Initial Insights from Focus Groups with Uninsured Parents

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Retaining Eligible Children and Families in SCHIP
and Medicaid
A Review of Research Prepared by Lake Snell
Perry Associates
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Agenda

• Overview of the project
• Factors that affect retention
• Ways to improve retention
• Communication strategies
• Q A

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Description of the Project

• LSPA reviewed existing research and interviewed
  experts to inform states, grantees and others
  about the challenge of retention in SCHIP and
  Medicaid

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Methodology

• 51 studies were collected and reviewed
• 24 in-depth telephone interviews were conducted
• 16 with leading experts
• 8 with Medicaid/SCHIP directors

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What We Learned about the Field

• Retention is a new topic
• Most studies are about retention in SCHIP, not in
  Medicaid
• Most of the research focuses on retaining
  children, not adults
• Most of the studies are state-specific

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Studies and Experts Agree on the Factors That
Affect Retention
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Procedural Barriers

• Studies show a large drop in enrollment during
  renewal periods due to
• Complex renewal forms
• Too much documentation
• Frequent renewal
• Face-to-face interviews
• Administrative errors
• Language barriers

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Cost-Sharing

• Families sometimes have difficulty paying SCHIP
  premiums
• The inflexibility of the payment rules may be a
  bigger problem
• Overall impact of cost-sharing does it lead to
  disenrollment or do families prefer paying?

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Awareness Gaps

• Families have gaps in their knowledge about SCHIP
  and Medicaid. Many are unaware
• That they need to renew regularly
• Of income eligibility levels
• That their premium amount for SCHIP is
  adjustable

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Life Circumstances

• Busy and fluctuating personal and economic lives
• Families move in and out of employment frequently
• Lives are less predictable
• They forgot or did not get around to it

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Valuing Health Coverage

• Most studies argue that low income families place
  a high value on health coverage, particularly for
  their children
• Others suggest that coverage is not always seen
  as necessary

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Perceptions of the Programs

• Stigma may not be a big factor in retention
• SCHIP and Medicaid often get high satisfaction
  rates
• Some negative attitudes about the programs,
  particularly Medicaid

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Delinking Problems

• Children may be wrongly losing Medicaid coverage
  when their parents lose public assistance
• According to one state study, 51 percent of
  children lose Medicaid coverage each year after
  leaving cash assistance

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Health Status

• Families with more health needs are more likely
  to stay enrolled
• At least one study did not find that children
  with more health needs stay enrolled
• Bottom line more research is needed

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Race, Gender and Income

• This is a new area of study
• One study showed that lower-income families were
  more likely to lose SCHIP coverage than higher
  income families
• A few studies found that African-American
  children were less likely to remain enrolled
• One study found that boys were slightly less
  likely than girls to lose coverage

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Vital Role of Third Parties

• Many experts say that community-based
  organizations, schools, employers, doctor
  offices, health plans and others can play a vital
  role in retention
• Caseworkers also play a vital role

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Studies and Experts Identify Many Ways to Improve
Retention
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Simplify the Renewal Process

• Consider passive renewal
• Require annual renewal as opposed to quarterly or
  every 6 months
• Limit face-to-face interviews
• Allow for self-declaration of income
• Use pre-filled renewal forms

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Simplify the Renewal Process

• Use shorter, simpler renewal forms
• Send renewal forms in self-addressed, stamped
  envelopes
• Allow renewal forms to be accepted at numerous
  sites
• Enable families to renew off-cycle when it may be
  more convenient

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Reach Out to At-Risk Families

• Contact families due for renewal to encourage
  them to renew
• Follow up with families that do not return their
  renewal forms
• Improve communication notices reminding families
  it is time to renew
• Keep addresses up to date

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Reach Out to At-Risk Families

• Increase reminder notices prior to the renewal
  deadline
• Create toll-free renewal information lines in
  different languages
• Provide reminder notices in multiple languages
• Train caseworkers to better assist families to
  complete the renewal process

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Offer Renewal Assistance

• Provide renewal assistance to first-timers
• Use community-based application assistors to
  help with renewal
• Reach out to community-based partners to help
  with renewal
• Pay community-based organizations for each
  renewal they assist

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Relax Premium Payment Rules (SCHIP)

• Help families who miss payments stay enrolled
• Create a universal premium amount to avoid
  confusion
• Allow for automatic paycheck deductions
• Shift to an annual payment with a reasonable cost

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Coordinate Program Databases

• Coordinate the databases of SCHIP and Medicaid to
  track movement between programs
• Reduce the number of renewals a family must
  complete by coordinating among food stamps and
  TANF

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Other Ideas

• Measure the effectiveness of renewal strategies
• Evaluate reasons for disenrollment to determine
  the real causes for loss of coverage

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Other Ideas

• Get enrolled families to use their coverage so
  they will value it more
• Complete the delinking of TANF and food stamp
  procedures from Medicaid

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Communication Strategies What States Are Doing
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What Some States Are Doing

• Mailing postcards in advance of renewal
• Redesigning the renewal notice to include a
  renewal checklist
• Creating a two-sided renewal form one side
  English, the other Spanish
• Using bright colored paper for renewal notices
  (if it is blue, it is time to renew)

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What Some States Are Doing

• Mailing SCHIP newsletter with retention messages
  to enrolled families
• Developing a renewal mailing that is different
  from other packets (i.e. bright yellow stickers
  on renewal mailings)
• Creating a refrigerator magnet urging families to
  renew that includes the renewal date

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What Some States Are Doing

• Using the SCHIP logo (instead of the Department
  of Health Logo) on program mailings
• Creating a training video for outreach workers
  that includes renewal tips
• Using premium payment coupons that include
  printed reminders about renewal

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Available Resources
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