Form CMS-10398-007 CHIPRA Cycle II - Outreach and Enrollment Grant Semi-Ann

CHIPRA Cycle II

Outreach and Enrollment Grant
Semi-Annual Report Template

Reporting Period: [relevant dates to be added prior to distribution]

Report Due Date: [relevant date to be added prior to distribution]

Grant Award Number

State

Name of Grantee

Focus Area Listed In Grant Application (number and name)

Name and Title of Person Completing Report

Authentication

I Certify the Accuracy of All Report Contents:

Authorized Certifying Official (Typed name in Lieu of Signature)

CMS Project Officer Approval

I have approved the contents of this report:

_____________________________________________________________________________CMS Project Officer (Typed Name in Lieu of Signature, and Date)

Reporting Requirements (Read Carefully)

To meet Congressional requirements—as expressed in the terms and conditions of your grant—you are required to report on your grant’s strategies and outcomes—specifically, the number of enrollments and renewals in Medicaid and CHIP that resulted from your grant. The Centers for Medicare & Medicaid Services (CMS) will use Grantees’ reports to prepare a Report to the United States Congress.

This Report to Congress will describe Grantees’ progress towards their CMS approved goals—as a group and individually—and will highlight successful outreach and enrollment strategies, discuss common enrollment and renewal challenges and barriers, and present the lessons learned about strategies to increase Medicaid and CHIP coverage of uninsured eligible children.

Important Information for Completing the Semi-Annual Report Template

This semi-annual report template provides a framework for describing and summarizing the outcomes for each of the reporting periods of the two-year CHIPRA Cycle II Outreach and Enrollment Grants. The reporting period for this semi-annual report is …. [relevant dates to be added prior to distribution.]

• This template is formatted for Microsoft Word software (doc format) and the template must be returned as a Word document. Do not send a PDF file. [To be deleted if the template is programmed in GRS.]

• Some questions provide tables for entering numbers, as well as sections for providing brief narrative answers. These questions include specific instructions for entering the data.

• Narrative should be entered in the template under each question, in single-spaced, 12 point, Times New Roman font.

• Word limitations are indicated for each question; 600 words equal approximately one page of single-spaced, Times New Roman font in 12 point type. The word limitations are intended as a guide. If you need to use more words to adequately describe your activities, you may do so. However, aim for both clarity and brevity when writing your narrative responses.

• You may attach no more than two pages of tables, graphs or other documents that contain grant information that is not covered by the questions in the template. For example, if your grant includes more than one state, you may use the additional tables to report information on applications and enrollments for each state separately. This additional information may not substitute for the information requested n the semi-annual report template.

• Focus Area 1 Grantees Only: All template questions may not apply to your project; please answer every question that applies, with particular attention to thorough answer to Question 1. You must also answer Questions 19-22.

Send the completed report to your CMS Project Officer by ….[relevant date to be added prior to distribution.]

All data reported must be the result of grant activities during this reporting period. The reporting period referred to in this Semi-Annual Report template is…..
[relevant dates to be added prior to distribution]

1. What Activities Did You Undertake During this reporting period?

1. Describe the progress you have made toward the milestones for this reporting period, as described in the work plan in your grant application. You may add additional milestones as needed.

Milestone	Progress	Status or Date Achieved (mo/day/yr)

2. Indicate any changes from the proposed schedule/timeline described in your grant application, showing the original schedule/timeline date, the revised date and provide a brief explanation of the reason for the modification. You may add additional milestones as needed.

Milestone	Original date (mo/day/yr)	Current date (mo/day/yr)	Explanation

2. Grant Evaluation Activities

Describe any activities you have undertaken during the reporting period related to your grant evaluation. (300 words)

3. What increased capacity for outreach and application assistance did you develop during this reporting period?

Answer Question 3 only if applicable.

