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pdfOMB Control Number 0938-1148 (CMS-10398 #7)
Connecting Kids to Coverage
Outreach and Enrollment
Semi-Annual Report Template
Project Title:
Funding Opportunity:
Reporting Period:
Report Due Date:
Cooperative Agreement Number:
State:
Name of Awardee:
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 Acknowledgement & Acceptance
I acknowledge and accept the content of this report:
________________________________________________________
CMS Project Officer (type name in lieu of signature)
Use this semi-annual report template to describe the progress of your Connecting Kids to
Coverage Healthy Kids Outreach and Enrollment grant.
The reporting period for this semi-annual report is:
All information reported must be the result of project activities during this reporting period.
This semi-annual report must be submitted to CMS through Grantsolutions.gov, as
described in the special terms and conditions of your cooperative agreement.
Semi-Annual Report Template for Awardees
This template is formatted for Adobe Acrobat software (.pdf format), and the template must
be returned as instructed.
•
Narrative should be entered in the template under each question. Length guidelines are
indicated for each question. Please aim for clarity when writing your narrative
responses.
•
Fields outlined in red are required. Leaving these fields blank will prevent your report
from being submitted.
•
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.
Submit the completed and signed report to the CKC evaluation team via Adobe
AND upload it to Grantsolutions.gov for review by your CMS Project Officer by:
PRA Disclosure Statement This information is being collected to assist the Centers for Medicare & Medicaid Services
(CMS) with the data needed to reflect the aggregate goals and accomplishments for this cooperative agreement
program. This mandatory information collection (42 U.S.C. 1396a) will be used to demonstrate the outcomes that result
directly from this funding opportunity, and will also be used to help evaluate the success of outreach and enrollment
strategies and identify areas that need improvement or mid-course corrections. Under the Privacy Act of 1974,
any personally identifiable information obtained will be kept private to the extent of the law. 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 0938-1148 (CMS-10398 #7). Public burden for all of the collection
of information requirements under this control number is estimated to range from 16 to 20 hours per
response, including the time reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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Semi-Annual Report Template for Awardees
1.
What activities were performed with CKC funding during this reporting
period?
1a.
Please list the milestones from the work plan in your project application. Describe
activities that demonstrate progress towards each milestone as long as they were
covered by CKC funding. 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
Date Milestone Was Achieved
(or status update, if
Activities Demonstrating Progress milestone not yet achieved)
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Semi-Annual Report Template for Awardees
1b.
Were any of these activities undertaken in collaboration with the National Connecting
Kids to Coverage Campaign, including the Back to School or Post-Open Enrollment
initiatives?
Yes
☐
No
☐
If yes, please explain what your collaboration with the National Campaign involved.
(200 words)
1c.
Have there been any changes from the proposed schedule or timeline described in
your project application?
Yes
☐
No
☐
If yes, showing the original schedule or timeline date and the revised date, briefly
explain the reason for the modification.
Milestone
Original Date Expected Date
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Explanation
Semi-Annual Report Template for Awardees
2.
Identifying children who are potentially eligible for CHIP and Medicaid
2a.
How did your organization go about identifying potentially eligible children to help
with enrollment or renewal? If you continued strategies that you have described in
previous reports without change, please indicate that in the space below.
2b.
Have you used used any data-driven strategies to find potentially eligible children?
Yes
☐
No
☐
If yes, please list the data sources you used and explain how you used these
sources. Please indicate any challenges you encountered, if any, in obtaining or using
the data. If you have already described strategies in your previous reports, please
only describe any changes you have made in the way you identify potentially eligible
children. (Total of 300 words per source)
Data source
How it was used
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Challenges
Semi-Annual Report Template for Awardees
ENROLLMENT AND RENEWAL DATA EXPLANATIONS AND OTHER OUTCOMES
3.
Explanation of enrollment and renewal data
3a.
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
verify the number of children and parents (as applicable) enrolled and renewed as a
direct result of CKC funding (e.g., data obtained from the state or county, calls to the
state eligibility determination office). (300 words)
3b.
Please provide any additional information to explain the results in the monthly
reports you submit. 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)
3c.
Is the number of new applications, enrollments, and/or renewals reported in your
monthly reports lower than expected (either overall or within your target
population)?
Yes
☐
No
☐
If yes, how do you plan to overcome the challenges you identified? (300 words)
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Semi-Annual Report Template for Awardees
4.
Outcomes other than enrollments and renewals in Medicaid, CHIP, and
insurance affordability programs
Your CKC project activities over the reporting period may have resulted in other positive
outcomes besides enrolling and retaining children in CHIP and Medicaid, and enrolling and
retaining parents in insurance affordability programs. If so, please describe these results in
the relevant section below. (400 words total)
4a.
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).
4b.
New outreach and enrollment policies and procedures that may be sustained after
the CKC project ends.
4c.
Enrollment of children in Qualified Health Plans offered through the state/federal
Marketplaces.
4d.
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.)
4e.
Any other positive unplanned or unanticipated outcomes as a direct result of your
CKC funding.
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Semi-Annual Report Template for Awardees
STRATEGIES
5.
Strategies to educate families and increase awareness
(200 words total)
5a.
Describe the strategy you considered most effective in increasing awareness of CHIP
and Medicaid in your target population.
5b.
What were the critical components of the strategy?
5c.
What evidence supports your conclusion that the strategy works? Please be specific.
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Semi-Annual Report Template for Awardees
6.
Most effective enrollment and renewal strategies
Your most effective strategies are those that, relative to others, resulted in more
enrollments and renewals from the CKC 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)
Strategy 1
a.
Describe the your most effective strategy.
Did this
strategy focus on new enrollments, renewals, or both?
New enrollments
b.
