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The Burden of Proof: How Much is Too Much for Child Health Coverage?

Prepared by:
Sarah C. Shuptrine
Kristine Hartvigsen


When families apply for Medicaid coverage for their children, they are warned of fraud penalties and must attest to their knowledge of the consequences of making untruthful statements when they sign the Medicaid application. Families generally are required to provide documentation to prove certain statements made on their application. In bureaucratic terms, such documentation is called "verification."

From the family’s perspective, this burden of proof can be problematic for many reasons. Obtaining required verification frequently involves third parties such as employers and noncustodial parents, who may not be cooperative. Complying with verification requirements can be particularly difficult for families with limited resources, especially those without transportation or child care. For parents who would lose wages if they take time off from work to collect the required documents, verification requirements present substantial application barriers. In addition to these practical concerns affecting access to coverage, a major problem is that the intrusive nature of the verification process adds considerably to the stigma associated with applying for government-sponsored child health coverage.

Medicaid application procedures and verification requirements evolved from welfare rules and are long overdue for an examination of their relevance to a health insurance program for children. Rules vary by state because states have considerable flexibility in deciding the extent to which verification is required.

States have been reluctant to reduce verification requirements due to concerns over quality control, particularly the federal Medicaid Eligibility Quality Control (MEQC) system. However, the pervasive and longstanding fear of the MEQC system is largely unfounded today. The federal Health Care Financing Administration (HCFA) is making special efforts to work cooperatively with states to make the eligibility process more family friendly.

In recent years, several states have demonstrated that it is possible to maintain eligibility quality control while alleviating some of the verification burdens placed on families. Among the southern states, Georgia has been a leader in reducing verification demands on families, and Georgia Medicaid officials testify that they have not experienced quality control problems as a result.

Given that there are approximately 4.5 million uninsured children who are eligible but not enrolled in Medicaid, it is clear that action is needed to improve access to Medicaid coverage. Actions are also needed to assure that eligible children do not lose Medicaid coverage due to procedural requirements at redetermination.

Efforts to simplify the eligibility process are also relevant to assuring access to the new state child health insurance (CHIP) programs. The same procedural requirements that have restricted access to Medicaid can become access barriers to CHIP. In addition, the federal statute specifies that children who are eligible for Medicaid are ineligible for CHIP. A letter from HCFA dated November 23, 1998, (see Appendix A) states that if a family fails to complete the application process for any reason, the child cannot be enrolled in CHIP. Thus stringent verification and other procedural requirements for Medicaid can hamper access to CHIP.

Because the issues are complicated, information and dialogue are essential to helping states ease the verification burden on families. To assist states, the Southern Institute on Children and Families on September 15-16, 1998, conducted a regional meeting to discuss child health coverage verification issues. Participating in the dialogue were Medicaid and/or CHIP officials from 15 southern states, as well as regional and central office HCFA representatives. (Participants are listed in Appendix B.) This report presents knowledge attained as a result of this discussion. The meeting and this report were made possible by a grant from The Robert Wood Johnson Foundation.

Prior to the Southern Institute meeting, a poll of 17 southern states and the District of Columbia was conducted to identify verification questions states wanted to pose to HCFA. These questions were compiled and sent to HCFA before the meeting. Some written responses were submitted at the meeting, and additional responses were developed after the meeting. This report includes the following information:

Where the term CHIP appears in the HCFA response, it refers to a separate CHIP program. References to Medicaid include both regular Medicaid and CHIP Medicaid expansions.

The Southern Institute meeting provided an opportunity for "give and take" on the interpretation of federal rules related to verification of income, age, citizenship, resources and family composition both at application and at redetermination. The discussion vividly demonstrated the need for clarification on verification and other eligibility process issues. It also clearly demonstrated that states have substantial authority to take actions to reduce the verification burden on families while maintaining the integrity of the eligibility process.

The Southern Institute wishes to express appreciation to the Health Care Financing Administration and state Medicaid/CHIP representatives who participated in this important initiative. It is hoped that this report will assist states in their efforts to simplify the application and redetermination processes for families seeking health coverage for their children.

Verification Requirements at Application

Verification Requirements at Redetermination

Additional Issues


  1. November 23, 1998, Screening Letter from HCFA
  2. Eligibility Verification Meeting Participants
  3. September 10, 1998, CHIP Eligibility Letter From HCFA
  4. January 23, 1998, Outreach Letter From HCFA