CMS-10398 (#7) • Cycle IV AI/AN Round II Outreach & Enrollment Grant Fi

OMB Control Number 0938-1148

American Indian and Alaska Native Round II

Connecting Kids to Coverage Grant
Semi-Annual Report Template for Grantees

Reporting Period: Semi-Annual Report 1 – November 12, 2014 to June 30, 2015

Report Due Date: July 30, 2015

Grant Award Number:      

State:      

Name of Grantee:      

Focus Area Listed in Grant Application:
     

Name and Title of Person Completing Report:
     

Authentication

I certify the accuracy of all report content:

     

Authorized Certifying Official (typed name in lieu of signature)

CMS Project Officer Approval

I have approved the content of this report:

     

CMS Project Officer (type name in lieu of signature; 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 CHIP and Medicaid 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 toward 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 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 2-year CHIPRA American Indian/Alaska Native (AI/AN) Round II Outreach and Enrollment Grants. The reporting period for this semi-annual report is November 12, 2014 to June 30, 2015. This semi-annual report must be submitted to CMS through grantsolutions.gov, as described in the Special Terms and Conditions of your grant award.

This template is formatted for Microsoft Word software (.docx format), and the template must be returned as a Word document. Do not send a PDF file.

• 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 are equal to approximately one page of single-spaced, Times New Roman 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 in the semi-annual report template.

Send the completed report to your CMS Project Officer by July 30, 2015.

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 November 12, 2014 to June 30, 2015.

1. What activities did you undertake during this reporting period?

Describe the progress you have made toward the milestones for this reporting period. Please take these milestones directly from the work plan in your grant application. Please note that the chart is expandable so that you can add additional milestones, if needed.

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

Indicate any changes from the proposed schedule or timeline described in your grant application, showing the original schedule or timeline date and the revised date; 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 and grant sustainability activities

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

     

2. Describe all activities you have undertaken during the reporting period to promote sustainability of grant efforts beyond the grant end date of November 11, 2016. (300 words)

     

3. Data for identifying children eligible for CHIP/Medicaid

If you are obtaining data to identify potentially eligible uninsured children, please indicate which data source(s) below you are using, and for each data source, indicate (a) from where you are obtaining these data, (b) how often you receive the data, (c) what challenges you may have faced obtaining and using the data (e.g., did the data include outdated information), (d) actions you took to address the challenges, and (e) the effectiveness of those actions.

Resource and Patient Management System (RPMS)

1. From where are you obtaining these data?

     

2. How often do you receive the data?

     

3. What challenges have you faced obtaining and using the data?

     

4. What actions did you take to address the challenge?

     

5. How effective were those actions?

     

State CHIP/Medicaid Agency enrollment data

1. From where are you obtaining these data?

     

2. How often do you receive the data?

     

3. What challenges have you faced obtaining and using the data?

     

4. What actions did you take to address the challenge?

     

5. How effective were those actions?

     

Census data

1. From where are you obtaining these data?

     

2. How often do you receive the data?

     

3. What challenges have you faced obtaining and using the data?

     

4. What actions did you take to address the challenge?

     

5. How effective were those actions?

     

Other tribal data

1. From where are you obtaining these data?

     

2. How often do you receive the data?

     

3. What challenges have you faced obtaining and using the data?

     

4. What actions did you take to address the challenge?

     

5. How effective were those actions?

     

Other data source(s) (please list:      )

1. From where are you obtaining these data?

     

2. How often do you receive the data?

     

3. What challenges have you faced obtaining and using the data?

     

4. What actions did you take to address the challenge?

     

5. How effective were those actions?

     

DATA ON CHILDREN WHO APPLIED

4. 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 all children for whom an application was submitted. Children are defined as individuals 0 through 19 years of age. Individuals over the age of 19 years who received application assistance as a result of your grant activities can be reported in “Other Outcomes.” Parents under 19 years of age and their children who received application assistance as a result of your grant activities should be reported in this section.

The chart below requests data for both AI/AN and non-AI/AN children whom you assisted with applications. If you cannot separate out the number of children who applied by AI/AN status, please report the total number of children who applied in the Total column, and leave the columns for AI/AN Children and Non-AI/AN Children blank.

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.

Number of Children for Whom Applications Were Submitted in the Reporting Period	Number
	AI/AN Children	Non-AI/AN Children	Total
Number of children for whom a new CHIP/Medicaid application was submitted	     	     	     
Number of children for whom a renewal CHIP/Medicaid application was submitted	     	     	     
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 were pending at the end of the current reporting period. (Include children for whom no determination has been made by the state. If you determine the number of children with pending applications in any way other than through state confirmation, please put “unknown” for the number pending.)	     	     	     

5. 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 personally assist with their renewal applications? Do not count children as personally assisted if you sent only a robocall, e‑mail, letter, postcard, or text message without any additional one-on-one assistance.

     

DATA ON CHILDREN WHO ENROLLED

6. 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 all children newly enrolled and renewed during the reporting period. Children are defined as individuals 0 through 19 years of age. Individuals over the age of 19 years who enrolled as a result of your grant activities can be reported in “Other Outcomes.” Parents under 19 years of age and their children who enrolled as a result of your grant activities should be reported in this section.

The chart below requests enrollment data for both AI/AN and non-AI/AN children. If you cannot separate out the number of children who enrolled or renewed by AI/AN status, please report the total number of children who enrolled in each of the Total columns, and leave the columns for AI/AN children and non-AI/AN children blank.

If you cannot distinguish between new 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 new enrollments and renewals in the Total row.

If your enrollment numbers include children whose applications were pending in an earlier reporting period and who became enrolled in this reporting period, please indicate here with an X: and report the number of children:      .

Program	Column A Number of Children Newly Enrolled			Column B Number of Children Renewed			Column C (Columns A + B)
	AI/AN	Non-AI/AN	Total	AI/AN	Non-AI/AN	Total	AI/AN	Non-AI/AN	Total
CHIP	     	     	     	     	     	     	     	     	     
Medicaid	     	     	     	     	     	     	     	     	     
Total	     	     	     	     	     	     	     	     	     

7. Explanation of enrollment data

1. 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). (300 words)

     

2. Please provide additional information, if needed, to explain your results. For example, if the number of new 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)

     

3. If your grant focused on engaging schools in outreach, enrollment, and retention activities, please report how many children were enrolled via the schools. Please break out the number enrolled by those newly enrolled and those renewed. If the enrollment numbers are higher or lower than expected, explain why you think this happened. (200 words)

     

4. If your grant focused on ensuring teens are enrolled and retained in CHIP/Medicaid, please report how many teens were enrolled. Please break out the number enrolled by those newly enrolled and those renewed. If the enrollment numbers are higher or lower than expected, explain why you think this happened. Teens are defined as children 13 through 19 years of age. (200 words)

     

8. Other outcomes

In addition to enrolling and retaining children in CHIP/Medicaid, your grant activities over the reporting period 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 the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

     

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

     

4. Enrollment of children and/or adults in qualified health plans offered through the state/federal insurance exchanges through the Affordable Care Act (ACA).

     

5. Establishment of new physical sites where families can apply for CHIP/Medicaid as a result of support through your grant. (List the number and types of sites and how often you are providing assistance at each new site.)

     

6. Any other positive unplanned or unanticipated grant outcomes?

     

STRATEGIES TO HELP ENROLL AND RENEW CHILDREN

9. Most effective strategies in the reporting period

Your most effective strategies are those that resulted in a greater number of enrollments and renewals from grant activities in your focus area. Although we realize that educating families with uninsured children potentially eligible for CHIP or Medicaid and raising community awareness about CHIP and Medicaid are important strategies for Grantees, please report only those strategies that resulted in enrollments or renewals that you could verify.

Not every strategy employed has to be considered as most effective; report only on those strategies deemed most effective relative to the other strategies you used.

