Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
S C  H
TATE  HILDREN S  EALTH 
I P (SCHIP) 
NSURANCE  ROGRAM 
R P
ENEWAL  ROCESS 
JANET REHNQUIST 
Inspector General 
September 2002 
OEI-06-01-00370  Office of Inspector General

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the department, the 
Congress, and the public.  The findings and recommendations contained in the inspections 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of OI lead to criminal convictions, 
administrative sanctions, or civil monetary penalties.  The OI also oversees state Medicaid fraud 
control units, which investigate and prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal support 
in OIG's internal operations.  The OCIG imposes program exclusions and civil monetary 
penalties on health care providers and litigates those actions within the department. The OCIG 
also represents OIG in the global settlement of cases arising under the Civil False Claims Act, 
develops and monitors corporate integrity agreements, develops model compliance plans, 
renders advisory opinions on OIG sanctions to the health care community, and issues fraud 
alerts and other industry guidance.  September 20, 2002 
/s/ 
Debra Robinson 
Director, Regional Operations 
Office of Evaluation and Inspections 
OIG Memorandum Report: State Childrens Health Insurance Program (SCHIP) Renewal

Process, OEI-06-01-00370

Thomas A. Scully

Administrator

Centers for Medicare & Medicaid Services

Elizabeth M. Duke, Ph.D.

Administrator

Health Resources and Services Administration

Attached is a memorandum report that examines the State Childrens Health Insurance Program

(SCHIP) renewal process from the parents perspective and identifies opportunities for

improvement. 

We evaluated all 50 States SCHIP renewal application forms and instructions, notices, SCHIP

cards, States telephone customer services, and State SCHIP web sites. The most common way to

renew SCHIP eligibility is with mail-in forms (42 States) that typically are not user-friendly. Thirty-

three States provide SCHIP renewal instructions that are difficult to read and understand.  Parents

are not notified in writing of the disapproval outcome of the renewal in 20 States, even though States

are required to send a written notice if eligibility is denied (SCHIP regulations at 42 CFR 

457.340).  Although all States provide children an SCHIP card, only 12 States include an expiration

date, which could alert parents to the end of the eligibility period.  Obtaining SCHIP renewal

information through States SCHIP customer service telephone lines was challenging.  Only 14

States included renewal information of any kind on their State SCHIP web pages. 

States can improve their SCHIP renewal process by making small modifications.  We suggest that

CMS take steps to ensure that States comply with the Federal regulation 

(42 CFR  457.340)  to issue final outcome notices if children are disenrolled.  We encourage the

Centers for Medicare and Medicaid Services and the Health Resources and Services Administration

to work with States to provide user-friendly SCHIP renewal application forms and instructions,

SCHIP cards with coverage expiration dates, customer service telephone menus with a renewal

