Identifying Children Eligible for Low Cost Health Insurance through Free and Reduced Lunch Applications

State: FL Type: Model Practice Year: 2015

The goal of the Florida Department of Health in Broward County, Florida KidCare Outreach Unit is to increase enrollment in the Florida KidCare and Medicaid Programs and to ensure they retain their coverage while they are eligible. This action is done through enrollment and retention activities. Broward County Public School System is the largest fully accredited school district in the nation and is the sixth largest school district in the United States. Broward County Schools is comprised of 293 schools and centers. The student population includes students form 164 countries who speak 52 languages. It is estimated that over 60,000 children in the Broward County School system is uninsured and without the medical and oral health that they so desperately need. Schools are widely accepted as an important setting for conducting children’s health coverage outreach and enrollment activities.  Broward County Health Department KidCare Outreach staff has developed a systemic method to facilitate identification of potentially eligible children through the Free and Reduce-Price Lunch Program and take affirmative steps to enroll eligible children in Medicaid and the Federal “Children’s Health Insurance Program” (CHIP). Broward County Health Department KidCare Outreach Staff met with the Superintendent of schools, to discuss the project and the need for the families. The project was brought to the school board and a Memorandum of Agreement (MOA) was executed through both legal departments. The agreement consists of two actions. First, that the school board would place the question regarding health  insurance coverage for the child on the free and reduce-cost lunch application, when the enrollment was complete into the free and reduced cost lunch program that they would  securely send us the list of children identified as not have health care coverage. The list contains the name of the child, the name of the parent, the contact information of the parent, and the address with zip code of the household. Second, that we would have a contact at each school that could be educated on the eligibility guidelines and contact information of our program for referring  families, as well as staff needing affordable coverage, through the school year.  This contact would also be sent the educational materials such as brochures and flyers to be distributed to the students in the material included in the packets to go home to the parents the first week of school and work with the Florida KidCare (CHIP in Florida) outreach staff to schedule an open enrollment day and be invited to participate in school-based events during the school year.Once the information is received by the outreach staff, the list is reviewed for multiple children in the same household, divided by zip code and assigned to an outreach person for contact of the family. Each family is contacted by telephone and offered an appointment for electronic assistance for families in need of the insurance program and technical assistance to families where a potential problem with their enrollment has been identified. Families indicating they are currently enrolled into one of the four program components (Medicaid, Medikids, Children’s Medical Services and Healthy Kids) are asked their “renewal date”. If the family does not know the date, every effort is made to assist the family receive the date of their renewal through the Medicaid and KidCare systems and at that time the date is placed on a postcard and entered into a database for future contact at the time at the time of renewal. While having the parents on the phone line, the families having KidCare are instructed how to set up their account for online access at home for when they need to service their account and hard–to-reach populations are assisted with information on document requirements.All responses from the original contact are coded with a number and kept in a data base for review and analysis at the end of each zip code.  Returned calls from messages left are recorded onto the data base of the family along with the response code.As a result of the project 85% of the Registrars, or other staff appointed at each school, and 100% of the school health technicians have been educated on the eligibility process and referral information and are referring families as they are identified. Broward County Schools include KidCare information in packets to the school employees during time of their open enrollment period for teachers and staff that are seeking an affordable alternative.  A list of 44,392 (2013/2014 School Year) potentially uninsured children was received for contact of families.  
