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