OMB Control Number XXXX-XXXX
Full Title of Grant Award: Click here to enter text.
Funding Opportunity: Click here to enter text.
Reporting Period: 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.
I certify the accuracy of all report content:
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Authorized Awardee Certifying Official (type name in lieu of signature; add date)
I have approved the content of this report:
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CMS Project Officer (type name in lieu of signature; add date)
To meet congressional requirements, as expressed in the terms and conditions of your cooperative agreement, you are required to report on your 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 monitor performance under the cooperative agreements, identify technical assistance needs, and prepare a report to the U.S. Congress.
The 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.
Use this semiannual report template to describe and summarize the outcomes of your Connecting Kids to Coverage Outreach and Enrollment project.
The reporting period for this semiannual report is [Insert Date] to [Insert Date]. All information reported must be the result of project activities during this reporting period.
This semiannual 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].
Please list the milestones from the work plan in your project application. Describe activities funded through this award and conducted during this reporting period that demonstrate progress towards each milestone. For example, you might describe any activities, trainings, or new community partnerships under this award that contribute to the goals of reaching your target population of uninsured, but eligible children (and parents, if relevant). (400 words).
Milestone |
Activities Demonstrating Progress |
Date Milestone Was Achieved (or status update, if milestone not yet achieved) |
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Which of these activities were undertaken in collaboration with the National Connecting Kids to Coverage Campaign, including the Back to School or Post-Open Enrollment initiatives? Please explain what your collaboration with the National Campaign involved. (200 words)
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Indicate any changes from the proposed schedule or timeline described in your project application, showing the original schedule or timeline date and the revised date; briefly explain the reason for the modification. You may add milestones as needed.
Milestone |
Original Date |
Expected Date |
Explanation |
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If your project is obtaining data to identify potentially eligible uninsured children, please indicate your sources and then answer a few questions about each source. (Total of 300 words per source)
☐ Resource and Patient Management System (RPMS)
How is your project obtaining these data?
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How often does your project obtain the data?
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What challenges has your project faced obtaining and using the data?
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What actions did your project take to address the challenge?
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How effective were those actions?
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☐ State CHIP/Medicaid Agency enrollment data
How is your project obtaining these data?
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How often does your project obtain the data?
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What challenges has your project faced obtaining and using the data?
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What actions did your project take to address the challenge?
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How effective were those actions?
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☐ Census data
How is you project obtaining these data?
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How often does your project obtain the data?
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What challenges has your project faced obtaining and using the data?
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What actions did your project take to address the challenge?
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How effective were those actions?
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☐ Tribal data
How is your project obtaining these data?
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How often does your project obtain the data?
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What challenges has your project faced obtaining and using the data?
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What actions did your project take to address the challenge?
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How effective were those actions?
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☐ Other data source(s) (please list: Click here to enter text.)
How is your project obtaining these data?
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How often does your project obtain the data?
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What challenges has your project faced obtaining and using the data?
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What actions did your project take to address the challenge?
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How effective were those actions?
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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 an application was submitted. If you were 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 cannot separate the number of children who applied by target/non-target status, please report the total number of children for whom an application was submitted 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 3. Children assisted in applying
Children
for whom |
Targeted children |
Other children |
Total |
Number of children for whom a new CHIP/Medicaid application has been submitted this reporting period |
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Number of children for whom a renewal CHIP/Medicaid application has been submitted this reporting period |
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Explain any limitations that may help us understand the data in Table 3.
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Please enter the number of all children who were newly enrolled and renewed.
The tables below request data for both target children and other children. If you were 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 cannot separate the number of children who enrolled or renewed by target/non-target status, please just 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 4.A. and 4.B. If you cannot distinguish between children newly enrolled and children renewed, enter data in table 4.C.
Table 4.A. Newly enrolled children
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Number of children newly enrolled as a direct result of this project, in this reporting period |
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Targeted children |
Other children |
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Table 4.B. Renewed children
Table 4.C. Newly enrolled and renewed children
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Explain any limitations that may help us understand the data in Tables 4.A, 4.B, and 4.C.
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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 during the reporting period.
The table below requests data for both parents of children you were targeting and other parents. If you were 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 cannot separate the number of parents who applied by 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 applied to renew. If you do not have separate data for these groups of parents, then enter the combined number in the Total row.
