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SCHIP: What's Happening? What's Next?
Outreach & Enrollment
Strategies That Work and How to Pay for Them—Part 1
William A. Smith, Ed.D., Executive Vice President and Director, Academy for Educational Development, Washington, DC.
Donna Cohen Ross, Director of Outreach, Center for Budget and Policy Priorities, Washington, DC.
This session was designed to share with States what the Academy for Educational Development (AED) has learned though its project, "Insure Kids Now," a Health Resources and Services Administration (HRSA) project related to outreach. According to AED, once parents are informed about State Children's Health Insurance Programs (SCHIP) and initiate enrollment into the program, many barriers may prevent their children from being insured because getting through the eligibility process is sometimes difficult. Recommendations were given to States to change eligibility and enrollment processes and practices.
As the presenters noted, each State is different, as is each States' SCHIP program. Outreach will work differently depending on ethnicity, area of a State, area of the country, and numerous other variables—some of which may not be realized. This was evident in Dr. Smith's presentation when he reported on pre-tests held with American Indians, Hispanic groups, and English-speaking groups conducted by AED. These participants were shown pictures that were designed to speak to parents of children 18 or under, low-income working and non-working parents whose children are not covered by a public or private insurance plan, and Spanish speakers. Both the pictures and messages included in the presentations were tested to ensure that the desired messages were being communicated. Through the focus groups, AED found that the different groups and individuals perceived the same images and messages differently and, surprisingly, not as expected.
Advice was given to ensure maximum effectiveness of outreach: No single outreach tactic will work for everyone, listen to clients (both those enrolled and not enrolled) by organizing consumer panels, and use the press to tell the story as news articles seem to legitimize messages.
Ms. Ross defined outreach not only as efforts to inform families about insurance opportunities and assist them in enrolling their children, but also to keep them enrolled rather than dropping out of the program or choosing not to re-enroll. States have evidence that some parents will not sign their children up for coverage if this means they will be enrolled in Medicaid.
Ms. Ross suggested that SCHIP presents the opportunity to challenge and change the "welfare stigma" by changing previous restrictive practices. She suggested the following policies and processes to facilitate outreach and enrollment: simplify the application and use the same one for both SCHIP and Medicaid, use funds for program promotion and application assistance, allow mail-in applications, do not require a face-to-face interview for either SCHIP or Medicaid, minimize verification requirements, simplify the re-determination process to ensure that children retain coverage, eliminate the assets test, adopt 12 months of continuous eligibility and presumptive eligibility. States should maximize the available funding sources available, which include funds from: Medicaid, SCHIP, Title V, the State, special Federal grant programs such as Healthy Child Care America, the Bureau of Primary Health Care, and Temporary Assistance for Needy Families (TANF).
Discussion followed and the panel suggested that outreach strategies would have to change to get the new public-charge policy message out to the public. States may want to enlist legal advocacy groups to help. The issue of income verification was also resolved in this session, as Ms. Chang announced that self-declaration was permissible. The Health Care Financing Administration (HCFA) would not count as errors against the State those families who self-declare income incorrectly, which would then prompt a State to enroll a child into the "wrong" program, (i.e., the family's countable income makes them eligible for Medicaid, but the family overstates their countable income so the State enrolls the child in SCHIP). Many States stressed that even though they have changed their policies and practices by making the application process easier, made the program look less like Medicaid, and marketed differently, enrollment is still not where Congress would like it to be. States explained that barriers exist that will take time to overcome such as provider participation and the stigma that exists toward those on public programs.
Academy for Educational Development. Pre-test of materials for Insure Kids Now. Washington (DC): The Academy, 1999 Feb.
Health Care Financing Administration, Health Resources and Services Administration, National Governors' Association, White House. Insure Kids Now. Web site: http://www.insurekidsnow.gov. 1999 Apr.