option, and web site access to general SCHIP renewal information. 
 Page 2 
You are welcome to provide comments but are not required to do so, since the report contains no 
recommendations. 
If you have any questions about this report or would like a meeting to discuss more detailed 
information, please contact Elise Stein, Director, Public Health and Human Services at 
(202) 619-2686. 
Attachment  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To evaluate the State Childrens Health Insurance Program (SCHIP) renewal process from the 
parents perspective and identify opportunities for improvement. 
BACKGROUND 
The State Childrens Health Insurance Program (SCHIP) allows States to expand health 
insurance coverage to certain low-income children. By September, 2001, more than 4.6 
million children who would otherwise be without health insurance were enrolled in SCHIP. 
Despite this progress, previous research suggests that eligible children are unintentionally 
disenrolled because their parents encounter difficulties navigating State SCHIP renewal 
processes, leaving them without health insurance. 
Our study examines the renewal process by simulating how parents might navigate that process. 
We collected renewal materials sent to parents from all 50 States. In addition, we accessed 
and evaluated telephone customer service lines and State SCHIP web sites.  Our review of 
these information sources provides insight into limitations within the SCHIP renewal process. 
FINDINGS 
42 States Renew SCHIP By Mail; 6 Continue Coverage Based On Self-Reports; 
2 Require In-Person Interviews 
<	 42 States require parents to complete and return forms by mail.  Of these 42 States, 10 
States provide user-friendly forms, e.g. plain language, adequate space and print size, 
minimal duplicate information. 
<	 6 States instruct parents to self-report any changes in family status.  Four of the six 
States require parents to respond only if there are changes.  Two States require parents 
to sign and return a pre-printed form if there are no changes in family status, or to 
update, sign and return the form if there are changes in status. 
<  2 States require in-person interviews to renew SCHIP. 
i 
SCHIP Renewal Process  OEI-06-01-00370  States Are Required To Send A Notice For Disapproval Of SCHIP Renewal, But 20 
States Do Not 
SCHIP regulations (42 CFR  457.340) require States to send parents a written notice if 
eligibility is denied, suspended or terminated.  We found that seven States send disapproval 
notices only, nine States send approval notices only, and 11 States do not send a final outcome 
notice. 
Although All 50 States Provide Children With An SCHIP Card, Only 12 Include An 
Expiration Date On The Card 
The coverage dates on the card alert parents that SCHIP coverage must be renewed at the end 
of the eligibility period. It is an important reminder for parents who did not receive renewal 
materials in time, and prompts them to contact their SCHIP offices. 
Parent Access To SCHIP Renewal Information Via Telephone Customer Service 
And The Internet Is Limited 
Fifty-four percent of telephone calls to SCHIP customer services resulted in obtaining general 
SCHIP renewal information.  Twenty-eight percent of the calls reached a person who was 
unable to provide the renewal information and/or told us to contact the case worker. Eighteen 
percent of calls resulted in either voice mail, a busy signal, or being on hold longer than 10 
minutes.  Thirty-four States use automated telephone menu systems for SCHIP customer 
service lines, but none of the automated telephone systems have a menu option for SCHIP 
renewal information. 
While 47 States have SCHIP web sites, 14 provide SCHIP renewal information. Only one 
State web site offers detailed information about the renewal process, including a sample form. 
CONCLUSIONS 
Renewing SCHIP coverage can be difficult for parents.  We encountered difficulties obtaining 
information when we simulated parental contact even though we have greater knowledge of the 
system and are, therefore, better equipped to negotiate it.  We identified problems with 
readability levels regarding renewal instructions and usability of forms.  We noted the absence 
of written notification for parents regarding the outcome of the eligibility renewal process and 
helpful SCHIP information on SCHIP cards in some States. We also identified problems with 
obtaining general renewal information from SCHIP customer service telephone lines and State 
SCHIP web sites. 
ii 
SCHIP Renewal Process  OEI-06-01-00370  OPPORTUNITIES FOR IMPROVEMENT 
We encourage the Centers for Medicare & Medicaid Services (CMS) and the Health 
Resources and Services Administration (HRSA) to work with States to incorporate the 
following: 
<  Take steps to ensure that States comply with the Federal regulatory requirement 
(42 CFR  457.340) to issue final outcome notices if children are disenrolled. 
<  Adopt user-friendly forms: offer plain language, adequate space and print size,  and 
minimize duplicate information. 
<  Include SCHIP coverage dates on the SCHIP card. 
<  Add a telephone menu option specifically for SCHIP renewal in those States that use 
automated telephone systems. 
<  Provide specific renewal sections on State SCHIP web sites. 
iii 
SCHIP Renewal Process  OEI-06-01-00370  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION .............................................................1

FINDINGS

42 States Renew SCHIP By Mail; 6 Continue Coverage Based On Self-Reports; 2 Require In-

Person Interviews............................................................ 6

SCHIP Renewal Instructions And Forms Can Be Difficult To Understand And Use ........... 8

Parents Are Not Always Notified Of Final Renewal Outcomes ..........................9

Although All 50 States Provide Children An SCHIP Card, Only 12 States Include An Expiration 

