REVISED ATTACHMENT K 3_Comments

ATTACHMENT K.3

CONSENT form for 51-state survey participants

51-state survey: PARTICIPANT INFORMED CONSENT

Study Title: Children’s Health Insurance Program Reauthorization Act Evaluation of Express Lane Eligibility

Principal Investigators: Jennifer Edwards, Dr.PH

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 Children’s Health Insurance Program’s (CHIP) and Medicaid Express Lane Eligibility (ELE) process. This study is funded by the U.S. Department of Health and Human Services (HHS). HHS has contracted with the Health Management Association and their partners Mathematica Policy Research and the Urban Institute to conduct this evaluation for them. Results from this evaluation are intended to inform policymakers how ELE, as well alternate approaches to simplifying enrollment and/or retention in CHIP and Medicaid (called non-ELE approaches), is working for children and families. You were identified through a public web search of Medicaid and CHIP directors in all 50 states and the District of Columbia.

Procedure

You are being asked to participate in a survey of Medicaid and CHIP administrators in all 50 states and the District of Columbia, which will do the following:

• Identify and catalog outreach strategies used by states and supplement existing knowledge of states’ enrollment and renewal practices, beyond information captured in existing surveys,

• Gather findings from states’ own analyses of the effectiveness and efficiency of these approaches,

• Obtain states’ perspectives on the value of ELE and non-ELE approaches, including determining the ongoing barriers to enrollment in ELE states,

• Determine states’ views of the implications of their enrollment and retention strategies on the upcoming Medicaid expansion populations, and

• Identify ways that ELE effectiveness could be improved

We will conduct the survey electronically, using a custom-designed internet-based survey running on a Dataweb platform. The survey will include questions with multiple-choice response options; branched questions (for example, depending upon answers, the respondent will be directed to particular follow-up questions or skip others); and an opportunity for the respondent to provide additional information, including statistics, in a comment box for several questions. The breadth of information might necessitate completing the survey in multiple sessions or by multiple respondents within the state agency; therefore, we will structure the survey instrument so it can be saved and re-opened by the same or a different individual. The survey will take approximately forty-five minutes to an hour to complete. Anyone can choose to complete a paper version of the survey, which will be emailed to each respondent.

Benefits

Participating in this survey may not benefit you personally. While you will not benefit directly from this study, your comments will help inform other policymakers about your state’s policies that may make it easier (or harder) 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 for participating.

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. Your state will be identified, but you will not be personally identified in any report or publication of this study without your prior permission. Similarly, none of your remarks will be quoted in our reports without your permission. 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. Records can be opened only by court order or produced in response to a subpoena or a request for production of documents.

Participation is Voluntary

Your participation in this interview is entirely 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 survey questions. Your participation will remain completely anonymous. The researchers involved in the study will protect the confidentiality of your responses.

Questions

If you have any questions about this survey. including any questions that concern your rights as a participant on the project, you can contact Sheila Hoag at (609) 275-2252. 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. You will receive a copy of this consent form for your records.

Agreement Statement

Do you agree to participate in the HHS Evaluation of Express Lane Eligibility?

Yes ____ No ____

Do you agree to having your name listed as a key informant who was interviewed for this study in the appendix of the report we will develop?

Yes ____ No ____

Date of Consent: ___________________

Signature of Participant: _____________________________________________ (Note, E-signature will be accepted as this is an internet survey).

If you complete a paper copy of the form, we must receive a copy of this consent form back. Please return a signed, scanned copy via email to Jennifer Edwards at [email protected] or by fax at (866) 328-6201.

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