Table 5. Parents assisted with applications
Parents
for whom |
Parents of targeted children |
Other parents |
Total |
Number of parents for whom a new application has been submitted this reporting period |
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Number of parents for whom a renewal application has been submitted this reporting period |
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Explain any limitations that may help us understand the data Table 5.
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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 during the reporting period.
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 table below requests data for both parents of children you were targeting and other parents. If you were 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 cannot separate the number of 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 6.A. and 6.B. If you cannot distinguish between parents newly enrolled and parents renewed, enter data in table 6.C.
Table 6.A. Parents newly enrolled
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Number of parents newly enrolled as a direct result of this project, in this reporting period |
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Parents of targeted children |
Other parents |
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Table 6.B. Parents renewed
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Number of parents renewed as a direct result of this project, in this reporting period |
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Parents of targeted children |
Other parents |
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Table 6.C. Newly enrolled and renewed parents
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Number of parents enrolled and renewed as a direct result of this project, in this reporting period |
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Parents of targeted children |
Other parents |
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Explain any limitations that may help us understand the data in Tables 6.A, 6.B and 6.C.
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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 numbers of children and parents (as applicable) enrolled and renewed (e.g., data obtained from the state or county, calls to the state eligibility determination office). (300 words)
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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)
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If the number of new applications, enrollments, and/or renewals is lower than expected (either overall or within your target population), how do you plan to overcome the challenges you identified? (300 words)
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Your project activities over the reporting period may have resulted in other positive outcomes besides enrolling and retaining children and parents in CHIP and Medicaid, and enrolling and retaining parents in other insurance affordability programs. If so, please describe these results in the relevant section below. (400 words total)
Enrollment of children, their families, or other adults in human services public programs such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).
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New outreach and enrollment policies and procedures that will be sustained after the project ends.
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Enrollment of children in Qualified Health Plans offered through the state/federal Marketplaces.
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Establishment of new physical sites where families can apply for CHIP, Medicaid, or other insurance affordability programs as a result of support through your project. (List the number and types of sites and how often you are providing assistance at each new site.)
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Any other positive unplanned or unanticipated project outcomes.
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Describe the strategy you considered most effective in increasing awareness of CHIP and Medicaid in your target population, and describe the components of the strategy you feel are critical to its effectiveness. (200 words)
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Your most effective strategies are those that, relative to others, resulted in more enrollments and renewals from project activities among your target population in the reporting period.
Answer the following questions for up to two of your most effective strategies. Please write your answers under each question. (600 words total for each strategy)
Describe the strategy and specify whether it focused on new enrollments, renewals, or both.
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How did you determine that this strategy was effective in enrolling and/or renewing children in CHIP and Medicaid (e.g., through a data-tracking mechanism that allowed you to track enrollments to the strategy)? If available, please report the percentage of your numbers of new enrollments and renewals in this reporting period attributable to this strategy.
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Was this strategy effective for the specific group(s) of children you were targeting? For example, was it more effective with school-aged children or with teens? Please explain.
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What lessons did you learn about this strategy? What components of this strategy do you feel are critical to its effectiveness?
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Did you change the strategy during the reporting period to improve its effectiveness in enrolling and/or renewing children in CHIP and Medicaid? If yes, please describe the changes.
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Can this strategy be replicated by organizations similar to yours? Please explain why or why not and note any special circumstances needed for replication.
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Describe the strategy and specify whether it focused on new enrollments, renewals, or both.
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How did you determine that this strategy was effective in enrolling and/or renewing children in CHIP and Medicaid (e.g., through a data-tracking mechanism that allowed you to track enrollments to the strategy)? If available, please report the percentage of your numbers of new enrollments and renewals in this reporting period attributable to this strategy.
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Was this strategy effective for the specific group(s) of children you were targeting? For example, was it more effective with school-aged children or with teens? Please explain.
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What lessons did you learn about this strategy? What components of this strategy do you feel are critical to its effectiveness?
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Did you change the strategy during the reporting period to improve its effectiveness in enrolling and/or renewing children in CHIP and Medicaid? If yes, please describe the changes.
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Can this strategy be replicated by organizations similar to yours? Please explain why or why not and note any special circumstances needed for replication.
