Moderator"s Guide

Attachment E2 (REVISED)

NON-ELE FOCUS GROUP MODERATOR GUIDE

AND RECRUITING SCRIPT FOR FOCUS GROUP PARTICIPANTS

Introduction and Overview of Purpose

Hello and welcome to our focus group. I’d like to begin by thanking each of you for taking time out of your day to be here. We appreciate it.

My name is ________, and my partner here is ________. We have been hired to conduct this focus group to talk with you about your experiences obtaining health insurance coverage and care for your children through the [Medicaid/CHIP] program.

Each of you has been invited here because one or more of your children is currently enrolled in [Medicaid/CHIP]. In particular, you’ve been invited because your child was enrolled through a policy called [insert non-ELE policy of interest] which is a system that [insert description of how policy works; for example presumptive eligibility would be described as enrolled your child in Medicaid/CHIP when they went to the doctor, clinic, or emergency room for care]. Over the next hour or so, we want to talk with you about your experiences having your children enrolled in [Medicaid/CHIP] through this system. We are having additional focus groups like this one in [other town]. We are interested in learning about your various experiences with [Medicaid/CHIP], ranging from how you heard about it, how your children were enrolled in the program, and how well you can access health care services with [Medicaid/CHIP] coverage. This will allow us to better understand how well (or not) this program works for enrollees. Also, it will allow us to help policymakers and providers improve their programs for health care consumers like you. So let’s get started.

Privacy

To protect your privacy, all of the information that you provide us are guaranteed to be kept confidential 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. [COMPANY NAME] can guarantee only the confidentiality and privacy 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.

Benefits

Participating in this focus group discussion may not benefit you personally. You will be asked about your experiences with the [state program name]. While you will not benefit directly from this study, your comments will help inform policymakers and providers about how well the [state program name] is serving children.

Risks

There is no known risk to you for 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 confidential, you may decide not to answer any questions that make you feel uncomfortable in any way.

Compensation

For your participation, you will receive $50 gift card; light food and refreshments will also be served.

Ground Rules

Before we go any further, let me go over a few “ground rules” for today’s discussion.

1. Have any of you ever been in a “focus group” before? Just so you know, a “focus group” is an informal small group discussion, moderated by a facilitator (me) who will guide the discussion through a series of questions, focused on a particular issue (in this case—health insurance coverage). I’d like us to just imagine that we’re sitting around a kitchen table, relaxed and casually chatting with some new friends. Sound good?

2. First, there are no “right” or “wrong” answers here today. Please feel free to share your views, even if they are different from what others have said. Please also know that we don’t work for Medicaid, CHIP, or the government, so our conversation today won’t affect your family’s coverage in any way. Please tell us your thoughts and opinions, whether they are positive or negative.

3. Second, your participation here is entirely voluntary. You are free to leave at any time. Also, your privacy will be completely protected. When we summarize the findings of the group, all responses will be “anonymous,” meaning nobody’s name will appear, and nothing you say will be attributed to you, so please be as open as possible in sharing your thoughts with us.

4. I would really like to encourage everyone to participate. Each of you does not have to answer each and every question, though, nor do you need to raise your hand to speak. If, however, some of you are shy or don’t get a chance to speak, I may call on you to give you a turn, because I’d like to know what everyone here thinks.

5. It is important that only one person speak at a time. We want to be respectful of everyone and give everyone their chance to speak. Also, you may have noticed that we are recording today’s discussion, so taking turns is important here too—if two people talk at once, we won’t be able to understand the tape.

6. Now, about the recording. We’re recording the session because we don’t want to miss anything. Even though we’ll be taking notes as fast as we can, I’m certain we won’t be able to write everything down! So, the taping is simply a back-up, a tool to ensure that we get all of your comments. Don’t worry, no one will be listening to these tapes besides the research team; your confidentiality will be protected.

7. I have a lot that I want to talk about with you today. So I may be forced, from time to time, to interrupt the discussion and move us along to another topic. But, don’t let me cut you off! If there’s something important you want to say, let me know before we change the subject.

8. Just a word about cell phones and restrooms. Please either turn off your cell phone or put it in “vibrate/silent” mode. If you need to use the restroom, please do so at any time; you do not need to ask permission. The restrooms are located _________.

9. We will be on a first name basis today, and we’ve placed name cards on the table in front of you to help us remember each other’s names.

