REVISED ATTACHMENT K 2_Comments

ATTACHMENT K.2

CONSENT FORMs for focus group participants

FOCUS GROUPS: PARTICIPANT INFORMED CONSENT

Study Title: Children’s Health Insurance Program Reauthorization Act (CHIPRA) Express Lane Eligibility (ELE) Evaluation

Principal Investigators: Ian Hill, MSW, MPA, and Sheila Hoag, MA

Sponsor’s Name: U.S. Department of Health and Human Services

Introduction/Purpose

You are invited to participate in the Department of Health and Human Services (DHHS) evaluation of the CHIPRA Express Lane Eligibility (ELE) evaluation. This study is funded by the U.S. Department of Health and Human Services (HHS). HHS has contracted with Mathematica Policy Research, the Urban Institute, and the Health Management Associates to conduct the study for them. Results from this evaluation are intended to inform policymakers how this program is working for children and families like yours. You were selected as a possible participant in this study because your child was enrolled in CHIP or Medicaid through a particular method we are studying. Before you decide to be a part of this study, you need to understand the risks and benefits associated with your participation.

Procedure

You are participating in a focus group. A focus group is an informal small group discussion, moderated by a facilitator who will guide the discussion through a series of questions, focused on a particular issue. In our focus group, we will ask questions about your experiences with CHIP and Medicaid enrollment, and keeping your child enrolled in the program. A colleague and I will be taking written notes of your answers. The focus group will be audio recorded with your permission. There will be no representatives from the [insert state name] Medicaid of CHIP office present at the focus group. If you do not agree to have the focus group recorded, please let me know.

There are no “right” or “wrong” answers; we are only interested in learning about your experiences and opinions. You may choose to not answer any and all questions that I ask, and you may leave the focus group discussion at any time as well. The focus group discussion will last between 1.5 and 2 hours.

Benefits

Participating in this focus group discussion may not benefit you or your children personally. You will be asked about your experiences with CHIP and Medicaid. While you will not benefit directly from this study, your comments will help inform policymakers and providers about how to make it easier for families to enroll their children in CHIP and Medicaid and keep them enrolled in those programs.

Risks

There is no known risk to you or your children participating in the focus group. Although we have made every effort to reduce any risk to you by participating in this focus group, and to make sure everything is private, you may decide not to answer any questions that make you feel uncomfortable in any way. Examples of sensitive questions include: “Have any of you used your [Medicaid/CHIP] card to get your child developmental care? (By developmental provider I mean a developmental specialist, a speech therapist, occupational therapist, physical therapist, or special education provider.)” We will also ask “Have any of you ever used your Medicaid/CHIP card to get specialist care for your child?”

Compensation

For your participation, you will receive a $50 gift card; light food and refreshments will also be served. The respondent payment for focus group participation will not count against your income or eligibility for public assistance.

Privacy

To protect your privacy, all of the information that you provide us will be kept private to the extent permitted by law as we develop our notes and evaluation reports. You will not be personally identified in any report or publication of this study. Recordings from each focus group will be stored in a project password protected folder that can only be accessed by the study's research team. The focus group notes/summaries will be locked in a file folder in a locked project office. Records can be opened by court order or produced in response to a subpoena or a request for production of documents. We will keep any records that we produce private to the extent we are required to do so by law. The records will be destroyed after the completion of the project by deleting them from the password protected project folder on the evaluation team’s research network. Mathematica Policy Research, the Urban Institute, and Health Management Associates can guarantee only the confidentiality of the notes and recorded information from the focus group. All documents created from the focus group will be shredded after the end of the project. If you agree to participate in this study, you must also agree to not share other focus group participants’ names or remarks with others outside of this group.

Participation is Voluntary

Your participation in this group, if you agree to take part, is voluntary. You have the right to withdraw your consent or stop your participation at any time without penalty. You also have the right to refuse to answer any questions during the focus group.

Questions

If you have any questions about this focus group, including any questions that concern your rights as a participant on the project, you can contact Sheila Hoag at (609) 275-2252, or Ian Hill at (202) 261-5374. Mathematica uses Public/Private Ventures (P/PV) in Philadelphia, PA, as their Institutional Review Board. You also may call Melissia Billarrial of P/PV at (800) 755-4778 (x4482) if you have questions about your rights as a participant in this study. This Review Board oversees the protection of human research participants.

[ALL PARTICIPANTS WILL RECEIVE A COPY OF THIS CONSENT FORM FOR THEIR RECORDS.]

Agreement Statement

Do you agree to participate in the HHS Evaluation of the CHIPRA ELE Program?

Yes ____ No ____

Do you agree to have this focus group recorded?

Yes ____ No ____

Date of Consent: ___________________

Name of Focus Group Moderator (print): __________________________________________

Signature of Focus Group Participant: ____________________________________________

Participant Name (print): _____________________________________________