Date On The Card; 24 States Do Not Include The State SCHIP Program Name  ........... 10

Parent Access To SCHIP Renewal Information Via Telephone Customer Service And The Internet

Is Limited................................................................. 11

Conclusions  ............................................................... 12

OPPORTUNITIES FOR IMPROVEMENT  ...................................... 13

ENDNOTES ................................................................ 14

APPENDIX 
A: SCHIP Forms At Renewal Time  .............................................16

BIBLIOGRAPHY ............................................................ 18

ACKNOWLEDGMENTS ..................................................... 20

SCHIP Renewal Process  OEI-06-01-00370  I N T R O D U C T I O N 
OBJECTIVE 
To evaluate the State Childrens Health Insurance Program (SCHIP) renewal process from the 
parents perspective and identify opportunities for improvement. 
BACKGROUND 
In 1997, Congress enacted the State Childrens Health Insurance Program (SCHIP) as Title 
XXI of the Social Security Act to expand health insurance coverage for certain low income 
children. A low-income child is generally defined in section 2110(b)(1) of the Act as a child 
whose family income exceeds the applicable Medicaid income level by not more than 50 
percent, or 200 percent of the federal poverty level (FPL), whichever is higher.  SCHIP is a 
State-run program that entitles States to approximately $40 billion in Federal funds through 
2007. Like Medicaid, SCHIP is a joint State and Federal program; however, the Federal 
match for SCHIP is higher than that for the Medicaid Program. States have three options for 
covering uninsured children under Title XXI: to create a separate SCHIP program, expand 
Medicaid, or to combine the two approaches. 
Enrollment and Disenrollment for SCHIP-eligible Children 
By 2000, all 50 States and the District of Columbia had received approval from the Centers for 
Medicare & Medicaid Services (CMS) to expand public health insurance coverage for children 
through SCHIP. By September 2001, CMS reported that more than 4.6 million children who 
would otherwise be without health insurance coverage were enrolled in SCHIP.1 
Despite the progress of SCHIP, eligible children still lack health care coverage. A July 2001 
report2 by the Urban Institute indicated that their analysis had also identified a sizable subgroup 
of low-income uninsured children (18 percent) who were uninsured at the time of the survey but 
who had been enrolled in Medicaid or SCHIP in the past year. In other words, these children 
had dropped out of the program.  The report also indicated that there are many reasons for 
parents not enrolling or discontinuing their children in public health insurance programs. 
Reasons include administrative difficulties associated with enrollment and renewal, parents lack 
of knowledge about public health insurance programs, not wanting public insurance for their 
children, or feeling such insurance is not needed. According to the State Annual Reports, 
numerous States cited that many parents never responded to the SCHIP renewal notices. 
Children may also become ineligible for coverage because of changes in family income, 
coverage by private insurance, moving out of State, or aging out of the program. 
1 
SCHIP Renewal Process  OEI-06-01-00370  SCHIP Evaluation Efforts 
Different agencies within the Department of Health and Human Services (HHS) have been 
conducting studies regarding SCHIP disenrollments.  The Assistant Secretary for Planning and 
Evaluation (ASPE) of HHS is conducting a congressionally mandated SCHIP evaluation to 
assess enrollment and disenrollment dynamics and to analyze the programs affect on 
beneficiary access, service, and satisfaction in 10 States.3 The Agency for Healthcare 
Research and Quality (AHRQ) conducts SCHIP research through the Child Health Insurance 
Research Initiative (CHIRI).  In one study by CHIRI, The Consequences of States Policies 
for SCHIP Disenrollment, a major finding was that the renewal process generates large 
disenrollments; about half of children previously enrolled are disenrolled at renewal time, but as 
many as 25 percent return within two months.  The Centers for Medicare & Medicaid Services 
(CMS) is in the process4 of completing a project for model application forms and notices for 
SCHIP and Medicaid.  In addition, several non-profit foundations published reports that mainly 
provided useful information regarding the mechanics of the renewal process, but they lacked 
