determine most other factors of Medical Assistance eligibility (e.g., verification of citizenship, State residency). Any SNAP, TANF, CC, WIC, or RCA eligible children that meet the specific program’s citizenship requirements, must also meet Medical Assistance citizenship requirements. A Reasonable Opportunity Period (ROP) for citizenship is allowed for ELE determinations. Refer to Section 2215-Citizenship/Immigration/Identity.
For Medical Assistance ELE determinations, DFCS should compare household income to the highest Medicaid income applicable to a child (0-19) which will be equal to 235% FPL. If household income is over 235% FPL but at or below 247% FPL, the child should be evaluated for ELE-PCK.
If a child is found eligible for PCK from the ELE determination, DFCS must provide notice that the child may qualify for Medicaid and/or lower premiums if evaluated using the regular eligibility determination and provide an avenue on how to request a full eligibility determination. A separate application is not required. Refer to Section 2194 - Peachcare for Kids® for ELE PCK premium amounts.
Children with third-party liability (TPL) are not eligible for PCK. |
If the child’s Medical Assistance eligibility cannot be determined based on the processes used for ELE (e.g., the child is over income for PCK using the “Express Lane” agency’s income finding), a full eligibility determination must be conducted using the regular Medical Assistance processes. The income findings from the “Express Lane agency” should not be used, and additional information or verification should be requested from the family as necessary.
If a full determination is conducted based on a request or denial for any potential ELE applicant, the application is no longer considered ELE.
For ELE applications, retroactive months requested should follow the regular eligibility determination process.
It is the expectation that the ELE determination will be completed at the same time as the SNAP, TANF, CC, WIC, or RCA application/renewal but no longer than 45 days from the date ELE was requested.
If a client submits a Change Request for an already active SNAP, TANF, CC, WIC, or RCA case with a child younger than 19 years old, determine eligibility according to ELE criteria.
If the client has an approved ELE determination and would like to opt out of the ELE process and have a full Medical Assistance determination made, the client can call the DFCS call center at 1-877-423-4746 or complete the opt-out statement and drop off at their local DFCS office or upload online at www.gateway.ga.gov at any time.
Procedures
Follow the steps below to determine Medical Assistance using the ELE application process:
Step 1 |
Accept SNAP, TANF, CC, WIC, or RCA application/renewal/change request for children under 19 years of age submitted through Gateway Customer Portal or other acceptable application/renewal forms. |
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Step 2 |
Determine ELE eligibility for CU19 or PCK based on the information collected at SNAP, TANF, CC, WIC, or RCA application/renewal/change including household size, residency, income, and citizenship. Children must meet Medical Assistance citizenship requirements |
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Step 3 |
Approve the case using the appropriate COA (CU19/PCK) if the applicant meets all eligibility criteria. If the child’s Medical Assistance eligibility cannot be determined based on the processes used for ELE (e.g., the child is over income for PCK using the express lane agency’s income finding), a full eligibility determination must be conducted using the regular Medical Assistance processes. The income findings from the express lane agency should not be used, and income eligibility should be determined using Medical Assistance policies and procedures.
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Step 4 |
Notify the AU of the eligibility determination. |
Special Considerations
Reasonable Opportunity Period (ROP) is allowed for ELE determinations.
Child(ren) eligible for PeachCare for Kids® may be subject to a premium. Send a determination notice to advise client to report any changes and the ability to opt out of ELE at any time.
If SNAP, TANF, CC, WIC, or RCA closes due to information not provided from VCL, the ELE case will remain active until the end of the ELE POE.
If retroactive months are requested and case is approved for ELE, the retroactive months need to follow the regular MAGI eligibility determination process.
If SNAP, TANF, CC, WIC, or RCA is active with at least one ongoing month at the end of the ELE renewal POE, the ELE case will be automatically renewed using the ELE process.
If SNAP, TANF, CC, WIC, or RCA is not active at the end of the ELE renewal POE, the ELE case would no longer be considered ELE, and renewal must follow the regular MAGI eligibility determination process.
Administrative renewals should not be completed for Medicaid cases whose Medicaid eligibility has been determined using Express Lane Eligibility (ELE). |
Gateway should not allow an ELE determination if an individual member is currently receiving Medical Assistance including:
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SSI or Medicare for ELE-CU19
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SSI, Medicare or TPL for ELE-PCK.
ELE determinations do not apply to:
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Expedited SNAP applications that are not approved for a full period of eligibility (POE)
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Transitional SNAP recipients
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Disaster Supplemental Nutrition Assistance Program (DSNAP) recipients
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Disaster Temporary Assistance for Needy Families (DTANF) recipients