10. Any questions? Okay, let’s begin.

1. Background Questions

11. Let’s start by going around the table and introducing ourselves. I’d like each of you to tell us your first name. Then, to break the ice, why don’t you share with all of us a little bit about your children. Why don’t you tell me how many children you have, and share with us one of the things you love about them.

12. What are some of the biggest concerns you have right now related to your kids? What do you worry about the most as a parent?

13. Does anyone else in your family have health insurance? And if so, what kind? (By “insurance,” I mean either private insurance that you get from your employer like Blue Cross, or a public health coverage program like Medicaid.)

• You?

• Your spouse?

• Your children?

14. For those of you who don’t have insurance, what are some of the reasons why you (and/or your family members) don’t have it?

2. Outreach

Okay, let’s turn our discussion to [Medicaid/CHIP]. I’d like you to think back to a time perhaps before you even had your children enrolled in the program.

15. Can you remember how you first heard about [Medicaid/CHIP]?

• At your children’s school?

• From friends?

• At a clinic or from a doctor?

• At another place in the community?

• At another program, like Food Stamps/SNAP?

• From advertisements on TV, radio, or a brochure/flyer?

16. Can you remember what, if anything, you heard about the program before you signed your child up?

• Did you hear that it was hard, or easy, to sign up for?

• Did you hear that it had good benefits (or not)?

• Did you hear that it had good doctors (or not), and whether it was easy (or difficult) to get care in the program?

2. Eligibility Determination, Enrollment, and Renewal

Let’s now talk about the systems that [Medicaid/CHIP] uses to establish children’s eligibility for the program, and the processes that families like you have to go through to sign their kids up. Once again, each of you is here because you have one or more children enrolled in [Medicaid/CHIP].

17. Once again, you’re each here because you have a child that’s been enrolled or had their enrollment renewed through this system called [insert non-ELE policy of interest]. We’ll talk specifically about that in a minute. But first, I’d like to take you back in time, if that’s possible.

How many of you had your children enrolled in [Medicaid/CHIP] in a prior time—perhaps one or two, or even more years ago?

For those of you who raised your hand: can you tell me why you enrolled your children in [Medicaid/CHIP] back then?

• Did he or she become sick?

• Did someone recommend that you enroll in [Medicaid/CHIP]?

• Did you need a specialist’s care?

• Did your children need dental care?

18. Back at that time, can you remember what the application process was like?

• Did you fill out an application and mail it in?

• Did you visit a county eligibility office?

• Did you apply at a doctor’s office or a hospital?

• Did you apply at a community based organization?

• Did you apply online?

• Did anyone help you through the process by helping you complete the form?

19. In general, how would you describe that process?

• Was it easy and/or convenient?

• Was it difficult? Why? How so?

• Was the application form short and user-friendly? Or was it long and difficult?

• Did you have to gather and submit documentation of income or assets?

20. Back then, do you remember whether your child ever lost their coveage under [Medicaid/CHIP]? In other words, such programs require families to renew their coverage every now and then (like once each year).

• Do you recall going through that process?

• Did your child end up losing their coverage at that point? If so, do you know why?

• Do you recall why that might have happened? For example,

• Did you intentionally decide to not renew the coverage?

• Or, was the process a hassle?

• Or, had you had bad experiences with doctors or clinics, and decided it wasn’t worth renewing?

• Or, did you think your child wasn’t eligible?

• Or, was there some other reason?

21. My final “back in time” question relates to [other social services program, e.g. SNAP, WIC, other]. How many of you are currently receiving [Other] for your family? Can you tell me what that application process was like?

• Was it easy and/or convenient?

• Was it difficult? Why? How so?

• Was the application form short and user-friendly? Or was it long and difficult?

• Do you have to gather and submit documentation of income or assets?

• Did anyone help you through the process?

22. How would you compare the two application processes—[Medicaid/CHIP and Other]?

• Which one was easier (or more difficult)?

• Why was it easier (or harder)?

OK, that’s enough looking back in time. Let’s now turn to the present. As I said earlier, you’re all here because your child was enrolled in or renewed enrollment in this program through this system called [insert name of non-ELE policy of interest]. Let’s spend the next chunk of time talking about that experience.

23. Can you describe the process of applying for Medicaid/CHIP this time, the most recent time your child enrolled in the program?

• How did you go about applying?