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

Strategy One

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

     

2. How did you determine that this strategy was effective in enrolling and/or renewing children in CHIP/Medicaid (e.g., through a data-tracking mechanism that allowed you to track enrollments to the strategy)? If available, please report the percentage of new enrollments or renewals attributable to this strategy.

     

3. Was this strategy effective for the specific group(s) of children you were targeting through your focus area? For example, was it more effective with school-aged children or teens? Please explain.

     

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 in enrolling and/or renewing children in CHIP/Medicaid? If yes, please describe.

     

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

     

Strategy Two

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

     

2. How did you determine that this strategy was effective in enrolling and/or renewing children in CHIP/Medicaid (e.g., through a data-tracking mechanism that allowed you to track enrollments to the strategy)? If available, please report the percentage of new enrollments or renewals attributable to this strategy.

     

3. Was this strategy effective for the specific group(s) of children you were targeting through your focus area? For example, was it more effective with school-aged children or teens? Please explain.

     

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 in enrolling and/or renewing children in CHIP/Medicaid? If yes, please describe.

     

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

     

Strategy Three

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

     

2. How did you determine that this strategy was effective in enrolling and/or renewing children in CHIP/Medicaid (e.g., through a data-tracking mechanism that allowed you to track enrollments to the strategy)? If available, please report the percentage of new enrollments or renewals attributable to this strategy.

     

3. Was this strategy effective for the specific group(s) of children you were targeting through your focus area? For example, was it more effective with school-aged children or teens? Please explain.

     

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 in enrolling and/or renewing children in CHIP/Medicaid? If yes, please describe.

     

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

     

10. Least effective strategies in the reporting period

Your least effective strategies are those that resulted in a lower number of enrollments and
renewals of potentially eligible children in CHIP/Medicaid from your grant activities. Not every strategy employed has to be considered as least effective; report only on those strategies deemed least effective relative to the other strategies you used. Please report only those strategies that resulted in enrollments or renewals that you could verify.

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

Strategy One

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

     

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

     

3. Was this strategy least effective for the specific group(s) of children you were targeting through your focus area? For example, was it less effective with school-aged children or teens? Please explain.

     

4. 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?

     

5. What lessons did you learn from this strategy?

     

Strategy Two

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

     

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

     

3. Was this strategy least effective for the specific group(s) of children you were targeting through your focus area? For example, was it less effective with school-aged children or teens? Please explain.

     

4. 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?

     

5. What lessons did you learn from this strategy?

     

Strategy Three

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

     

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

     

3. Was this strategy least effective for the specific group(s) of children you were targeting through your focus area? For example, was it less effective with school-aged children or teens? Please explain.

     

4. 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?

     

5. What lessons did you learn from this strategy?

     

11. Based on your experience in implementing grant activities, have you (1) discontinued a strategy, (2) implemented minor changes to improve the effectiveness of a current strategy, and/or (3) sought CMS Project Officer approval to implement a new strategy in this reporting period? If so, please explain. (200 words)

     

STRATEGIES
TO EDUCATE FAMILIES AND INCREASE AWARENESS

12. Describe the strategy you considered most effective in increasing awareness of CHIP/
    Medicaid in your target population, and describe the components of the strategy you feel are critical to its effectiveness. (200 words)

     

CHALLENGES

13. 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 question 13b. (200 words)

     

2. Enrollment and renewal challenges in your focus area

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).

     

Please describe no more than four enrollment and renewal challenges that you may have encountered. Consider challenges as they relate to the populations you targeted and your grant’s focus area. 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. (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.

     

Lessons Learned

14. Outreach and enrollment lessons learned

What are the most important lessons you have learned about how to increase new enrollments and/or renewals in CHIP/Medicaid? Do not include lessons learned about administering a grant program; please focus only on overarching lessons learned about outreach and enrollment. Do not repeat the lessons learned reported in the strategy section above. (400 words)

Lessons learned:      

Lessons learned specific to your focus area:      

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