Medicaid Enrollees and Disenrolles

ATTACHMENT C2
CASE STUDIES FOR CHIP 10—STATE EVALUATION PROTOCOL:
COMMUNITY—LEVEL ENROLLMENT AGENCIES

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Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Children’s Health Insurance Program (CHIP)
Case Studies of CHIPRA 10-State Evaluation
Community-Level Enrollment Agencies

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2. Case Studies of CHIPRA 10 State Evaluation
Community-Level Enrollment Agencies Topic Summary List
Topic
Background and
Overview
Eligibility and
Enrollment Process

Subtopic
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Outreach Strategies

Financing
Overall Lessons Learned

Mission
Populations served/ local community
Walk-through of application process (including Medicaid, if
applicable)
Changes in the application process as a result of CHIPRA
Processes after application is completed
o Eligibility determination
o “Screen and enroll” process
Walk-through of process to renew CHIP eligibility
Differences between the redetermination process for CHIP and
Medicaid
Changes in enrollment and eligibility processes since 2006
Personal views on enrollment and eligibility processes
Referral process between CHIP and Medicaid at enrollment
Satisfaction with rates of retention under CHIP and Medicaid

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Specific types of outreach the agency has conducted (if
applicable)
• Outcomes of these outreach activities
• How agency is funded
• Changes to funding as a result of CHIPRA
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Most successful efforts to enroll eligible children in CHIP and
Medicaid
Greatest challenges in identifying, enrolling and re-enrolling
eligible children
Suggested changes for the future

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2. Case Studies of CHIPRA 10 State Evaluation Implementation
Protocol for Community-Level Enrollment Agencies
Key Informant Info:
Name: ____________________
Title: ____________________
Agency: ___________________

Phone: ____________________
Fax:____________________
E-mail: ____________________

Thanks very much for agreeing to meet with us. We have been funded by the Office of the
Assistant Secretary for Planning and Evaluation of the Department of Health and Human
Services (DHHS) to conduct a national evaluation of the Children’s Health Insurance Program
(CHIP), as mandated by the U.S. Congress in the Children’s Health Insurance Program
Reauthorization Act of 2009.
DHHS previously conducted a congressionally-mandated evaluation of CHIP following its
enactment 1997; that evaluation ended in 2005. This current evaluation is patterned after our
previous work and comprises both quantitative and qualitative activities. We are here as part of
the qualitative/case study component of the project, for which we are visiting ten states to study
their recent experiences with CHIP and Medicaid and changes resulting from CHIPRA. We are
primarily interested in hearing from you today about CHIP and Medicaid in your state from
2006-onward, as our prior evaluation allowed us to track the program until then. We will be
conducting site visits to the following states—Texas, California, Florida, Ohio, Alabama,
Louisiana, New York, Michigan, Utah, and Virginia.
Information will be gathered from a broad range of key informants. At the state level, we are
meeting with officials responsible for Medicaid and CHIP administration; public health and Title
V/Maternal and Child Health; eligibility determination (enrollment brokers and/or social services
agencies); and statewide child advocacy groups. In addition, we will meet with individuals in
each state’s Governor’s office and the state Legislature to gather insights on the political debates
that have surrounded CHIP design and ongoing implementation. At the local level, we will meet
with such informants as: county social services administrators; front-line eligibility workers;
agencies and staff involved with outreach and enrollment; pediatric providers or clinics;
managed care plans; special providers serving children and adolescents with special health care
needs; and local child advocates. We will also be conducting a small number of focus groups
with parents of children enrolled in CHIP, among others.
During these interviews, we will discuss a broad range of issues, including the history and
development of CHIP in your state, benefits offered, program design, participation trends,
outreach and enrollment, access and utilization trends, cost sharing and premiums, and
anticipated impacts of health reform on CHIP.

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Information gathered during our site visit will be used in a series of state-specific case study
reports, as well as interim and final cross-cutting reports based on the findings across the study
states. Qualitative findings will also appear in our Reports to Congress. None of the information
you share with us today will be quoted without your permission, but we do generally list the
names of the people we’ve spoken with in an appendix to our final report. Would that be okay
with you?
Thanks very much for agreeing to meet with us. Do you have any questions about our project?
May we proceed with our questions?
I. Background and Overview
1. To start with, could you please give us some background information on you
agency/organization and tell us about the role you play in the CHIP and Medicaid programs.
2. What is the traditional mission and activities of your organization? What populations have
you traditionally served?
3. Now please tell us about your local community.
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What is its demographic/racial/ethnic mix?
What are the levels of uninsurance in your community to your knowledge?
What is your impression of the health status of the community?