1. New Fixed Sites

Over the reporting period, how many fixed physical sites where families can apply for CHIP/Medicaid have you established as a result of your grant activities? These sites can include new sites where outreach workers regularly provide assistance, the offices of new partners that provide application assistance, as well as new sites where you have placed kiosks or laptop computers to submit applications electronically. List the number and types of sites and how often you are providing assistance (e.g., twice a week at two offices and once a week at a social service organization serving Hispanics). (200 words)

2. New Mobile Sites

Over the reporting period, how many mobile physical sites where families can apply for CHIP/Medicaid have you established as a result of your grant activities? These sites can include an outreach worker that travels to temporary locations or a site in a vehicle where workers provide application assistance. Please describe. (200 words)

2. New Outreach and/or Application Assistance Workers

1. Over the reporting period, how many new paid outreach and/or application assistance workers did you hire with grant funds? This includes Americorps volunteers for whom the grant did fund their stipend.

Number of new outreach and/or application assistance workers (report as FTEs): _____

2. Over the reporting period, how many partner organization staff did you train to provide outreach and/or application assistance through this grant?

Number of partner organization staff trained: _________

3. Over the reporting period, how many new volunteers did you train to provide outreach and/or application assistance through this grant? (This includes Americorps volunteers for whom the grant did not fund their stipend.)

Number of volunteers trained: ________

2. New State Eligibility Workers

Over the reporting period, has the Medicaid or CHIP Agency out-stationed new eligibility workers as a result of grant activities?

Number of new out-stationed Agency eligibility workers (report as FTEs): ________

4. Outreach Funding Maintenance of Effort

Only Grantees that are State Medicaid and/or CHIP Agencies should complete the following table.

State Outreach & Enrollment funding prior to grant award (year based on FFY 2011)	State Outreach & Enrollment Funding in Current Period	Change
$	$	$

5. Data for Identifying Children Eligible for CHIP/Medicaid

1. If you are obtaining data for targeting outreach activities to identify potentially eligible uninsured children and/or children coming up for program renewal, (1) what type of data are you using, (2) how and from where are you obtaining these data, and (3) how often do you receive the data? (200 words)

2. Did you face any challenges obtaining these data or challenges using the data, e.g. did it include outdated information? If so, describe the challenge, the actions you took to address it and their effectiveness. (200 words)

DATA ON CHILDREN WHO APPLIED

5. How Many Children Applied for CHIP/Medicaid as a Result of Your Grant Activities, During the Reporting Period?

In the table below, enter the number of children for whom an application was submitted. Report separately the number of children newly applying and those renewing. If you do not have separate data for newly applying and renewing children, then enter the combined number in the Total row.

If you are only able to report the number of applications—which can include more than one child—please indicate that with an X here: __________.

If reporting the numbers of applications, enter the data in the table below and explain why you are unable to provide data on the number of children. (200 words)

NUMBER OF CHILDREN FOR WHOM APPLICATIONS WERE SUBMITTED IN THE REPORTING PERIOD	Number
1. Number of children for whom a NEW CHIP/Medicaid application was submitted
2. Number of children for whom a RENEWAL CHIP/Medicaid application was submitted
3. TOTAL number of children for whom CHIP/Medicaid applications were submitted (Children with new + renewal applications)
Of the total number:
Number of children whose applications were DENIED
Number of children whose applications are PENDING at the end of the current reporting period. (Include those for which no determination has been made.)

5. For Focus Area II (Retention) and all Grantees Working on Retaining Eligible Children.

If these questions are not applicable, indicate with N/A in the responses.

Of the total number of children for whom a renewal application was submitted this reporting period:

1. How many children did you contact prior to their renewal date?
   _________________

2. Of the children you contacted, how many did you assist with their renewal applications?
   ________________

5. What Are the Characteristics of the Children Who Applied for CHIP/Medicaid as a Result of Your Grant Activities, During the Reporting Period?

In the two tables below, if you do not have separate data for children with new and renewal applications, then enter the combined numbers in the Total row.