Ross DC, Jacobson W. Free and low cost health insurance: children you know are missing out. Washington, DC: Center on Budget and Policy Priorities, 1998.
Min DeParle NA, Fox CF. Outreach to uninsured children. Letter to State health officials. Baltimore (MD): Health Care Financing Administration, 1998 Jan.
Richardson SK. SCHIP eligibility letter. Baltimore (MD): Health Care Financing Administration, 1998 Sep.
Richardson SK. Screen and enroll requirement. Baltimore (MD): Health Care Financing Administration, 1998 Nov.
Health Care Financing Administration and U.S. Department of Health and Human Services. Market research for Medicaid project description and preliminary results. Children's Health Insurance Program. Baltimore (MD): The Administration, 1999 Jan.
Health Care Financing Administration and U.S. Department of Health and Human Services. State SCHIP outreach survey. Baltimore (MD): The Administration. 1999 Mar.
Summer L, Carpenter MB, Kavanagh L. Successful outreach strategies: ten program that link children to health services. Washington (DC): U.S. Department of Health and Human Services and Health Resources and Services Administration, 1999 Jan.
U.S. Department of Health and Human Services and Health Resources and Services Administration. MCH Program Interchange: Focus on outreach. Washington (DC): The Department, 1999 Jan.
Strategies That Work and How to Pay for Them—Part 2
Gregory A. Vadner, M.P.A., Director, Division of Medical Services, Missouri Department of Social Services, Jefferson City, MO.
David Parrella, Ph.D., Director, Medical Care Administration, Connecticut Department of Social Services, Hartford, CT.
Sandra Shewry, M.S.W., M.P.H., Executive Director, California Managed Risk Medical Insurance Board, Sacramento, CA.
This session introduced the case study States. Each presenter briefly explained their SCHIP program and described their State's strategies for outreach and enrollment. To complement this session, a "SCHIP Swap Table" was set up with outreach materials from States participating in this workshop. Participants were encouraged to take other States' materials to share with their SCHIP and Medicaid staff. This proved a useful forum in which to share ideas and see the innovative outreach materials, applications, and other tools States are using in their SCHIP programs.
Mr. Vadner of Missouri represented the Medicaid SCHIP expansion States. Missouri's SCHIP program is administered out of the same agency as Medicaid and operates under an 1115 waiver. The SCHIP program extends coverage to those not eligible for Medicaid to infants in families with incomes from 185 to 300 percent of the Federal poverty level (FPL); ages 1 to 6 from 133 to 300 percent; and ages 6 to 18 from 100 to 300 percent. There is no cost-sharing for children in families with incomes from 0 to 185 percent of the FPL, but for children in families with incomes between 186 and 225 percent of the FPL, families are charged a $5 copayment for professional services. Families with incomes between 226 and 300 percent of the FPL must pay $65 per month to participate, and copayments are charged for professional services ($10) and prescriptions ($5). (Well-child visit copayments are waived.)
Missouri does marketing rather than outreach, and they have not spent large sums of money on marketing, as other States have. Instead, Missouri has reduced their application from 21 pages to 2, out-stationed caseworkers in hospitals, and set up toll-free telephone centers. Their enrollment material has been widely disseminated to organizations and other State agencies, and they rely on private sector advertisement efforts and periodic events to "get the word out" about SCHIP. They have also set up automatic enrollment for Medicaid graduates so they do not have to apply for SCHIP when they are no longer eligible for Medicaid, and a steering committee has been formed to give recommendations for future marketing efforts.
Mr. Parrella of Connecticut represented the combination SCHIP program. Both the Medicaid SCHIP expansion (HUSKY A) and State-designed SCHIP program (HUSKY B) are administered by the same agency that administers Medicaid. Waxman Kids will be phased in to Medicaid by 2002, but they remain part of the SCHIP Medicaid expansion until then. Children ages 0-18 in families with incomes from 185 to 300 percent of the FPL are covered under the State-designed program. Copayments are applied to all children in the State-designed program beginning at 185 percent of the FPL. Families with incomes from 235 to 300 percent of the FPL pay $30 per child per month premium with a maximum amount of $50 per family. The State also has two supplemental programs for children with intense physical and mental health needs called HUSKY Plus for children in families with incomes from 185 to 300 percent of the FPL.