• Did you have to do anything?

• Did you receive a letter from the state saying that your child might be eligible for Medicaid or CHIP coverage?

• Can you remember what the letter said?

• Do you remember if it asked you to do anything in response, such as call the Department to give them permission to enroll or renew your child’s enrollment, or to provide additional information?

• What did you think about that letter?

• If applicable to non-ELE policy of interest: Did it strike you as odd that the state was telling you that your child was eligible for [Medicaid/CHIP], and you hadn’t even filled out an application?

• Was that weird?

• If applicable to non-ELE policy of interest: Did you like the idea that you didn’t need to apply or do anything to renew?

• If applicable to non-ELE policy of interest: Or were any of you hesitant to grant the state permission to use your information for Medicaid/CHIP eligibility?

• Did any of you call the number on the letter to ask for help, or to better understand what was going on? How did that go?

24. Let’s talk about what happened next. Did you receive a second letter that included a card, which told you your child was enrolled in [Medicaid/CHIP]?

• When did that happen; in other words, how much time passed between the first and the second letter?

• Do you remember what the letter said?

• What did you think about that letter?

• If applicable to non-ELE policy of interest: Did it strike you as odd that the state was telling you that your child was eligible for [Medicaid/CHIP], and you hadn’t even filled out an application?

• Was that weird?

• If applicable to non-ELE policy of interest: Did you like the idea that you didn’t need to apply?

• Did it say anything about what kind of services your child was covered for?

• Did it say anything about whether you needed to choose a doctor?

• Did it give you an option to accept or decline the coverage?

25. How did you feel when you learned that your child was enrolled in [Medicaid/CHIP]?

• Did it make you happy and/or relieved?

• If applicable to non-ELE policy of interest: Or did it feel strange, or confusing, to receive something that you had not asked for? (Since you hadn’t actually applied for Medicaid/CHIP?)

26. How long have your children been enrolled in [Medicaid/CHIP]?

27. For those of you with children who have been in [Medicaid/CHIP] for over 12 months, have you ever had to renew your coverage?

28. What was it like to renew your coverage?

• Did you have to do anything ?

• What did you have to do?

• Send in a renewal application? By mail? Online?

• Provide additional information?

• Permit the state to use other data? If so, did you have give permission to the state to use your personal information from another program?

• Show up in person?

• Or was renewal “automatic,” where you really didn’t need to do anything?

  1. What did you think of this, when it is automatic and you don’t have to do anything?

29. For those of you who had children who were enrolled in Medicaid or CHIP before this time, what did you think of [insert name of non-ELE policy of interest], compared to the older system of enrolling/renewing coverage in [Medicaid/CHIP]?

• Did you like the new system better? Why? Why not?

• Was it at all confusing or disorienting? Tell me about that…

30. Do you think that you would have ended up applying for [Medicaid/CHIP] anyway, if there was no system like [insert non-ELE policy of interest]?

• If yes, why? Would you have just applied the next time your child needed care?

• If no, why not? Was the old process too much of a hassle, or too difficult or confusing?

3. Access to Care and Benefits

I’d like to spend just a little time talking with you about going getting health care for your child under [Medicaid/CHIP].

31. First of all, were you ever unsure about whether or not your child actually had [Medicaid/CHIP] coverage? In other words, did this new way of enrolling or renewing coverage confuse you about when or if your child was actually covered?

32. How many of you have used your child’s [Medicaid/CHIP] card in the last year to obtain care for your child?

33. Where did you go to get health care for your children when they were sick or injured?

• A doctor’s office?

• A clinic?

• A hospital?

34. Was it easy to get in to see this provider? Or, did you have any trouble getting your children in to receive care? For example, do you ever have:

• Trouble getting appointments (or long delays in getting appointments)?

• Long travel time/distance to doctor’s office?

• Long waits in the doctor’s office?

• No care available “after hours,” when you’re not working?

35. Generally, are you happy and satisfied with the quality of health care your child receives through [Medicaid/CHIP]?

• Why? Why not?

Let’s now discuss your experiences obtaining other kinds of care while your children have been on [Medicaid/CHIP].

36. Have any of you ever used your [Medicaid/CHIP] card to get dental care for your child?

• How did that go? Was it easy to find and get in to see a dentist?

• Did you feel like you received high quality dental care from this provider?

37. Have any of you used your [Medicaid/CHIP] card to bring your child to the eye doctor?

• How did that go?