1. Race/Origin

In the table below, enter the number of children of each race who applied for CHIP/Medicaid. Please provide data on the race of all children, including those of Hispanic/Latino ethnicity.

If you do not know how many children of a particular race applied (for example, if you do not collect data for that racial category), enter “unknown” in the appropriate box.

If you know that you did not receive applications from any children in a particular racial category, enter a zero (“0”).

The numbers in the total column should equal the numbers in the first three rows of the Question 6 table. If it does not, please provide an explanation.

Number of Children for Whom Applications Were Submitted	Asian/ Pacific Islander	Black/ African American	American Indian/ Alaska Native	White-European/ Middle Eastern	More Than One Race	Unknown Race	TOTAL Number Who Applied
Number of Children for whom a NEW Application was submitted
Number of Children for whom a RENEWAL Application was submitted
TOTAL

2. Hispanic/Latino Ethnicity

In the table below, enter the number of children who applied for CHIP/Medicaid as a result of grant activities that self-identified as Hispanic/Latino. This includes children of any race.

If you do not know how many children self-identified as Hispanic/Latino, enter “unknown” in the appropriate box. If you know that you did not receive applications from any Hispanic/Latino children enter a zero (0).

Number of Children for Whom Applications were Submitted in the reporting period	Number Self-Identified as Hispanic/Latino
Number of Children for whom a NEW application was submitted
Number of Children for whom a RENEWAL application was submitted
TOTAL

5. Efforts to Reach Other Target Groups

Answer this question only if applicable.

If your grant targeted a specific group other than those listed in the race and ethnicity tables above (e.g., teens, homeless children, rural children, or children with English as a second language), please enter the requested data for each target group in the table below.

Description of Target Group	Number of Children for Whom an Application was Submitted

DATA ON CHILDREN WHO ENROLLED

5. How Many Children Were Enrolled or Renewed in CHIP/Medicaid as a Result of Your Grant Activities, During the Reporting Period?

Please enter the number of children enrolled and renewed during the reporting period.

If you cannot distinguish between enrollments and renewals, enter the combined number in column C.

If you cannot distinguish between CHIP and Medicaid, enter the combined number of CHIP/Medicaid enrollments and renewals in the TOTAL row.

	(Column A) Number of Children Enrolled	(Column B) Number of Children Renewed	(Column C) Sum of Numbers in Columns A & B
CHIP
Medicaid
TOTAL

5. What Are the Characteristics of the Children Who Enrolled and Renewed in CHIP/Medicaid as a Result of Your Grant Activities, During the Reporting Period?

In the two tables below, if you do not have separate data for CHIP and Medicaid, or for enrollments and renewals, then enter the combined numbers in the Subtotal and Total rows.

1. Race/Origin

In the table below, enter the number of children of each race who were enrolled or were renewed in CHIP/Medicaid. Please provide data on the race of all children including those of Hispanic/Latino ethnicity. Add subtotals and the overall total.

If you do not know how many children of a particular race were enrolled (e.g., if you do not collect data for that racial category), enter “unknown” in the appropriate box. If you know that you did not enroll any children in a particular racial category, enter a zero (“0”).

The numbers in the TOTAL Number Enrolled column should equal the numbers in Question 10 for enrollments and renewals in CHIP and Medicaid.

Number of Children Enrolled or Renewed in CHIP/Medicaid	Asian/ Pacific Islander	American Indian/ Alaska Native	Black/ African American	White-European/ Middle Eastern	More Than One Race	Unknown Race	TOTAL Number Enrolled
Enrollments
CHIP
Medicaid
Subtotal
Renewals
CHIP
Medicaid
Subtotal
TOTAL
If you do not have data to enter in the categories listed above, then use the following categories.
TOTAL CHIP: Enrollments and Renewals
TOTAL Medicaid: Enrollments and Renewals
TOTAL

2. Hispanic/Latino Ethnicity

In the table below, enter the number of children who self-identified as Hispanic/Latino who were enrolled or were renewed in CHIP/Medicaid as a result of grant activities. This includes children of any race.