Connecticut has taken a multifaceted approach to outreach. Outreach is viewed as critical, not only to reach the uninsured population, but to negate the impact of adverse selection. The State is coordinating the eligibility and enrollment process with county eligibility offices and the single point-of-entry contractor, Benova. Regional offices determine final eligibility for Medicaid. Benova does final eligibility determination for SCHIP as well as health plan enrollment for both Medicaid and SCHIP.
Ms. Shewry represented State-designed SCHIP programs. Although California has a small Medicaid SCHIP expansion, the SCHIP programs are administered by different entities. The Department of Health Services administers the Medicaid SCHIP expansion, and the Managed Risk Medical Insurance Board (MRMIB) is responsible for administering Healthy Families, the State-designed SCHIP program. Healthy Families covers children ages 1 to 6 in families with incomes from 133 to 200 percent of the FPL and ages 7 to 18 for families with incomes from 100 to 200 percent of the FPL. Families with incomes between 150 and 200 percent of the FPL are charged between $6 and $9 per child per month, depending on the health plan they have chosen. Families with incomes between 100 and 150 percent are charged between $4 and $7 per child per month. Five-dollar copayments are also charged for certain services.
California has done extensive outreach and has committed more than $10 million of State money to outreach. Its strategies are multifaceted and multilingual. In addition to TV and radio ads and print media in all languages, the State also pays an application assistance fee to entities that are trained to assist families in completing the application. All outreach methods and strategies are aimed at achieving the following program goals:
- Increase the awareness of low-income uninsured families about the availability of comprehensive low- or no-cost health coverage for children as well as the importance of timely and ongoing care for children. Motivate such families to obtain coverage for their children.
- Provide a choice of health plans for families to choose from in obtaining coverage for their children.
- Provide an application and enrollment process that is easy for targeted low-income families to understand and use.
- Ensure that financial barriers do not keep families from enrolling their children in the program.
- Ensure that health services purchased by the program are accessible to enrolled children.
- Ensure the participation of community-based organizations in outreach and education activities.
- Encourage the inclusion of traditional and safety net providers in health plan networks.
- Strengthen and encourage employer-sponsored coverage to the maximum extent possible.
- Ensure that enrolled children with significant health needs receive access to appropriate care.
Missouri Department of Social Services. MC+ for Kids. Fact Sheet. Jefferson City (MO): The Department, 1999 Jan.
Missouri Department of Social Services. MC+ for Kids. Application. Jefferson City (MO): The Department, 1999 Apr.
Connecticut Department of Social Services. HUSKY B. Outreach. Hartford (CT): The Department, 1998 May.
Connecticut Department of Social Services. HUSKY A. Outreach. Hartford (CT): The Department, 1998 May.
Connecticut Department of Social Services. HUSKY Plus Behavioral answers to commonly asked questions. Hartford (CT): The Department, 1998 Nov.
Connecticut Department of Social Services. HUSKY Plus Behavioral general information. Hartford (CT): The Department, 1999 Jan.
Connecticut Department of Social Services. HUSKY Plus Physical for children with intense physical needs. Hartford (CT): The Department, 1999 Jan.
Connecticut Department of Social Services. HUSKY Plus referral form. Hartford (CT): The Department, 1998 Jul.
Connecticut Department of Social Services. The HUSKY Plan benefit package. Connecticut's New Children's Health Insurance Initiative. Hartford (CT): The Department, 1999 Jan.
California Department of Social Services. Medicaid for Children and Healthy Families. Application. Sacramento (CA): The Department, 1999 Mar.