CMS-10398 (#7) Cycle Vb. Connecting Kids to Coverage Final Report Templ

OMB Control Number XXXX-XXXX

Connecting Kids to Coverage

Outreach and Enrollment

Final Report Template

Full Title of Grant Award: Click here to enter text.

Funding Opportunity: Click here to enter text.

Report Due Date: Click here to enter text.

Cooperative Agreement Number: Click here to enter text.

State: Click here to enter text.

Name of Awardee: Click here to enter text.

Name and Title of Person Completing Report: Click here to enter text.

Authentication

I certify the accuracy of all report content:

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Authorized Certifying Official (typed name in lieu of signature; add date)

CMS Project Officer Approval

I have approved the content of this report:

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CMS Project Officer (type name in lieu of signature; add date)

Reporting Requirements

To meet congressional requirements, as expressed in the terms and conditions of your cooperative agreement, you are required to report on strategies and outcomes—specifically, the number of enrollments and renewals in CHIP and Medicaid that resulted from your project. The Centers for Medicare & Medicaid Services (CMS) will use awardees’ reports to prepare a report to the U.S. Congress.

This Report to Congress will describe awardees’ 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 coverage in Medicaid and CHIP among uninsured eligible children and their parents.

Completing the Final Report

Use this final report template to describe and summarize the outcomes of your Connecting Kids to Coveraeg Outreach and Enrollment project.

This final report covers the duration of your cooperative agreement; it also specifically asks for the number of enrollments, renewals, and applications that resulted from your project for the last reporting period, [insert date] to [insert date].

This final report must be submitted to CMS through Grantsolutions.gov, as described in the special terms and conditions of your cooperative agreement.

This template is formatted for Microsoft Word software (.docx format), and the template must be returned as a Word document. Please 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. Please also provide an explanation of any data limitations that may help better understand the quantitative data reported in each table.

• Narrative should be entered in the template under each question, in single-spaced, 12-point, Times New Roman font. Length guidelines are indicated for each question; 600 words are equal to approximately one page of single-spaced, Times New Roman 12-point type. Please aim for both clarity and brevity when writing your narrative responses.

• You may attach up to two pages of additional narrative, tables, graphs, or other documents that contain project information that is not covered by the questions in the template.

Upload the completed report into Grantsolutions.gov for review by your CMS Project Officer by [insert due date according to reporting period].

1. How many children applied for CHIP/Medicaid as a direct result of your project activities?

In the table below, enter the number of children for whom an application was submitted.

The table below requests data for both target children and other children for whom applications have been submitted as part of your cooperative agreement-funded project. If your project was targeting all children in your geographic area, or a specific group of children (such as AI/AN children or Latino teenagers) but you cannot distinguish between target/non-target status, please report the total number of children who applied in the Total column, and leave the other columns blank.

Report separately the number of children who newly applied and those who applied to renew. If you do not have separate data for these groups of children, then just enter the combined number in the Total row.

Table 1. Children assisted in applying

Children for whom applications have been submitted as a result of your project activities	Targeted children	Other children	Total
Number of children for whom a new CHIP/Medicaid application has been submitted this reporting period
Number of children for whom a renewal CHIP/Medicaid application has been submitted this reporting period
Total
Cumulative number of children for whom a new CHIP/Medicaid application has been submitted from the start of this project through the final reporting period
Cumulative number of children for whom a renewal CHIP/Medicaid application has been submitted from the start of this project through the final reporting period
Cumulative Total

Explain any limitations that may help us understand the data in Table 1.

Click here to enter text.

2. How many children were enrolled or renewed in CHIP/Medicaid as a direct result of your project activities?

Please enter the number of all children newly enrolled and renewed.

The tables below request data for both target children and other children. If your project was targeting all children in your geographic area, or if you were targeting a specific group of children (such as AI/AN children or Latino teenagers) but you cannot distinguish by target/non-target status, please report the total number of children who enrolled or renewed in the Total column, and leave the other columns blank.

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

If you can distinguish between children newly enrolled and children renewed, enter data in tables 2.A. and 2.B. If you cannot distinguish between children newly enrolled and children renewed, enter data in table 2.C.

Table 2.A. Newly enrolled children

Program	Number of children newly enrolled as a direct result of this project, in this reporting period			Cumulative number of children newly enrolled as a direct result of this project, from the start of the project through the final reporting period
	Targeted children	Other children	Total	Targeted children	Other children	Total
CHIP
Medicaid
Total

Program	Number of children renewed as a direct result of this project, in this reporting period			Cumulative number of children renewed as a direct result of this project, from the start of the project through the final reporting period
	Targeted children	Other children	Total	Targeted children	Other children	Total
CHIP
Medicaid
Total

Table 2.B. Renewed children

Program	Number of children enrolled and renewed as a direct result of this project, in this reporting period			Cumulative number of children enrolled and renewed as a direct result of this project, from the start of the project through the final reporting period
	Targeted children	Other children	Total	Targeted children	Other children	Total
CHIP
Medicaid
Total

Table 2.C. Newly enrolled and renewed children

Explain any limitations that may help us understand the data in Tables 2.A, 2.B and 2.C.

