CMS-10398 #7 Final Report Template

OMB Control Number 0938-1148 (CMS-10398 #7)

Connecting Kids to Coverage
Outreach and Enrollment
Final Semi-Annual Report Template
Project Title:
Funding Opportunity:
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)

Final Semi-Annual Report Template for Awardees

Reporting Requirements
Use this final semi-annual report template to describe the progress of your CKC Outreach
and Enrollment project.
This final semi-annual 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 Adobe Acrobat software (pdf format), and the template must
be returned as instructed.


Narrative responses should be entered in the fields 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 those fields blank will prevent your report
from being submitted.



You may upload 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 in 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 midcourse 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
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Final Semi-Annual Report Template for Awardees

ENROLLMENT AND RENEWAL DATA EXPLANATIONS
1.

Explanation of enrollment and renewal data

1a.

Please describe the system you use for tracking applications from the time they are
submitted, through the review process, to approval or denial. Also describe how you
verify the numbers of children and parents (as applicable) enrolled and renewed as a
direct result of the CKC funding (e.g., online data portal with the state or county,
calls to the state eligibility determination office). (300 words)

1b.

Please provide additional information, if needed, to explain your enrollment results to
date as reported 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)

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Final Semi-Annual Report Template for Awardees

EFFECTIVE STRATEGIES
2.

Most effective strategies

2.1.

If you could continue the most effective strategy to EDUCATE AND INCREASE
AWARENESS in families you used under your current cooperative agreement, which
would you choose to continue and why? Please be specific. For example, if attending
education and outreach events was an effective strategy, which kinds of events (e.g.
community-organized health fairs, assemblies at schools in low-income areas) were
the most effective? (300 words)

2.2.

Please also explain why you think a particular strategy was effective. Do you ask
applicants how they heard about the help you offer?

2.3

If you could continue the most effective ENROLLMENT AND RENEWAL strategy you
used to help children newly enroll and stay enrolled through renewal, which would
you choose to continue and why? Please be specific. For example, if your use of
application assistors or navigators to help people submit applications was effective,
were there particular kinds of staff (e.g. bilingual, experienced outreach or
application assistance workers) who were most effective, or were particular kinds of
locations (e.g. grocery stores, middle schools) more productive than others? (300
words)

2.4

Please also explain why you think a particular strategy was effective in enrolling and
renewing children. For example, do you keep track of which staff at which locations
complete the most applications?

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Final Semi-Annual Report Template for Awardees

CONTINUATION OF ACTIVITIES
3.

Continuation of activities after the cooperative agreement period

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

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Final Semi-Annual Report Template for Awardees

LESSONS AND CHALLENGES
4.

Lessons learned

What are the three most important things your organization has learned over the course of
the funding period about enrolling Medicaid/CHIP eligible children, and parents? You may
list lessons learned about any aspect of your activities, including identifying, contacting, and
engaging eligible families, helping children, and their parents to apply for coverage, or
helping them to stay covered. In your answers, consider whether you would have done
anything differently if you had known at the start of the funding period what you know now.
(300 words)
4.1.

Lesson 1

4.2.

Lesson 2

4.3.

Lesson 3

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Final Semi-Annual Report Template for Awardees

5.

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

Looking ahead over the next year or two, what do you think are the two biggest 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 are the best ways organizations similar to your organization can
implement to overcome this challenge? (300 words)
5.1.

Biggest challenge

5.2.

Best way organizations similar to your organization can overcome this challenge

5.3.

Second biggest challenge

5.4.

Best way organizations similar to your organization can overcome this challenge

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