If you do not know how many children self-identified as Hispanic/Latino, enter “unknown” in the appropriate box. If you know that you did not enroll or renew any Hispanic/Latino children in CHIP and Medicaid, enter a zero (0).

Number of Children Enrolled or Renewed in CHIP/Medicaid	Number Self-Identified as Hispanic/Latino
Enrollments
CHIP
Medicaid
Subtotal
Renewals
CHIP
Medicaid
Subtotal
TOTAL
If you do not have data to enter in the categories listed above, then use the following categories.
TOTAL CHIP: Enrollments and Renewals
TOTAL Medicaid: Enrollments and Renewals
TOTAL

5. Explanation of Enrollment Data

1. Please provide additional information, if needed, to explain your results. For example, if the number of enrollments and renewals is much higher or lower than your expected progress toward your CMS approved goal, explain why you think this happened. (200 words)

2. Please describe your system for tracking applications—from the time they are submitted, through the review process, to approval or denial. Also describe how you determine the number enrolled; e.g., data obtained from the state or county, calls to the State eligibility determination office, etc. (300 words)

3. Please provide additional information, if needed, that will help to explain the enrollment numbers by race and ethnicity. For example, if you targeted specific racial or ethnic groups and unexpectedly attracted other racial or ethnic groups, please describe this. (200 words)

5. Efforts to Reach Other Target Groups

Answer this question only if applicable.

If your grant targeted a specific group other than those listed in the race and ethnicity tables above (e.g., teens, homeless children, rural children, or children with English as a second language), please enter the requested data for each target group in the table below.

Description of Target Group	Number of Children Enrolled and Renewed in Medicaid/CHIP

5. Other Outcomes

In addition to enrolling and retaining children in CHIP/Medicaid, your grant activities may have resulted in other positive outcomes, such as those listed below. If so, please describe these results in the relevant section below. (400 words)

1. Enrollment of other populations in CHIP or Medicaid, such as pregnant women, parents, or other adults.

2. Enrollment of children, families, or other adults in public programs other than CHIP/ Medicaid, such as SNAP and WIC.

3. New outreach and enrollment policies and procedures that will be sustained after the grant ends.

4. Any other positive unplanned/ unanticipated grant outcomes?

STRATEGIES
to Help Enroll and Renew Children

5. Most Effective Strategies in the Reporting Period

Your most effective strategies are those that resulted in a greater number of enrollments/renewals from grant activities, relative to the other strategies you used.

When you answer the questions about your most effective strategies, please ensure that you address the specific questions and issues as they relate to the populations you targeted and your grant’s focus area (I – Information Technology, II – Retention, III – Schools, IV – Coverage Gaps, and V – Teens).

Answer questions for up to 3 strategies. Please write your answers under each question.
(600 words total for each strategy.)

Strategy One

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. How did you determine that this strategy was effective? If available, please report the percentage of enrollments or renewals attributable to this strategy.

3. Please describe whether this strategy was effective for the specific group(s) of children you were targeting; and/or more effective with certain target groups than with others. For example, was it more effective with teens, members of specific racial or ethnic groups, or those in certain geographic areas?

4. What lessons did you learn about this strategy? What components of this strategy do you feel are critical to its effectiveness?

5. Did you modify the strategy during the reporting period to improve its effectiveness? If yes, please describe.

6. Can this strategy be replicated by organizations similar to yours? Please explain why or why not?

7. In your estimation, do you consider this strategy to be effective relative to its overall cost?

Strategy Two

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. How did you determine that this strategy was effective? If available, please report the percentage of enrollments or renewals attributable to this strategy.

3. Please describe whether this strategy was effective for the specific group(s) of children you were targeting; and/or more effective with certain target groups than with others. For example, was it more effective with teens, members of specific racial or ethnic groups, or those in certain geographic areas?

4. What lessons did you learn about this strategy? What components of this strategy do you feel are critical to its effectiveness?