information about what parents and/or guardians might experience when they navigate that 
process. 
The Office of Inspector General has issued nine SCHIP-related inspection reports in the last 
three years. The three most recent reports are: State Childrens Health Insurance Program: 
Ensuring Medicaid Eligibles are not Enrolled in SCHIP (OEI-05-00-00241), State 
Childrens Health Insurance Program: Assessment of State Evaluation Reports (OEI-05-00-
00240), and Federally Funded Health Centers and Low Income Childrens Health Care: 
Improving SCHIP Enrollment and Adapting to a Managed Care Environment (OEI-06-98-
00321). None of the previous OIG work examined the renewal process. 
METHODOLOGY 
Study Focus 
In this report, we described what parents of SCHIP-enrolled children in all 50 States5 may 
experience when they renew their childrens SCHIP eligibility.  We focused on evaluating 
SCHIP renewal notices and application forms and accessing renewal information through 
SCHIP customer services. 
Data Collection and Analysis 
We used both qualitative and quantitative approaches to focus on three distinct aspects of the 
renewal process to: 1) describe States program type and renewal process approach; 
2) review State SCHIP renewal materials and information sent to parents; and 3) assess States 
SCHIP customer service via the telephone and the Internet. Our contacts with States SCHIP 
policy staff initially included requests for renewal materials and information; we also contacted 
them later in the study on an as-needed basis to clarify policy or questions raised by our data. 
2 
SCHIP Renewal Process  OEI-06-01-00370  SCHIP program types and renewal approach:  We extracted SCHIP renewal information 
from the State Annual Evaluation, CMS web site, individual State SCHIP web sites, and 
recent publications by the Urban Institute, Kaiser Family Foundation, National Academy for 
State Health Policy, and other research institutes. These sources provided us with information 
about the SCHIP program plan and characteristics for each State. We constructed simple 
frequencies for program types (separate, combined, or Medicaid expansion programs) and for 
States approaches to the SCHIP renewal process itself. 
SCHIP Renewal Materials: From August 30 to September 30, 2001, we collected SCHIP 
renewal materials directly from individual State SCHIP offices including SCHIP renewal 
applications, renewal notices and follow-up letters, SCHIP cards, and any other relevant 
SCHIP renewal materials that the States were using at the time of our data collection. We 
received responses from all 50 States although three States did not provide all materials.6 We 
analyzed the content of all SCHIP renewal instructions received for readability by using the 
Readability Statistics tool in Microsoft Word.  In addition, we developed a check list of 
criteria for systematically rating usability of the forms for renewal. 
Readability  The Readability Statistics tool uses both the Flesch-Kincaid Index and Flesch 
Reading Ease Scale.  The Flesch-Kincaid Index measures the school-grade writing level. 
Materials written at the 7th to 8th grade reading level are the standard for what is readable by 
and suitable for the general public. The Flesch Reading Ease Scale provides scores based on 
sentence and word length: a score of 100 is very easy to read, 0 is extremely difficult to 
read, and 65 equates to plain English. 
Usability  We rated usability of the forms used at renewal time based on the forms general 
appearance, adequacy of fields for information requested, and print size. The criteria for rating 
usability of forms were: 
C  Good:  Form has ample white space (so the form is not crowded), font size is 
readable without difficulty, field size is large enough for writing in requested 
information. 
C  Fair:  A mixed rating, with some of the elements rated good and some rated poor. 
C  Poor:  Appearance of form is crowded/cluttered, font size is small and difficult to read, 
fields size is too small for writing in information requested. 
SCHIP cards:  We also reviewed SCHIP cards to determine if the card displayed coverage 
dates and the States unique SCHIP program names. These cards are directly issued from the 
State or the Managed Care Organization that is under contract with the State to provide 
SCHIP services. 
Parent access for SCHIP renewal via telephone and the Internet: Individual SCHIP 
customer service telephone lines in all 50 States were evaluated from two aspects.  First, we 