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3. How many parents have applied for CHIP, Medicaid, or another insurance affordability program as a direct result of your project activities?

If you proposed to assist parents with applications in your project proposal, or if assisting parents has since become a part of your strategy, please enter the number of parents for whom an application was submitted.

The table below requests data for both parents of children your project was targeting and other parents. If your project was targeting all children in your geographic area, or was targeting a specific group of children (such as AI/AN children or Latino teenagers) but you cannot distinguish target/non-target status, please report the total number of parents who applied in the Total column, and leave the other columns blank.

Report separately the number of parents who newly applied and those who renewed. If you cannot distinguish between these groups of parents, then enter the combined number in the Total rows.

Table 3. Parents assisted with applications

	Parents of targeted children	Other parents	Total
Number of parents for whom a new application has been submitted this reporting period
Number of parents for whom a renewal application has been submitted this reporting period
Total
Cumulative number of parents for whom a new application has been submitted from the start of this project through the final reporting period
Cumulative number of parents for whom a renewal application has been submitted from the start of this project through the final reporting period
Cumulative Total

Explain any limitations that may help us understand the data in the Table 3.

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4. How many parents were enrolled or renewed in an insurance affordability program as a direct result of your project activities?

If you proposed to assist parents with enrollments and renewals in your project proposal, or if assisting parents has since become a part of your strategy, please enter the number of parents who were newly enrolled and renewed.

If you are only able to report verified numbers of parents enrolled and renewed in certain insurance affordability programs, such as Medicaid and CHIP, and not those enrolled and renewed in other insurance affordability programs, please note this in the data limitations field.

The tables below request data for both parents of children your project was targeting and other parents. If your project was targeting all children in your geographic area, or was targeting a specific group of children (such as AI/AN children or Latino teenagers) but you cannot distinguish parents who enrolled or renewed by target/non-target status, please report the total number of parents who enrolled or renewed in the Total column, and leave the other columns blank.

If you can distinguish between parents newly enrolled and parents renewed, enter data in tables 4.A. and 4.B. If you cannot distinguish between parents newly enrolled and parents renewed, enter data in table 4.C.

Table 4.A. Parents newly enrolled

Program	Number of parents newly enrolled as a direct result of this project, this reporting period			Cumulative number of parents newly enrolled as a direct result of this project, from the start of the project through the final reporting period
	Parents of targeted children	Other parents	Total	Parents of targeted children	Other parents	Total
Any insurance affordability program

Table 4.B. Parents renewed

Program	Number of parents renewed as a direct result of this project, this reporting period			Cumulative number of parents renewed as a direct result of this project, from the start of the project through the final reporting period
	Parents of targeted children	Other parents	Total	Parents of targeted children	Other parents	Total
Any insurance affordability program

Table 4.C. Parents enrolled and renewed

Program	Number of parents enrolled and renewed as a direct result of this project, this reporting period			Cumulative number of parents enrolled and renewed as a direct result of this project, from the start of the project through the final reporting period
	Parents of targeted children	Other parents	Total	Parents of targeted children	Other parents	Total
Any insurance affordability program

Explain any limitations that may help us understand the data in Tables 4.A, 4.B and 4.C.

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5. Most effective strategies

Question: If you had a limited amount of money and staff and could implement just one or two of the most effective strategies you used to help children newly enroll and stay enrolled through renewal, which would you choose to continue and why? Consider strategies used under your current cooperative agreement and any previous rounds of funding. (300 words)

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6. Most cost-effective strategies

Question: If you compare the amount of cooperative agreement funding you received with the number of children your project newly enrolled or renewed, which strategies do you think were the most cost-effective? Explain why. Consider strategies used under your current cooperative agreement and any previous rounds of funding. (300 words)

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7. Continuation of activities after the cooperative agreement period

Question: Will you continue implementing any project activities once the funding ends? If so, which activities, and how will they be funded? (300 words)

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8. Lessons learned

Question: What are the most important things your organization has learned about identifying, contacting, and engaging eligible families to assist them with the application and renewal process for CHIP and Medicaid? What, if anything, would you have done differently if you had the chance? (300 words)

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9. Primary challenges in increasing the percentage of eligible children enrolled and retained and the most effective approaches to overcome them

Question: Looking ahead over the next year or two, what do you think are the key challenges in increasing the percentage of eligible children enrolled in CHIP and Medicaid in your state?

Please discuss any types of challenges: state policies, cultural belief, language, transportation, administrative issues, funding, or anything else you think important.

For each challenge, what do you believe are the most effective approaches to overcome them? (300 words)

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10. Recommendations for increasing the percentage of eligible children enrolled and renewed

Question: Based on lessons you have learned, what recommendations can you make that would help other organizations that want to implement projects to increase the percentage of eligible children enrolled and renewed in CHIP and Medicaid? Consider planning the project, educating families, becoming known in the community, marketing, and establishing partnerships and collaborations. (200 words)

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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 Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is XXXX-XXXX. The time required to complete this information collection is estimated to average 16 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, MD 21244-1850.