5. Did you modify the strategy during the reporting period to improve its effectiveness? If yes, please describe.

6. Can this strategy be replicated by organizations similar to yours? Please explain why or why not?

7. In your estimation, do you consider this strategy to be effective relative to its overall cost?

Strategy Three

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. How did you determine that this strategy was effective? If available, please report the percentage of enrollments or renewals attributable to this strategy.

3. Please describe whether this strategy was effective for the specific group(s) of children you were targeting; and/or more effective with certain target groups than with others. For example, was it more effective with teens, members of specific racial or ethnic groups, or those in certain geographic areas?

4. What lessons did you learn about this strategy? What components of this strategy do you feel are critical to its effectiveness?

5. Did you modify the strategy during the reporting period to improve its effectiveness? If yes, please describe.

6. Can this strategy be replicated by organizations similar to yours? Please explain why or why not?

7. In your estimation, do you consider this strategy to be effective relative to its overall cost?

5. Least Effective Strategies in the Reporting Period

Your least effective strategies are those that resulted in a lower number of enrollments/renewals from grant activities, relative to the other strategies you used.

When you answer the questions about your least effective strategies, please ensure that you address the specific questions and issues as they relate to the population(s) you targeted through your grant’s focus area (I – Information Technology, II – Retention, III – Schools, IV – Coverage Gaps, and V – Teens).

Answer questions for up to 3 strategies. Please write your answers under each question.
(600 words total for each strategy.)

Strategy One

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. Explain why this strategy was less effective than others; include any challenges or barriers to its effectiveness.

3. Describe any modifications you made to improve this strategy’s effectiveness and whether they made a difference. If you have made no modifications and you plan to continue using this strategy in the future, what do you plan to do to improve its effectiveness?

4. What lessons did you learn from this strategy?

Strategy Two

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. Explain why this strategy was less effective than others; include any challenges or barriers to its effectiveness.

3. Describe any modifications you made to improve this strategy’s effectiveness and whether they made a difference. If you have made no modifications and you plan to continue using this strategy in the future, what do you plan to do to improve its effectiveness?

4. What lessons did you learn from this strategy?

Strategy Three

1. Describe the strategy and specify whether it was focused on enrollments, renewals, or both.

2. Explain why this strategy was less effective than others; include any challenges or barriers to its effectiveness.

3. Describe any modifications you made to improve this strategy’s effectiveness and whether they made a difference. If you have made no modifications and you plan to continue using this strategy in the future, what do you plan to do to improve its effectiveness?

4. What lessons did you learn from this strategy?

CHALLENGES

5. What Challenges Did You Face In the Reporting Period?

1. Administrative and Management Challenges

Discuss any administrative or management challenges you faced when implementing your grant—such as staff turnover—and how you dealt with them. Do not include detailed information about challenges you encountered when implementing your outreach and application assistance strategies—such as difficulty obtaining information needed to target outreach activities. This information is to be reported in the next question. (200 words)

2. Enrollment and Renewal Challenges

Discuss enrollment and renewal challenges you faced when implementing your grant. Enrollment and renewal challenges are those that make it difficult to reach and engage families in the application process: e.g., beliefs or attitudes people have that make them reluctant to enroll, such as stigma associated with public benefits; lack of transportation to application assistance sites; lack of awareness about CHIP/Medicaid; and complex eligibility rules and requirements that are difficult for families to understand and comply with.

Under the questions below, please describe no more than four enrollment and renewal challenges that you may have encountered. Describe the challenge in detail and how you addressed it. State whether you successfully dealt with the challenge and if not, describe your next steps to address the challenge.