II. Eligibility and Enrollment Process
4. In the discussions we have had with state officials, we learned a great deal about enrollment
and eligibility policies. But now that we are at the local level, it would be helpful if you
could walk us through the process that a parent would follow to apply for CHIP for their
children.
a) When people come in to apply, about how long do they have to wait before meeting with
an eligibility worker/application assistor? Is there a place for their kids to play? If they
go out to lunch, do they lose their place in line?
b) How much time do workers/assistors spend with each applicant?
c) What forms must be filled out? How long are they? (May we have a copy?)
d) What verification is needed?
e) Do families usually have everything they need to apply with them? What proportion of
families typically need to follow up by submitting additional documents and other
verification?
f) Do they have to come in, in person, to do this, or can they submit such material by mail?
g) Does your state offer on-line applications? Are you able to help families fill out their
applications on line? Can they submit it online, or only fill it out online (and have to print
it out and send it in)?
h) What proportion of applicants do you never hear from again?
i) What do you do if a family doesn’t speak English?
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j) What would you do if a father told you he was in the country illegally?
l) Does your state offer Express Lane eligibility (i.e., utilizing eligibility for other public
programs such as WIC or SNAP to evaluate eligibility and enroll in coverage)? If so,
what have been your early experiences? If not, what do you think of this idea?
m) Do you also process Medicaid applications? Is the process the same? If not, can you walk
me through the application process for Medicaid?
5. Can families fill out their applications at home (either on-line of in paper and mail them in to
you), or must they come in for a face-to-face interview?
As you probably know, legislation to continue the CHIP program, known as the CHIPRA
legislation, was passed in February 2009.
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6. Are you aware of any ways in which the application process has changed as a result
CHIPRA?
• For example, do data matching capabilities allow you verify income or citizenship
information directly?
• Have you made any other changes to the process since spring 2009, whether or not they
occurred as a result of CHIPRA?
7. Are there other community-based agencies or providers in your county/community that are
helping families fill out applications? How many traditional Medicaid eligibility
determination sites are there in your community?
8. Are you a presumptive eligibility site? Are there presumptive eligibility sites in your
community?
a) What kinds of providers / organizations are permitted to conduct presumptive eligibility?
b) How does the follow-up process operate?
9. Now let’s turn to your staff. How many staff would you say you have who assist in
enrollment and determine eligibility? Did you/your staff receive special training to conduct
enrollment and eligibility determination?
10. Now we would like to discuss with you the process after applications are completed.
a) Are you authorized to make “official” eligibility determinations or do you forward
completed applications to another agency?
b) If so, who? Is this a central “clearinghouse” for processing or are there multiple such
sites around the state?
c) How long does processing of applications take for CHIP and Medicaid (i.e. how much
time elapses from when a form is completed/submitted, and when a notification of
approval or denial is sent to a family)? Is there any priority given to children’s
applications?
d) Can we get a copy of the letter families receive when they are notified of approval?

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11. What steps were taken in the design of your enrollment strategy to maximize enrollment by
working families?
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Keeping offices open longer?
Providing transportation vouchers to the offices?
Ensuring enrollment staff workers have appropriate language skills?
Others?

12. Does your state have a shared application for CHIP and Medicaid enrollment?
a) If not, can you please describe the key differences the between the CHIP enrollment
process and Medicaid?
b) Are you aware of any plans to institute a joint application? What impact do you expect
this would have?
13. Now could you tell us about the “screen and enroll” process?
a) How do you/your staff refer applicants who appear to be Medicaid eligible to the
Medicaid eligibility agency, and vice versa?
b) Is there a place on your CHIP applications where families can indicate whether they do or
do not want their applications referred to/reviewed by Medicaid?
14. Now let’s turn to eligibility redetermination under CHIP and Medicaid.
a) Though we already have some information on the redetermination process, could you
please walk us through the process that a parent would follow to renew CHIP eligibility
for their children.
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How often must eligibility be redetermined?
When and how often are families notified?
Do you offer automatic renewal?
What forms are required to be completed? Are forms pre-populated or do they need to
be filled out? (May we have a blank copy?)
Can the forms be mailed in, or is a face-to-face interview required?
What assistance is provided to fill out the form?
What verification requirements must be submitted?
How long do families have to comply before their children are disenrolled?
If a child is being disenrolled, is their eligibility for Medicaid assessed? How does
that process work? Is the process the same for children being disenrolled for
Medicaid – is their eligibility for CHIP assessed? Do you know what proportion of
children disenrolling from CHIP are referred to Medicaid, and vice versa?

b) Now could point out for us the key differences between the redetermination process for
CHIP and that for Medicaid, if there are any.