examined success rates in obtaining renewal information using telephone 
3 
SCHIP Renewal Process  OEI-06-01-00370  numbers shown in renewal materials that the States sent us; we also noted whether customer 
service representatives were helpful and courteous when we requested assistance or 
information.  Second, we analyzed types of telephone systems with particular emphasis on 
renewal information as an option on automated menus. 
From October 24th to November 26th, 2001, we called individual State SCHIP customer 
service telephone numbers obtained from the following sources: States SCHIP renewal 
materials, SCHIP cards, and States SCHIP web sites.  We created a structured protocol for 
telephone calls to systematize this portion of the data collection. This protocol included a set of 
questions asked of all customer service representatives, an assessment of telephone systems 
(automatic vs. live person), and the helpfulness of the person who answered the phone. To 
minimize bias, we systematically made multiple calls to each State using different days and times 
of day. We made at least four telephone calls to an SCHIP telephone number for each State. 
The telephone calls were unannounced, and we did not reveal our identity or research intention. 
As part of the simulation, we tried to proactively obtain information about renewing SCHIP as 
if we were parents who needed SCHIP renewal information. We asked their help for a variety 
of reasons, ranging from not understanding the process, to having lost information sent by the 
State or its contracted agency. 
To obtain SCHIP renewal information from individual States SCHIP web sites, we visited 
each States web site twice - - once during the last week of August 2001 and again during the 
first week of December 2001.  For each visit to the web sites, we searched for renewal 
information only; we did not examine any other aspect of States SCHIP web sites. If we 
could locate renewal information, we also examined it for usefulness to the parent; that is, how 
much information about renewal would a parent know after reviewing the renewal information 
on the web site. 
Definition of Terms 
Individual States use slightly different terminology to describe the SCHIP renewal processes. 
In this report, we will use renewal to represent similar terms such as re-enrollment, re-
certification, and redetermination. We use the term parent to include any person with legal 
authority to act on behalf of the SCHIP-enrolled child, and we use child to mean one or more 
children. 
Limitations 
State SCHIP programs are continuously evolving so the findings for this report are limited to 
the time period when we completed data collection for the study (August 27 to December 5, 
2001).  In addition, our findings may understate challenges that parents experience when 
renewing their childrens SCHIP coverage. We may have been more determined to deal with 
the SCHIP system when difficulties arose, and we are probably more knowledgeable about the 
SCHIP program than parents whose experience we were trying to simulate. Furthermore, even 
though we were able to approach other aspects of renewal as if we were a parent dealing with 
4 
SCHIP Renewal Process  OEI-06-01-00370  the system, we, of course, did not have the specific child case information needed to examine 
the exchanges between case workers and parents in those States where case workers handle 
the renewal process. Also, we did not examine the actual re-enrollment rates that are 
associated with the various SCHIP renewal approaches, application forms, and notices that 
States use for SCHIP renewal. 
This study was conducted in accordance with the Quality Standards for Inspections issued by 
the Presidents Council on Integrity and Efficiency. 
5 
SCHIP Renewal Process  OEI-06-01-00370  F  I  N  D  I  N  G  S 
To evaluate the States SCHIP renewal process from the parents perspective and identify 
opportunities for improvement, we analyzed all 50 States renewal application forms and 
instructions, notices, SCHIP cards, States telephone customer services, and State SCHIP 
web sites. We encountered difficulties obtaining information when we simulated parental 
contact with renewing agencies. Because we have a wider knowledge of the system and are, 
therefore, better equipped to navigate it, we believe that parents can find the system a greater 
challenge to negotiate than we did. We identified problems with readability levels of renewal 
instructions and usability of forms. We noted the absence of written notification for parents 