The Florida Department of Health in Broward County is one of the most populous counties in Florida, with over 1.8 million residents and is known for its ethnic diversity. Broward County is ranked fifth among top ten counties with the largest absolute growth of foreign-born population. Broward County became a minority-majority country in 2006 and is one of the most highly diverse areas in the United States. Demographers attribute the unprecedented shift to the exploding Caribbean and Latin American populations. These young and growing immigrant communities are among the most economically distressed and medically underserved in the State of Florida, largely due to the cultural misunderstanding of health care coverage and the high cost of health care. In addition, English proficiency affects a person’s ability to fill out health insurance applications and other form.Based on the 2010 Broward County Behavior Risk Factor Surveillance System, 21.77% of the Non-Hispanic Black and 33.8% of the Hispanic in Broward County lacked health insurance compared to just 8.8% of Whites. It can be estimated that 12.8% of the population under age of 19 is currently uninsured.The free and reduced lunch project, targets the lower income population; therefore we are reaching the target we have attempted to reach.  With a list of over 45,725 contacts to make and additional daily duties to accomplish, utilizing part-time Inters and limited staff, it is nearly impossible to complete all contacts with in one school year.  Middle October when the new list is received, the rotation is continued using the new contact list for a first contact to families not contacted in the first cycle. This prevents multiple contacts to the same family within the school year.The first cycle of this project a list of 45,725 possibly uninsured children were identified. From this list 16,502 families were contacted within a 17 month period of a grant received from the University of South Florida, School of Public Health, Florida Covering Kids and Families to conduct the Free and Reduced Lunch project.  Of the families contacted, there were 544 online applications representing approximately 1257 children submitted to the Healthy Kids Corporation for processing and enrollment. In the past, children had been targeted through flyers being distributed through the school system, at Open House at schools  and at some school events, but never before had the free and reduced lunch program been used to target uninsured children, making this partnership with the local community health department and the school system an innovative and productive partnership. In addition, educating school health technicians and school nurses, provided and monitored by the local health department, to identify the uninsured children they meet through the clinic for referral makes a creative use of existing tools and partnership.All data collected for the project was recorded to capture results set with SMART (specific, measurable, realistic, and timely) goals in mind.  A specific goal was set to identify and contact 5,000 families in the first twelve months and 6,000 families to be contacted during the second twelve month of the grant period. In addition, an enrollment goal of 1200 children from the Free and Reduced Lunch list would be enrolled into one of the four Florida KidCare components. The success would be measured by the increase in on-line applications as reported from the Florida Healthy Kids Corporation. It was thought that with grant funding to supply the cost for an additional staff person to contact and follow up with families that this number was achievable, and in results, the number was reached. As follow up with the family is an important step to assure completion of the process to enrollment, the goal was set to follow up with 90% of all families applied for through the Free and Reduced Lunch project.  In completion of the project, 100% of the families had received a follow up contact.  The goals set for performance measures and tracking measures consisted specifically with the designated timeline of the grant.   Even though the grant was for a 24 month cycle from August 18, 2011 and continued through August 17, 2013, time for setting up the tracking documents, hiring of staff, and to implement the project was taken into account when considering when setting reachable goals. Data was collected monthly during this period by the KidCare Outreach Coordinator, allowing for the provision of continuous quality improvement through timely feedback to project staff as issues were identified and course corrections were required and implemented.  Progress toward the achievement of the outcomes in data indicators, both quantitative and qualitative was monitored. Evaluation tools were appropriate to monitor the outcomes of the project given the specific indicators of numbers serviced, education, hiring of staff, and improvement in health care coverage.As a grant recipient, data collection and reporting activities are reviewed and monitored by Florida Covering Kids and Families (FL-CKF) at the Lawton Chiles Center for Healthy Mothers and Healthy Babies, South Florida University. FL-CKF continually assessed the effectiveness of the grant activities through a meaningful, targeted evaluation of strategies and a summative assessment of overall project success.  At the end of the grant period, all results were compiled and were included in an end of the year project evaluation report that was shared with CMS.  As such, FL-CKF used project application codes to track applications submitted through programs associated with separate grant activities in order to determine the quantity of applications as a first step in exploring successful enrollment approaches. Determination information on these applications was used to assess the enrollment approval and denial rates of each project. The numbers of enrollment for the Broward County Project were 15.79% more than all other CHIP school based projects receiving the same grant for the grant period, for different projects, throughout the state of Florida.  Florida KidCare Outreach Manager was selected for a peer-to peer Key information interview to obtain lessons learned and recommendations for expanding the approach statewide. In addition, Florida KidCare Outreach manager was asked to present the project at a statewide project conference for implementation in other counties within the state of Florida. The state-focused meetings included questions assessing perceptions of best practices, implementation challenges, and lessons learned, as well as an assessment of technical assistance that was provided by FL-CKF. All the data described above was summarized and reported to CMS and participating partners.
