Retaining Eligible Children

and Families in SCHIP and

Medicaid

A Review of Research Prepared by Lake Snell Perry & Associates

Agenda

• Overview of the project

• Factors that affect retention

• Ways to improve retention

• Communication strategies

• Q & A

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

Methodology

• 51 studies were collected and reviewed

• 24 in-depth telephone interviews were conducted – 16 with leading experts– 8 with Medicaid/SCHIP directors

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

Studies and Experts Agree on

the Factors That Affect

Retention

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

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?

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

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”

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”

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

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

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

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

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

Studies and Experts Identify

Many Ways to Improve

Retention

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

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

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

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

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

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

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

Other Ideas

• Measure the effectiveness of renewal strategies

• Evaluate reasons for disenrollment to determine the real causes for loss of coverage

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

Communication Strategies:

What States Are Doing

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”)

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

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

Available Resources