regarding the outcome of the eligibility renewal process and helpful SCHIP information on 
SCHIP cards in some States. In addition, we identified problems with obtaining general 
renewal information from SCHIP customer service telephone lines and State SCHIP web sites. 
The SCHIP renewal process could be improved by making small modifications. 
42 States Renew SCHIP By Mail; 6 Continue Coverage Based On 
Self- Reports; 2 Require In-Person Interviews 
Mail-in forms (42 States)  Forty-two States7 send SCHIP renewal application forms to 
parents and require them to complete and return them to continue SCHIP coverage for their 
children.  Mail-in forms generally appear to be burdensome; parents may experience difficulty 
in completing them because of length, lack of pre-printed information previously submitted, or 
unclear instructions. (See full discussion of forms starting on page 8). States may provide 
parents with other options, such as allowing parents to call in the information via telephone or 
make in-person visits to their case workers to complete renewal forms. Appendix A provides 
detailed information. 
Continued coverage for unchanged eligibility status (6 States)  Six States 
automatically renew SCHIP eligibility unless there is a change in status. The States send 
parents letters or forms that typically provide pre-printed information about household members 
and income/expenses supplied by the parents on their initial application. These States also 
provided parents the clearest and easiest to read SCHIP renewal materials. Of the six States, 
four send a letter and require the parent to respond, only if there is a change in income or family 
status. The other two States require slightly more effort -- the parent receives a renewal form 
that is pre-printed with previously submitted information and which must be signed and 
returned. In addition, if there is a change in eligibility status, the parent must update the 
information on the form. 
In-person interviews (2 States)  Only two States require an in-person interview for 
parents to renew their childs SCHIP eligibility.  One State sends notices to parents 
6 
SCHIP Renewal Process  OEI-06-01-00370  with a preset appointment time and requires parents to come to the office for the scheduled 
time. This State does not send any forms for SCHIP renewal prior to the in-person interview. 
The other State sends parents forms to be completed and brought with them to the in-person 
interview and gives the parent a 90-day period to schedule the interview at their convenience. 
SCHIP renewal process approaches do not differ between the States SCHIP 
program types 
The three types of SCHIP programs are Medicaid expansion, separate program, and a 
combination of Medicaid expansion and separate program. Our findings indicate that there is 
no relationship between SCHIP renewal process approaches and SCHIP program types.8 
(See Table 1.) 
Table 1: SCHIP Program Types by Renewal Process Approaches 
CONTINUED  IN-PERSON 
MAIL-IN FORMS  ELIGIBILITY  INTERVIEW 
SCHIP PROGRAM TYPES  (n = 42 States)  (n = 6 States)  (n = 2 States) 
COMBINED (19)  15  3  1 
MEDICAID EXPANSION (15)  13  1  1 
SEPARATE PROGRAM (16)  14  2  0 
States send prior notification postcards, follow-up notices and return envelopes 
to assist parents in the SCHIP renewal process 
Eight States send pre-notification postcards or letters to the parent to let them know that they 
will be receiving forms for renewing SCHIP coverage.  Twenty-one States send follow-up 
notices to parents to remind them to return their forms and documentation.  State follow-up 
notices range from a simple reminder to instructions for providing specific missing information 
and/or documents, the date SCHIP coverage will expire if they do not provide the 
information/documents, and how to contact State SCHIP offices if they need help. 
Fourteen States send the parent a return envelope with the form. These envelopes minimize 
non-response by reminding parents to return the forms and providing the proper address. One 
State marks important SCHIP mail in a special way. This State includes a bright neon-yellow 
sticker on the outside of the envelope to help ensure that the parent identifies it as important 
SCHIP renewal information.  States such as California, Texas, and Minnesota with diverse 
populations have an instructional SCHIP renewal handbook that is available in several other 
languages to better serve parents with limited English proficiency. 
7 