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Your least effective strategies are those that resulted in fewer enrollments and renewals of potentially eligible children relative to other strategies you used in the reporting period.
Answer the following questions for up to two of your least effective strategies. Please write your answers under each question. (600 words total for each strategy)
Describe the strategy and specify whether it focused on new enrollments, renewals, or both.
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Explain why this strategy was less effective than others, including evidence showing how ineffective it was. Include any challenges or barriers to its effectiveness.
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Was this strategy least effective for the specific group(s) of children you were targeting? For example, was it less effective with teens or with younger children? Please explain.
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Describe any changes you made to improve this strategy’s effectiveness and whether they made a difference. If you have made no changes and you plan to continue using this strategy in the future, what do you plan to do to improve its effectiveness?
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What lessons did you learn from this strategy?
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Describe the strategy and specify whether it focused on new enrollments, renewals, or both.
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Explain why this strategy was less effective than others; include any challenges or barriers to its effectiveness.
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Was this strategy least effective for the specific group(s) of children you were targeting? For example, was it less effective with school-aged children or with teens? Please explain.
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Describe any changes you made to improve this strategy’s effectiveness and whether they made a difference. If you have made no changes and you plan to continue using this strategy in the future, what do you plan to do to improve its effectiveness?
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What lessons did you learn from this strategy?
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Have you (1) discontinued a strategy, or (2) sought approval from the CMS Project Officer to implement a new strategy in this reporting period? If so, please explain. (200 words)
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Please list all strategies used during this reporting period that have not been captured in any of the previous questions above.
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Administrative and management challenges
Discuss any administrative or management challenges you faced when implementing your project and how you dealt with them. These may include, for example, staff turnover, insufficient staff or lack of staff with the right skills, competing demands on project leadership, and so forth. (200 words)
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Enrollment and renewal challenges
Discuss the two most difficult enrollment and renewal challenges you faced when implementing your project. These may include, for example, beliefs or attitudes that make people reluctant to enroll, such as stigma associated with public benefits; lack of transportation to application assistance sites; lack of awareness about CHIP and Medicaid; or complex eligibility rules and requirements that are difficult for families to understand and comply with. Consider challenges as they relate to the populations you targeted.
Answer the following questions for up to two of your most difficult challenges. Please write your answers under each question. (300 words total for each challenge)
Describe the challenge and how it creates a barrier to enrollment and/or renewal.
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Describe the actions you took to address the challenge, and state whether they were effective.
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Have you overcome the challenge? If not, what are your next steps to do so?
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Describe the challenge and how it creates a barrier to enrollment and/or renewal.
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Describe the actions you took to address the challenge, and state whether they were effective.
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Have you overcome the challenge? If not, what are your next steps to do so?
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What are the most important lessons you would share with peers about how to increase new enrollments and/or renewals in CHIP and Medicaid? (400 words)
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What technical assistance topics would be most useful to your project in the next six months? Check all that apply.
☐ Using data to identify potentially eligible children and parents
☐ Using eligibility and enrollment data to track progress
☐ Establishing memoranda of understanding (MOUs) with states
☐ School-based strategies
☐ Communications strategies
☐ Effective messaging
☐ Including culture in our messaging
☐ Selecting the best media to disseminate our messages
☐ Using social media effectively
☐ Engaging hard-to-reach populations
☐ Teens
☐ Latino/Hispanic families
☐ American Indian/Alaska Native families
☐ Families in rural areas
☐ Immigrant families
☐ Medicaid and CHIP eligibility, enrollment, and renewal policies
☐ Other topics—please specify:
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What forms of technical assistance would be most useful to your project in the next six months? Check all that apply.
☐ Receiving issue briefs or tool kits, and other resources in the interest areas I checked above.
☐ Access to a bibliography with hyperlinks so I can find resources that interest me.
☐ Webinar presentations
☐ Presentations by peers
☐ Facilitated discussions with small groups of peers
☐ Newsletter-style updates on the successes and challenges of peers
☐ Help desk to answer specific questions
☐ Technical assistance in other formats—please specify:
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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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Semi-Annual Reporting Template |
| Subject | Reporting template for American Indian/Alaska Native (AI/AN) Round Two Outreach and Enrollment Grants |
| Author | CGeorge |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |