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Outreach/Enrollment

Despite the initial difficulties that many States encountered in implementing their SCHIP programs, enrollment has grown since the program was first established. However, many children eligible for SCHIP remain uninsured.

There were 11 million uninsured children in the U.S. prior to the enactment of SCHIP in 1997. Over 7 million of these children were in low-income families.1 By fiscal year (FY) 2000, 3.3 million children nationwide were insured through SCHIP (with 995,121 in Medicaid expansion programs and 2,316,784 in separate SCHIP programs), up from the nearly 2 million children enrolled in FY 1999. In addition, a significant number of children who were eligible for Medicaid even in the absence of any SCHIP expansions have enrolled in Medicaid because of SCHIP-related outreach and coordinated eligibility processes.²

Certainly one approach to enrolling more low-income children in SCHIP is to expand program eligibility requirements. This, in fact, has occurred in many jurisdictions. As of September 2000, 36 States and the District of Columbia had expanded their original SCHIP eligibility criteria to cover older children or children in families with somewhat higher income levels.2 However, Halfon and colleagues caution that such eligibility expansions alone will not necessarily result in higher enrollment. They note that similar expansions were legislated for Medicaid programs in the late 1980s and early 1990s, but millions of eligible children remained uninsured.³

Factors Influencing Enrollment

Studies support what many policymakers have realized: factors other than the specific program age and income eligibility criteria can negatively influence the program's effectiveness in enrolling low-income uninsured children. These factors include a lack of public awareness of coverage under such public programs, as well as barriers created by the enrollment process itself.

According to a study from the Kaiser Commission on Medicaid and the Uninsured,⁴ national parental surveys suggest that the following policy and process changes would lead to increased Medicaid and SCHIP enrollment.

• Streamline the enrollment process. More than half of the parents whose eligible children were not enrolled in Medicaid or SCHIP said that they felt the enrollment process was too lengthy. They suggested a number of ways to make the process more user friendly:

  • Make it more convenient through mail-in or phone-in applications and extended office hours.
  • Enroll eligible children automatically when signing up for other programs (e.g., School Lunch Program).
  • Create more convenient locations for enrollment.
  • Provide enrollment materials and assistance in different languages.
  • Emphasize Medicaid and SCHIP as programs for low-income working families to avoid the stigma of welfare.
• Simplify eligibility criteria. States can help families complete the enrollment process by eliminating asset tests, employing income disregards, and adopting 12-month continuous eligibility.
• Expand outreach and communicate program information clearly. The majority of parents of eligible uninsured children had little contact with the welfare system and were unaware of Medicaid or SCHIP eligibility rules. Thus, States may wish to target these families to let them know how to initiate the enrollment process.
• Improve the product. Efforts to maintain and monitor the quality of care in SCHIP and Medicaid are critical to countering negative perceptions of these public programs.

Current Initiatives

The Federal Executive Branch, many States and localities, and other entities have devoted a great deal of attention to outreach and enrollment simplification strategies. (Visit http://www.cms.hhs.gov/home/schip.asp for official Health Care Financing Administration (now CMS) SCHIP outreach guidance.) Several foundations and Federal agencies, including the Agency for Healthcare Research and Quality (AHRQ), are studying outreach approaches. For example:

• The Robert Wood Johnson Foundation is supporting Covering Kids, a national communications campaign designed to educate parents about their eligibility, boost enrollment rates of eligible children in SCHIP or Medicaid, and provide accurate and timely information to the press and opinion leaders about the need to cover eligible children. This program was initiated as a result of the foundation's findings, which showed that 6 out of 10 families were not aware that their children were eligible.⁵
• AHRQ is funding a 5-year project at Boston Medical Center designed to identify, through focus groups, why parents are unable to obtain insurance for their uninsured children and whether specially trained community-based case managers are more effective than traditional methods in reaching out to and enrolling uninsured children in public insurance programs.⁶

Several State initiatives to increase awareness of SCHIP, simplify enrollment, and improve the retention of otherwise uninsured children within the program are described below.

Some States are using marketing campaigns to enroll more eligible uninsured children. A study by the Kaiser Commission on Medicaid and the Uninsured⁷ conducted interviews with officials from 48 States to determine how they publicize SCHIP and Medicaid programs through the media. Highlights of the findings included:

• The majority of States with separate SCHIP programs have given SCHIP an appealing name so as not to sound like a government program.
• Thirty-five States promote their SCHIP and Medicaid programs together.
• Two-thirds of the States target specific geographic areas and/or populations.
• Most States use a variety of print, television, and radio ads that are pretested in the market area.
• Over two-thirds of the States have attempted to evaluate the success of their promotional efforts.