SCHIP Renewal Process  OEI-06-01-00370  SCHIP Renewal Instructions And Forms Can Be Difficult To 
Understand And Use 
Thirty-three States provide parents renewal instructions that are difficult to read 
Despite different renewal approaches, all 50 States send written SCHIP renewal instruction 
notices to parents.  According to the Flesch-Kincaid Index, materials written at the 7th and 8th 
grade reading level are the standard for what is readable by, and suitable for, the general public. 
In 26 States, written instructions received by parents for SCHIP renewal were at the more 
difficult reading levels of 10th to 12th grade. Seven States were at the 9th grade reading level, 
which is marginal for readability according to the standard (see Table 2). 
Table 2: Readability of Instructions Provided at Renewal Time 
GRADE LEVEL  5 - 6th  7 - 8th  9th  10th  11th  12th 
STATES (n =49 States)*  2  14  7  12  6  8 
*We did not receive the material from one State. 
Using the Flesch Reading Ease Scale of 0 to 100, 100 being very easy to read and 65 
equated with plain English, we found that 49 States renewal instructions had an average 
reading scale of 56, i.e., close to plain English. Fifteen of the 49 States fell into the more 
difficult to read category of below 50 on the reading scale. 
Of the 42 States requiring mail-in forms, 25 States created a form specifically for 
renewal; 17 States require parents to re-complete the original application form 
Of the 25 States with renewal forms specifically created for renewal, 12 States pre-print some 
sections with SCHIP eligibility information previously submitted by the parent at the initial 
enrollment. Thus, parents do not have to provide the same information again. Of the 17 States 
that require parents to re-complete the original application form, only one State provides a pre-
printed form. The original application forms used for renewal were not distinctly marked to 
indicate that they were being used for renewal purposes.  In comparison, we found that forms 
created for renewal purposes only were more user-friendly than the original application forms. 
Table 3 shows this comparison. (See Methodology and Appendix A for details.) 
8 
SCHIP Renewal Process  OEI-06-01-00370  Table 3: Comparison of Renewal Forms and Original Applications 
for Renewing SCHIP Eligibility By Mail 
FORM CHARACTERISTICS  RENEWAL FORMS  RE-COMPLETE ORIGINAL 
(n = 25 States)  APPLICATIONS 
(n = 17 States) 
USES PREPRINTED INFORMATION 
Yes  48%  (12)  16%  (1) 
No  52%  (13)  84%  (16) 
AVERAGE FORM LENGTH  2 pages  4 pages 
READING GRADE LEVEL 
Easy (5th - 8th))  32%  (8)  29%  (5) 
Fair (9th - 10th)  48%  (12)  23%  (4) 
Difficult (11th - 12th)  20%  (5)  47%  (8) 
USABILITY 
Good  40%  (10)  35%  (6) 
Fair  52%  (13)  59%  (10) 
Poor  8%  (2)  6%  (1) 
INCLUDES OF RIGHTS AND 
RESPONSIBILITIES* 
Yes  64%  (16)  88%  (15) 
No  36%  (9)  12%  (2) 
*Rights and Responsibilities certify that parents understand and authorize the conditions of eligibility. 
Of the 42 States, 10 States9 have user-friendly forms, which we defined as having at least three 
of four form characteristics listed in Table 3: pre-printed information, shorter lengths, easy 
reading grade levels, and good usability.  The 10 States have only 21 percent of the SCHIP 
children ever enrolled during the year 2001, which indicates that the majority of parents are 
faced with forms that are difficult to use.10 Only one of the 10 States belongs to the top 10 most 
populous States for SCHIP enrollees.11 
Parents Are Not Always Notified Of Final Renewal Outcomes 
States are required to send a notice for disapproval of SCHIP renewal, but 20 
States do not 
SCHIP eligibility must be renewed at least every 12 months.  If eligibility is denied, suspended, 
or terminated, SCHIP regulations at 42 CFR  457.340 require States to send parents a written 
notice. We found that States take the following actions: 
	 23 States send approval or disapproval notices to parents depending on the 
outcome of the renewal. 
  7 States send disapproval notices only. 
  9 States send approval notices only. 
  11 States do not send a final outcome notice. 
9 
SCHIP Renewal Process  OEI-06-01-00370  The 11 States that do not send a final outcome notice instead send two or more follow-up 
notices that inform parents that SCHIP coverage will be discontinued if parents do not complete 
required renewal actions by a certain deadline. Without an outcome notice that clearly indicates 
disapproval or approval at the end of the renewal process, parents may make erroneous 