☐
Renewals
☐
Both
☐
What evidence supports your conclusion 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 (or enter “Not
available”).
c.
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?
Yes
☐
No
☐
If yes, please specify which groups and explain.
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Semi-Annual Report Template for Awardees
d.
What components of this strategy do you feel are critical to its effectiveness? Why
is this particular strategy effective?
e.
Did you change the strategy during the reporting period to improve its
effectiveness in enrolling and/or renewing children in CHIP and Medicaid?
Yes
☐
No
☐
If yes, describe the changes and whether they made a difference.
f.
Can this strategy be replicated by organizations similar to yours?
Yes
☐
No
☐
Please explain why or why not and note any special circumstances needed for
replication.
Strategy 2
a. Describe your second most effective strategy.
Did this strategy focus on new enrollments, renewals, or both?
New enrollments
b.
☐
Renewals
☐
Both
☐
What evidence supports your conclusion 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)?
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Semi-Annual Report Template for Awardees
If available, please report the percentage of your numbers of new enrollments and
renewals in this reporting period attributable to this strategy (or enter “Not
available”).
c.
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?
Yes
☐
No
☐
If yes, please specify which groups and explain.
d.
What components of this strategy do you feel are critical to its effectiveness? Why
is this particular strategy effective?
e.
Did you change the strategy during the reporting period to improve its
effectiveness in enrolling and/or renewing children in CHIP and Medicaid?
Yes
☐
No
☐
If yes, describe the changes and whether they made a difference.
f.
Can this strategy be replicated by organizations similar to yours?
Yes
☐
No
☐
Please explain why or why not and note any special circumstances needed for
replication.
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Semi-Annual Report Template for Awardees
7.
Least effective enrollment and renewal strategies
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)
Strategy 1
a.
Describe your least effective strategy. If no strategy was “least effective,” enter
“N/A” and explain.
Did this
strategy focus on new enrollments, renewals, or both?
New enrollments ☐
Renewals
☐
Both
☐
N/A
☐
b.
Explain why this strategy was less effective than others; including evidence that
supports your conclusion. Enter “N/A” if no “least effective” strategy.
c.
Was this strategy least effective for the specific group(s) of children you were
targeting? For example, was it less effective for school-aged children or teens.
Yes ☐
No
☐
N/A
☐
If yes, please specify which groups and explain.
d.
Did you make any changes to improve this strategy’s effectiveness?
Yes ☐
No
☐
N/A
☐
If yes, describe the changes you made to improve this strategy’s effectiveness and
whether they made a difference.
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Semi-Annual Report Template for Awardees
If you made no changes and plan to continue using this strategy in the future, what
do you plan to do to improve its effectiveness?
e.
What lessons did you learn from this strategy? Enter “N/A” if no least effective
strategy.
Strategy 2
a.
Describe your second least effective strategy.
Did this
strategy focus on new enrollments, renewals, or both?
New enrollments
☐
Renewals
☐
Both
☐
b.
Explain why this strategy was less effective than others; including evidence that
supports your conclusion.
c.
Was this strategy least effective for the specific group(s) of children you were
targeting? For example, was it less effective for school-aged children or teens.
Yes
☐
No
☐
If yes, please specify which groups and explain.
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Semi-Annual Report Template for Awardees
d.
Did you make any changes to improve this strategy’s effectiveness?
Yes
☐
No
☐
If yes, describe the changes you made to improve this strategy’s effectiveness and
whether they made a difference.
If you made no changes and plan to continue using this strategy in the future, what
do you plan to do to improve its effectiveness?
e.
What lessons did you learn from this strategy?
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Semi-Annual Report Template for Awardees
8.
DISCONTINUED AND NEW STRATEGIES
8a.
Have you discontinued a strategy in this reporting period?
Yes
☐
No
☐
If yes, please explain. (150 words)
8b.
Have you sought approval from the CMS Project Officer to implement a new strategy
in this reporting period?
Yes
☐
No
☐
If yes, please explain. (150 words)
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Semi-Annual Report Template for Awardees
CHALLENGES AND LESSONS
9.
What challenges did you face in the reporting period?
9a.
Administrative and management challenges
Discuss any administrative or management challenges you faced when
implementing your CKC 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)
9b.
Enrollment and renewal challenges
Discuss the two most difficult enrollment and renewal challenges you faced when
implementing your CKC 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 for enrollment.
Answer the following questions for up to two of your most difficult challenges in increasing
the percentage of eligible children enrolled in CHIP and Medicaid. Please write your answers
under each question. (300 words total for each challenge)
Challenge 1
a.
Describe your biggest challenge to increasing the percentage of eligible children
enrolled in CHIP and Medicaid in your state.
b.
How did this create a barrier to enrollment and/or renewal?
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Semi-Annual Report Template for Awardees
c.
Describe the actions you took to address the challenge, and explain whether they
were effective.
d.
Have you overcome the challenge?
Yes
☐
No
☐
If not, what are your next steps to do so?
Challenge 2
a.
What is your second biggest challenge to increasing the percentage of eligible
children enrolled in CHIP and Medicaid in your state.
b.
How did this create a barrier to enrollment and/or renewal?
c.
Describe the actions you took to address the challenge, and explain whether they
were effective.
d.
Have you overcome the challenge?
Yes
If not, what are your next steps to do so?
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☐
No
☐
Semi-Annual Report Template for Awardees
10.
Outreach and enrollment lessons
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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Semi-Annual Report Template for Awardees
Technical Assistance
11.
Technical assistance needs and preferences
11a.
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:
11b.
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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Reset Form
| File Type | application/pdf |
| File Title | Connecting Kids to Coverage Outreach and Enrollment Semi-Annual Report Template |
| Author | CKC |
| File Modified | 2022-05-26 |
| File Created | 2022-01-25 |