38. Have any of you used your [Medicaid/CHIP] card to get medicine for your child?

• How did that go? Did your child get what he/she needed?

Sometimes our regular doctors may refer our children to other doctors for more care, or more specialized care.

39. Have any of you used your [Medicaid/CHIP] card to get specialist care for your child?

• How did that go?

• What kind of specialist did you visit?

• Was it easy to find and get an appointment with this specialist?

• Did you feel like you received high quality care from this provider? Why? Why not?

Sometimes our children need help with their development, or behavior problems. For example, a child that is not talking enough, or a child or is having a hard time learning or getting along with other children.

40. 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.)

• How did that go?

• Was it easy to find and get an appointment with this provider?

• Did you feel like you received high quality care from this provider? Why? Why not?

41. Overall, what do you think of the benefits covered by [Medicaid/CHIP]?

• Do they meet the needs of your children?

• Have your children ever needed a service that was not covered by the program? If so, what service was not covered?

3. Overall impacts on daily life

Okay, we’re almost done.

42. We’ve spent the last hour or so talking about your children’s health coverage under the [Medicaid/CHIP]. In closing, I’d like to ask you: How do you feel, knowing your child has health insurance? Does having health insurance make a difference in your life, your family’s life, and your children’s lives? How so?

• If yes, listen for:

  1. Peace of mind/sense of security?

  2. Easier access to care? (e.g., more providers available? Easier to see a provider?)

  3. Better quality of care?

  4. Lower cost?

  5. What else?

• If no, listen for:

  1. I can get care for my kids without insurance

  2. It costs too much

  3. Afraid of public charge

  4. What else?

3. Lessons Learned

43. Finally, tonight we’ve discussed two different systems for getting our children into [Medicaid/CHIP]. In the old system, you filled out an application and submitted it to the state. In the new system, the state [insert description of how non-ELE policy works]. Once more,

• What do you think of these two approaches? Which one do you like better? Why?

• Do you think that one approach is better for getting health insurance to kids? Why?

44. Is there anything that the state could do to make the process of getting [Medicaid/CHIP] coverage for children work better? What?

45. Have you heard about changes that are coming in 2014 to health coverage, sometimes called health reform or federal health reform?

• If so, do you know that if you do not have health insurance, you might become eligible for this coverage in 2014? Is that something you already have and don’t need, or something you would look forward to having for yourself?

• Would it be easy if you could enroll “automatically” like through the Express Lane Eligibility process your child enrolled through?

46. Is there anything else that you’d like to talk about tonight? Anything that we haven’t discussed that you’d like to?

If that’s all, I’ll just say “THANKS” for all your helpful participation today! You’ve been a great group…

Focus Group Recruitment Procedures

& Recruiting Script

1. Procedures for Focus Group Recruitment

Our recruitment strategy for focus groups relies on State enrollment files to identify enrollees who enrolled through the ELE/Non-ELE pathway of interest. We will obtain agreement from States to provide contact information to the Mathematica and Urban Institute staff. We will request enrollment files from the state and then sample a pool of potential participants from these rolls. Research staff will telephone these families directly and recruit them for the groups using a pre-set script.

Recruiters will emphasize to clients that participation is entirely voluntary, that they will be offered $50 as a “thank you” for their participation, and that light refreshments will be provided during the focus groups. As shown below, we will also assure that the client’s identity and information remain private, and explain that there are no benefits or risks known to participating. We will remind participants that they cannot communicate outside the focus group about the content of the focus group or what any individual said. We believe that this approach to recruitment is both effective and efficient for our focus groups.

2. Focus Group Recruitment Script

Call to Recruit Respondents of Children Enrolled in CHIP or Medicaid

(Contact information provided by State CHIP or Medicaid agency)

Hello. May I please speak to [NAME]?

[NAME] NOT AVAILABLE:

What would be a good time to call back to reach [NAME]?

Thank you. I will call again at [TIME]. Thanks for your time. Goodbye.

[NAME] SPEAKING/COMES TO PHONE:

[Hello]/ My name is ___________. I’m calling [from COMPANY] on behalf of the U.S. Department of Health and Human Services to find out if you would be willing to participate in a small group meeting to talk about your experiences with health care services for your children. [The State CHIP/Medicaid agency gave us a list of people who had recently enrolled in CHIP/Medicaid] and we used the list to randomly select your name. This meeting is being organized by Mathematica Policy Research and the Urban Institute, two firms hired to do a study about CHIP and Medicaid in your state.