Please ensure that you discuss challenges as they relate to the populations you targeted and your grant’s focus area (I – Information Technology, II – Retention, III – Schools, IV – Coverage Gaps, and V – Teens). If you are targeting more than one target group, note if the challenge is the same for all groups; if not, how do they differ. (300 words total for each challenge)

Challenge 1

1. Describe the challenge and how it creates a barrier to enrollment and/or renewal.

2. Describe the actions you took to address the challenge, and state whether they were effective.

Challenge 2

1. Describe the challenge and how it creates a barrier to enrollment and/or renewal.

2. Describe the actions you took to address the challenge, and state whether they were effective.

Challenge 3

1. Describe the challenge and how it creates a barrier to enrollment and/or renewal.

2. Describe the actions you took to address the challenge, and state whether they were effective.

Challenge 4

1. Describe the challenge and how it creates a barrier to enrollment and/or renewal.

2. Describe the actions you took to address the challenge, and state whether they were effective.

5. Overall Outreach and Enrollment Lessons Learned

What are the most important lessons you have learned about how to increase enrollments and/or renewals in CHIP/Medicaid? Please include, but do not feel you need to limit yourself to, lessons learned about your target population. Do not repeat the same lessons learned reported in the strategy section (above). (400 words)

If your grant is a Focus Area 2, 3, 4 or 5 grant, STOP HERE.

If your grant is a Focus Area 1 grant,

continue and answer the following questions

19. Are you implementing one or more of the following technologies? If yes, answer the questions below.

a. New or enhanced web-based/online system for completing and submitting applications:

For enrollment? Yes/No _______ For renewal? Yes/No _______

If Yes:

1. Can the new or enhanced online application be submitted by any applicant with access to the internet? Yes/No _______

2. As a result of the new or enhanced system, can applicants now submit electronic signatures?
Yes/No _______

3. As a result of the new or enhanced system, can applicants now submit scanned documents electronically? Yes/No _______

If so, what documents can be submitted electronically? (e.g., income, residency, etc.)

List all: ____________________________________________________________________

b. New use of electronic databases to verify employment, income and other information.

Yes/No ________________

c. Any other new use of technology?

Describe (300 words)

20. For each technology you have implemented or enhanced (e.g., online application, use of databases to document income), answer the following questions.

If you have not yet implemented the new or enhanced technologies in the reporting period, you may skip these questions.

Technology 1

1. What is the technology?

2. Has the technology made it easier for families to apply for, enroll in and/or renew their children in CHIP/Medicaid?

3. How many children have applied for CHIP/Medicaid or applied to renew their coverage using the technology?

4. How many children have been enrolled or renewed in CHIP/Medicaid through the use of the technology?

Technology 2

1. What is the technology?

2. Has the technology made it easier for families to apply for, enroll in and/or renew their children in CHIP/Medicaid?

3. How many children have applied for CHIP/Medicaid or applied to renew their eligibility using the technology?

4. How many children have been enrolled or renewed in CHIP/Medicaid through the technology?

Technology 3

1. What is the technology?

2. Has the technology made it easier for families to apply for, enroll in and/or renew their children in CHIP/Medicaid?

3. How many children have applied for CHIP/Medicaid or applied to renew their eligibility using the technology?

4. How many children have been enrolled or renewed in CHIP/Medicaid through the technology?

Technology 4

1. What is the technology?

2. Has the technology made it easier for families to apply for, enroll in and/or renew their children in CHIP/Medicaid?

3. How many children have applied for CHIP/Medicaid or applied to renew their eligibility using the technology?

4. How many children have been enrolled or renewed in CHIP/Medicaid through the technology?

21. Have the new technologies implemented resulted in a more efficient and less costly application/enrollment/renewal process?

For example, has the application processing time decreased? Has the amount of mail returned “address unknown” decreased? Has the percentage of applications denied for lack of documentation been reduced?

If so, please describe the impact of the new technologies and how you determined whether it was more efficient/less costly. (300 words)

If you have not yet implemented the new or enhanced technologies in the reporting period, you may skip this question.

22. Are the technology elements that you are designing and/or implementing able to be replicated by, shared with, or used by other entities (i.e., States or community-based organizations)? Describe why or why not. What plans or efforts do you currently have to share new technologies? (200 words)

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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