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15. Have any of your enrollment and eligibility processes changed since 2006? How about since
the enactment of CHIPRA in February 2009? (e.g. introduction of joint forms, introduction
of community-based enrollment, express lane eligibility procedures, etc.).
16. Now let’s turn to your experiences conducting CHIP and Medicaid enrollment. Do you feel
that the process is working well?
a) Do you think that the design of the application form makes enrollment easy? Are there
any changes you would like to see?
b) What do you think of mail-in or online versus face-to-face applications?
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Do mail-in/on-line applications make your life easier or more complicated (e.g.
following up on mistakes by families)?
Do mail-in/on-line applications make life easier for applicants and boost enrollment?
Is this benefit worth it, in your opinion?

c) If you are a community-based enroller/application assistor: Please describe your
experience with the policy of offering community based enrollment assistance.
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How has the role of assisting families with applying for CHIP/Medicaid fit with
your/your agency’s traditional mission and functions?
Is the process going smoothly, or do you find it difficult to conduct this function on
top of your other responsibilities?
Do you feel you/your agency receives sufficient financial compensation to carry out
this enrollment function? Have grant funds / “finders fees” been adequate to permit
your agency to staff up/build up the capacity to perform enrollment?
Has the addition of community-based application assistance made life easier for
applicants and boosted enrollment?

d) If you have presumptive eligibility, How do you feel this policy is working?
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Has your role as a PE provider fit well with your agency’s traditional functions?
Is the process going smoothly, or do you find it difficult to conduct this function on
top of your other responsibilities?
Are you compensated sufficiently to continue conducting PE?
How well has the referral process worked? Do most families follow-up their receipt
of PE with formal applications for full CHIP/Medicaid eligibility?
With all the other strategies being implemented to facilitate families’ enrollment of
children into CHIP/Medicaid (eg, such as mail-in applications and community-based
application assistors), do you see added benefits of having presumptive eligibility, as
well? Or is PE somewhat redundant, given the other strategies that are in place?
Has PE made life easier for applicants and boosted enrollment?

17. We are also interested in hearing about how well the referral process between CHIP and
Medicaid is working at enrollment. How well do you think the “screen and enroll” process is
working? Are there areas you think need improvement? If so, please describe those?

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18. Are there parts of the enrollment and eligibility determination process that you still feel are a
barrier to enrollment (form, face to face interview, verification requirements, administrative
burden, time taken to process, policies that require children to be uninsured for a certain
length of time before enrolling)?
19. Now let’s turn to other factors that might affect enrollment.
a) In your experience how does perception of CHIP and Medicaid affect enrollment?
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Has the “public charge” issue affected CHIP and Medicaid enrollment?
How do families perceive the CHIP and Medicaid programs? Is one program viewed
more positively than the other? Does this affect enrollment into either program?

b) Do you perceive that premiums are presenting a challenge to enrolling families, or do
families tell you that the premiums are affordable? Are families surprised when they learn
they have to contribute to the cost of coverage?
c) Do you encounter many applicants that already have health insurance for their children?
Do families ever discuss the issue of whether they would like to drop their current
insurance to sign up for CHIP?
d) What impact do you think raising income eligibility standards will/would have on
enrollment in your state?
20. Do you feel that the CHIP and Medicaid eligibility redetermination processes work well?
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Are you satisfied that the redetermination interval is appropriate?
Are families sufficiently notified about the need for/importance of eligibility renewal?
How well does the redetermination form work?
How about the need (or not) for a face-to-face interview?
Is sufficient assistance provided to fill out the form?
Are the verification requirements too burdensome?
Is the amount of time families have to comply before their children are disenrolled
adequate?

21. Now we would like to ask you about how satisfied you are with rates of retention under
CHIP and Medicaid.
a) Do you feel that the numbers and types of families retaining eligibility at redetermination
is adequate, or do you see many interruptions in coverage amongst children as a result of
the redetermination process (“churning”)?
b) In your experience, what are the major reasons why children lose coverage at
redetermination?
• “Lost” cases
• Failure to pay premiums
• Families getting jobs that carry private insurance
• Families losing jobs and moving into Medicaid
• Barriers in the process of redetermination?
• Others?
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c) In your mind what have been the key factors and strategies boosting retention (if any)?
22. Are there any changes to the enrollment, eligibility and redetermination procesess that would
you like to see?

III. Outreach Strategies
23. Is this agency involved with CHIP and/or Medicaid outreach?
a) If so, what specific outreach activities has this agency conducted?
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What is the message of this outreach?
Do these activities relate to state-developed outreach campaigns?
Is your outreach targeted in any way to any special populations?
How intensive are these activities?
Has the level of outreach you provide changed in recent years?

b) What have been the outcomes of these outreach activities?

IV. Financing
24. How is your agency funded?
a) Have you received any new outreach funding as a result of CHIPRA?
25. Do you feel that you are sufficiently funded to carry out your job to an optimal level?

V. Overall Lessons Learned
26. Which of your efforts to enroll eligible children in CHIP and Medicaid have been the most
successful? Why? Do you have data to support this belief? If so, could you share it with us?
27. What are the greatest challenges in identifying, enrolling and re-enrolling eligible children
into CHIP and Medicaid?
28. Are there any groups of children you think need to be more targeted by your outreach and
enrollment strategy?
29. What changes would you like to see in the future?

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