Heathcare-associated Infections|Nutrition, Physical Activity, and Obesity
The Goal of the Free and Reduced Lunch project was to use the already existing school database of low income children to target for needed health care coverage. The objective was to determine possible eligibility of these children for Medicaid and CHIP coverage and get the ones eligible for Medicaid or CHIP successfully enrolled into the program.  The goal of enrollment was set at 90% of possibly eligible children would be enrolled into one of the Florida KidCare components.  The remaining 10% allow for families that would not follow through with the process, or would not send the premium payment of $15 of $20 for the first month’s payment if they did not qualify for Medicaid.  Since this population contains a high rate of immigrant families that may not qualify for the program, it was important that we have a list of additional resources that we could refer them to for their medical services. Partnerships were created with the local federally funded health centers (FQHC) as well as the local hospital districts (Memorial Healthcare and Broward Health) and free clinic “Luz Del Mundo” who serves immigrant families free of cost.  Once the initial contact to the family was made and the child was determined to be a candidate for enrollment, an appointment was made with the family to complete the online application. The families would be assigned to the nearest local health department office that contained a KidCare outreach staff person.  If the family did not have transportation, staff would schedule an appointment at the school which the child attends because traditionally that location is within walking distance from the home.When scheduling the appointment, the parent is instructed as to the documents required for enrollment and it is suggested the parent bring them to the appointment. Although they actually have 120 days to supply the documentation, it was discovered that if they are not faxed to the Healthy Kids processing center at the time of the appointment, many times the family does not get the documents to the processing center in adequate time and the application is denied. Once the electronic application is complete the documents are either scanned and sent electronically or faxed to the processing center in Tallahassee.  At this time the information on the family is entered into the project database which consists of the names and address of the family, the name, date of birth, and social security number of the children and the confirmation number of the electronic application.In approximately ten (10) days, a follow up call is placed to the family to track a response from the processing center.  If the family has not received a letter in regard to their application, a call is placed to the processing center for determination confirmation. If the family has been determined eligible for Medicaid, the family is given the account service hotline phone number for any issues they may have.  If the family is determined eligible for any of the other CHIP programs, they are instructed on setting up their account for payment of premiums online and account any other account services. The entire process can take from four to six weeks when proper documents are not  sent, however by instructing the family of the items to bring to the appointment and following up with the family the application process was cut down to two to three weeks. It was for this reason, that a partnership in the form of a Memorandum of Understanding (MOA) with the State Medicaid and CHIP Agencies was important for the purpose of data collection and sharing as well as to obtain access to family account review portals for family resolution of technical issues. During the initial interview with clients, it is often discovered that there are additional social services the family may need.  Partnerships were created with the local housing authority for family referrals for housing, Feeding South Florida which is a local food bank, and many other social service agencies.Many times we are asked by community organizations to share the information on the free and reduced lunch in order for them to contact families that may be in need of the social services they offer, however due to HIPPA and SHERPA laws, this is never permitted.Since 1999, the Florida Department of Health in Broward County KidCare Outreach Program has contributed to the statewide Florida KidCare enrollment program through the institution and use of a Broward based hotline phone number, 954 INSURES.  This line is dedicated to KidCare and offers Broward residents a user friendly means to access one-on-one personal assistance from a KidCare Outreach worker.  Information is provided regarding KidCare enrollment. For some callers, that information is the dates, times and directions to outreach events, while others seek immediate assistance to complete a KidCare application.  When needed an appointment is scheduled at the location convenient to the family. The local KidCare INSURES line is a vital navigation tool, guiding prospective applicants through the application process. In 2005, the state discontinued funding outreach for the Florida KidCare Program, it was necessary to seek replacement funding to keep the hotline active and to assure enrollment and technical assistance to families seeking resolution to their issues, especially in a time where the programs enrollment was closed and children ageing out of Medicaid could not obtain coverage until a new assigned open enrollment period began.  This was a time of family confusion and distrust of the program due to the massive number of issues and lack of coverage during this time. The Florida Department of health created a partnership with the Children’s Services Council of Broward County and received grant monies to keep the hotline, and provided two staff to manage the program.  The original funding was in the amount of $52,000. Within a few months, the program had opened up and it was back to year around enrollment again, however with no state funding.The idea of the free and reduced lunch application list began in 2006 when the idea was taken to the School Board of Broward County, and the partnership commenced with the signing of the Memorandum of Agreement.  The food and nutrition department would get the information on the application and after all the applications were processed a list was send the Broward County Health Department for contact to evaluate eligibility for the KidCare program. Although funding from the Children’s Services Council had increased to $145,000 giving the program additional staff; staff was assigned to specific contractual duties for fulfilment of the contract so, the free and reduced lunch list received minimum attention.  Several small grants were given to focus on the list for a few months, but never enough for an actual project.In mid-summer of 2011 a grant (CHIPRA CYCLE II) opportunity was announced by the University of South Florida for school based outreach of the Children’s Health Insurance Program (CHIP) that they had received for a statewide project by the Centers for Medicare and Medicaid Services, DHHS.The Department of Health in Broward County applied for the grant for Broward County and was awarded the amount of $64,988 to complete two year “Free and Reduced Lunch List” project.  The period of performance under the sub agreement commenced on August 18, 2011 and continued through August 17, 2013. The budget included $49,920 for a full time Other Personnel Services (OPS), Project Coordinator at $13.00 per hour for the time of the grant and 1.45% of requested salary dollars to cover Medicaid tax in the amount of $724.00. In addition, cost of training supplies, marketing, Printing/duplication, postage, and wireless connection in the amount of $5,272; travel to the conference in Chicago and mileage n for local travel in the amount of $3,000; indirect costs of $6,069 at 10.3% of total direct costs were also included. After the first several months of the project it was discovered that contractual required activities and reporting was time consuming and additional assistance was needed to assist with phone contact. As such, the Program Manager for volunteer Services within our agency, (LHD) assigned two Interns from our partnerships with local University’s to assist with the project as a requirement of the degree they were seeking.  Although the interns are only in the office for a few hours a week, this action has proven to increase calls by 37%, making this strategy a smart decision as well as securing grant funding for a second cycle of funding.