However, the researchers determined that States' ad campaigns face two challenges that may impede their progress in increasing enrollment:

• The ads lack sufficient detail about what services are covered, who qualifies, and whether there are any premium payments.
• Few States are attempting to target former welfare beneficiaries, who may still be eligible for enrollment.⁷

Presumptive Eligibility

Presumptive eligibility is allowing health care providers and other organizations that serve low-income clients to give temporary Medicaid coverage to children. Families must follow through on the regular application process by the end of the following month or the temporary coverage will expire.8

States have been slow to use the potential of the eligibility category. As of 1999, seven States had adopted presumptive eligibility for Medicaid-eligible children and five had also adopted presumptive eligibility in the separate SCHIP programs.4 States have had a presumptive eligibility option for pregnant women covered by Medicaid for over 10 years, but presumptive eligibility for children is a relatively new concept.

Express Lane Eligibility

Express lane eligibility is an approach used to expedite enrollment of uninsured children in SCHIP and Medicaid by identifying them through other income-comparable publicly funded programs. These programs may include the Food Stamp Program, the National School Lunch Program, the Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Temporary Assistance for Needy Families, among others.

There are different levels of implementing express lane eligibility, including strategies that can be implemented immediately and those that require further Federal guidance. Multiple program variables, including eligibility guidelines, program administration, and the technological ability to link between programs, determine the method of implementation. The following are some possible strategies States can adopt:

• Create one application for multiple programs.
• Target outreach to children in income-comparable public programs.
• Streamline the enrollment process for children already connected to income-comparable public programs.
• Define groups of kids already enrolled in income-comparable public programs as automatically eligible for Medicaid and SCHIP.9

Continuous Eligibility

Monthly or seasonal changes in income cause many medical assistance recipients to slip in and out of eligibility. With continuous eligibility, States have the option to allow children to remain eligible for SCHIP or Medicaid for up to one full year, even when their family income changes. Under this option, enrollees are not required to report increases in income or provide interim reports during the eligibility period. According to a report by the National Conference of State Legislatures,10 continuous eligibility:

• Eases the administrative burden on State agencies (although it may increase overall program costs).
• Relieves enrollees of the responsibility of frequent reporting requirements.
• Addresses enrollees' difficulty in finding care in months when their coverage otherwise would lapse.

While States have been successful in enrolling children into their SCHIP programs, new approaches to marketing and enrollment may be necessary for States to increase enrollment and improve retention. States must individually determine which marketing approaches, enrollment processes, and eligibility mechanisms will help them to fully realize the promise of SCHIP.

1 Weinick R, Weigers ME, Cohen JW. Children's health insurance, access to care, and health status: new findings. Health Aff 1998 Mar-Apr; 56(1):55-73.

2 Health Care Financing Administration (now CMS) SCHIP Web site: http://cms.hhs.gov/schip/.

3 Halfon N, Inkelas M, Newacheck PW. Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement. Milbank Q 1999; 77(2):181-204.

4 Perry M, Kannel S, Valdez B, et al. Medicaid and children: overcoming barriers to enrollment. Washington: The Kaiser Commission on Medicaid and the Uninsured; Jan 2000.

5 Mycek S. Covering Kids communications campaign uncovers misconceptions and boosts inquiries. Advances, The Robert Wood Johnson Foundation Quarterly Newsletter 2001.

6 Agency for Healthcare Research and Quality. Current child health research projects by State. Rockville (MD). Available at: http://www.ahrq.gov/child/usamap.htm.

7 Perry M. Marketing Medicaid and CHIP: a study of State advertising campaigns. Menlo Park (CA): The Kaiser Commission on Medicaid and the Uninsured; Oct 2000.

8 Families USA. Promising ideas in children's health insurance. Washington (DC): Families USA; Apr 2000.

9 Horner D, Lazarus W, Morrow B. Express lane eligibility: how to enroll large groups of eligible children in Medicaid and CHIP. Menlo Park (CA): The Kaiser Commission on Medicaid and the Uninsured; Dec 1999.

10 Steinberg D. Keeping kids enrolled: continuity of coverage under SCHIP and Medicaid. Washington (DC): National Conference of State Legislatures; Jan 2000.