If you decide to take part in the informal small group discussion, called a focus group, we will give you a $50 gift card to thank you for your time. Please note that gift cards do not count against your income or eligibility for public assistance. The meeting will take between 1 and a half to two hours, and will be held at [insert location] on [insert date] at [insert time] and last for an hour and a half to two hours. All your comments will be kept private from everyone outside the research team. Participation is voluntary, and there will be no penalty for deciding to participate or not.

Before you agree to participate, you should consider that it will involve participating in the group for up to two hours, as well as involve travel time to and from the focus group site. We would like you to carefully consider the commitment before you agree to participate. There is no known risk to you for participating in the focus group. Although we have made every effort to reduce any risk to you by participating in this focus group, and we can assure you that everything discussed in the group is confidential and private, if you attend, you may decide not to answer any questions that makes you feel uncomfortable in any way.

Participating in this focus group discussion may not benefit you personally. You will be asked about your experiences with the [state ELE/non-ELE program name]. While you will not benefit directly from this study, your comments will help inform policymakers and providers about how well the [state ELE/non-ELE program name] is serving children. There may be questions that you think are sensitive, such as whether your child has needed help with their development or behavior problems. You are not required to answer these questions if you do not wish to answer them.

To protect your privacy and the privacy of all participants, all of the information that you provide us at the focus group are guaranteed to be kept confidential and private 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. 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, so that their privacy is also protected.

Would you be interested in participating?

Possible responses:

Yes—recruiter, confirm date/time/location information, set reminder time to call back.

No—recruiter, thank them for their time.

Maybe—recruiter, “Can I tell you a little bit more about the discussion to help you decide?” then answer any questions.

IF ASKED, PLEASE RESPOND TO QUESTIONS (note to recruiters, this information is also stated above before the person is asked to participate, but participants may want something re-stated or get more details):

What kind of meeting is it?

It is called a focus group. A focus group is an informal small group discussion, moderated by someone who will guide the discussion through a series of questions that will focus on a particular issue (in this case we will focus on health insurance coverage).

Who is organizing the Focus Group?

Mathematica Policy Research and The Urban Institute are organizing this meeting as part of a study they are conducting for the Department of Health and Human Services about CHIP and MEDICAID services.

Where is this meeting?

The group will meet at [LOCATION].

When are you meeting?

We will meet on [DATE] at [TIME].

How long will this take?

The discussion should last about 1.5-2:00 hours. We know your time is precious and we will give you $50 to thank you for your time. We will also serve light refreshments.

Are there any risks or benefits for participants?

There is no known risk to you for 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 confidential and private, you may decide not to answer any questions that make you feel uncomfortable in any way. Before you agree to participate, you should consider that it will involve participating in the group for up to two hours, as well as involve travel time to and from the focus group site. We would like you to carefully consider the commitment before you agree to participate.

Participating in this focus group discussion may not benefit you personally. You will be asked about your experiences with the [state ELE/non-ELE program name]. While you will not benefit directly from this study, your comments will help inform policymakers and providers about how well the [state ELE/non-ELE program name] is serving children.

Will my information be kept private? Is my information shared with anyone, or can I share information I learn at the group?

To protect your privacy and the privacy of all participants, all of the information that you provide us are guaranteed to be kept confidential and private 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. [COMPANY NAME] can guarantee only the confidentiality and privacy 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.

REMINDER CALL SCRIPT [1-2 days before focus group date]

Hello. May I please speak to [NAME]?

[NAME] NOT AVAILABLE:

What would be a good time to call back to reach [NAME]?

Thank you. I will call again at [TIME]. Thanks for your time. Goodbye.

[NAME] SPEAKING/COMES TO PHONE:

[Hello]/ My name is ___________. I’m calling [from COMPANY] on behalf of the U.S. Department of Health and Human Services to remind you about the upcoming focus group on [INSERT DATE, TIME] at [INSERT LOCATION NAME.]

As a reminder, we will give $50 to thank you for your time. The meeting will take between 1 and a half to two hours, and all of your comments will be kept private from everyone outside the research team.

IF ASKED PLEASE RESPOND TO QUESTIONS AS INDICATED ABOVE.