When evaluating the project several issues were reviewed. The questions were asked, to what degree was the LHD’s school based project able to collaborate with the school board and its nutrition department to conduct the Free and Reduced Lunch project successfully?; To what degree was educational information on the Florida KidCare Program (CHIP) dispersed to families from the Free and Reduced Lunch list; what was the success rate of insuring uninsured children? How many children were insured through this effort?The objective of the project was to determine possible eligibility of these children for Medicaid and CHIP coverage and get the ones eligible for Medicaid or CHIP successfully enrolled into the program.  The goal of enrollment was set at 90% of possibly eligible children would be enrolled into one of the Florida KidCare components. The goal of 90% enrollment was met.A strong partnership with the school system opened up doors that we could not have imagined.  Not only did we get the list of potentially uninsured children, schools showed interest in having “Enrollment Days” set for the families of the children attending their school; educational materials was kept at all the front offices and when the materials needed replenishment, the person assigned for contact would call the INSURES line to request replacement information; school nurses would contact the INSURES line for uninsured children identified in the school clinics; and our office was contacted by the Human Recourses office of the Broward County School System to include KidCare material in the school benefits package for teachers.  Many teachers have uninsured children because they cannot afford the high cost through their employment. A secure partnership through collaboration with the school system was sealed.Data collected gave results of the enrollment numbers through the Free and Reduced lunch contact.  Additional data collected such as age and ethnic background of the child, the kind of insurance the child had if found to have coverage, and the citizenship status of the family gave an insight of the health care coverage within the zip code contacted. One particular issue identified was that 34% or more of the contacts listed on the list had phone numbers that were no longer in service. This did not seem unusual at first due to the fact that zip codes with the most transient populations were targeted first.  It was only after contacts in more upscale neighborhoods commenced that we discovered there was something unusual.  Comments from parents were included in the data recorded, and it did not take long to resolve the issue. The outreach team met with the nutrition department to discuss the findings and discovered that the list of over 100,000 children eligible for the Free and Reduced Lunch program had not been purged for children aging out of school or moving away. To resolve this issue, the school board designed a new application to collect accurate data the following school year.Data collected was sent to the Project Grantee at University of South Florida (USF), and was also entered into a database on a webpage to be shared with the Department of Health and Human Services.  The project was determined by USF to be successful in that the project best practices and lessons learned of the project were presented at a statewide conference as well as featured in the Robert Wood Johnson, Florida Covering Kids and Families “Innovations” publication. Data indicated that 37% of the children from the list were actually found to be uninsured. Some families thought they were uninsured but had Medicaid; others would not qualify due to status or could not afford the full pay. Families found to be possibly eligible were set an appointment and an application was submitted for enrollment.  From that 37% the enrollment rate was 97% with 1257 children being enrolled into health care coverage.
DOH-Broward KidCare program learned that it is important to create practices and activities that have established infrastructure for sustainable school–based outreach.  That has been done with the creation of the partnership between the school board and the LHD KidCare Outreach Program. In addition this partnership has the ability to create opportunities for reach beyond targeted populations.  Since school staff has been trained on the process of assisting families with the KidCare application, they would be able to sustain enrollment for the children as long as the school staff continue to have the desire to do so. However, we have also learned that some staff does not want to take the time to do it.  These staff is the ones that referred the families to our office. It was also learned that some partnering schools are very energetic and take healthcare coverage of their students very seriously, these staff create opportunities to have “Enrollment Days” and include KidCare at every school event.Contact to the Free and Reduced Lunch applicants is also sustainable, the application continues to include the question of coverage and the list is sent to DOH-Broward every year. As long as there is funding for staff to continue the project it has been set up and ready to continue. There is minimal cost for this project. Staff salaries, office space with telephone, office supplies and a laptop computer with printer are needed.  Families that do not have health care coverage typically use the emergency room as their medical home costing up to four times as much as would a doctor visit.  Preventative care as well as oral care, that is so important to sustaining the health of a child is lost. The grant amount of $64,988 with the match of indirect costs and housing by the LHD saved the state millions of dollars in unpaid emergency room visits by enrolling these children into healthcare coverage through CHIP. The Florida Department of Health in Broward County is a primary stakeholder in this project and is committed to a partnership with this project.   As long as invested partners continue to share the cost of sustaining financial support, it will be continued.
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