assumptions about whether their child is still eligible for SCHIP coverage.  In addition, 
disenrollment information explains the reasons a case may have been discontinued, whether the 
parent can provide more information in order to show eligibility, or how to contest a 
disenrollment decision. 
Although All 50 States Provide Children An SCHIP Card, Only 12 
States Include An Expiration Date On The Card; 24 States Do Not 
Include The State SCHIP Program Name 
Including coverage dates on SCHIP cards can be a powerful reminder to parents that SCHIP 
must be renewed and may prompt parents to contact their SCHIP offices if they do not receive 
renewal materials in a timely fashion.  Despite all 50 States providing these cards12 to enrolled 
children, only 12 States show both the effective and expiration dates of SCHIP coverage on the 
card. Nine States just show the effective date of the coverage on the card but not the expiration 
date. 
States typically select a unique SCHIP program name that can appear on the card and help 
build program recognition.  Unique SCHIP program names, such as Husky, MIChild, LaChip 
and Badger Care, help to reduce the perceived stigma of seeking public assistance.  These 
unique SCHIP names also help parents identify correspondence related to the program. 
Although these unique names appear on renewal materials, only 24 States printed their 
designated SCHIP program name on the SCHIP card. Parents may be confused if the program 
name that appears on their card is different from the name on the renewal materials that they 
receive in the mail. In such situations, when parents receive SCHIP renewal materials and do 
not recognize the SCHIP name, they may simply disregard them. 
10 
SCHIP Renewal Process  OEI-06-01-00370  Parent Access To SCHIP Renewal Information Via Telephone 
Customer Service And The Internet Is Limited 
Obtaining SCHIP renewal information through States SCHIP customer service 
telephone lines is challenging 
Using telephone numbers obtained from renewal forms and notices, SCHIP cards, and State 
SCHIP web sites, we made a total of 257 telephone calls, with a minimum of four to each State. 
The results of our telephone calls to all 50 States SCHIP customer service lines were: 
<  54 percent of calls resulted in obtaining requested general SCHIP renewal 
information.  Based on our experiences, persons who provided us with the 
renewal information were almost always courteous and helpful. 
<  28 percent of the calls reached a person who was unable to provide general 
SCHIP renewal information and/or who told us to contact the case worker. 
<	 18 percent of the calls resulted in a busy signal (7 percent), being on hold longer 
than 10 minutes (3 percent), or reaching a voice mail box (8 percent). 
As indicated in the methodology section, we simulated parents experiences, but we did not 
have a specific childs information nor could we reveal our identity. When we reached voice 
mail we were, therefore, unable to leave a message. Consequently, we were not able to 
determine if the telephone calls that reached voice mail (8 percent) would result in calls being 
returned to us. 
We found that 19 States rely on case workers for the renewal process.  In these States, case 
workers are the primary source for obtaining renewal information. Of the calls made to these 19 
States, 55 percent resulted in obtaining requested SCHIP renewal information.13 In 26 percent 
of these calls, case workers would not provide us with renewal information, even general 
information, without specific identifying information for a child, such as a social security number. 
The remaining 19 percent of these calls resulted in reaching voice mail.  We did not receive any 
returned calls from the case workers because we did not leave any messages on their voice 
mails. 
Of the 34 States with automated telephone menus, none offered specific SCHIP 
renewal menu options 
Our telephone calls reached one of the following three venues: an operator (16 States), an 
automated system with an operator (32 States), and an automated system with no operator (2 
States). For those calls that reached an automated system, none offered specific renewal 
information or procedures, although eight of 34 States included a menu option for verifying 
eligibility status. Also, at times we were not sure if we had reached the SCHIP customer service 
telephone line since the initial greeting message from the automated 
11 
SCHIP Renewal Process  OEI-06-01-00370  system or operator was not clear.  For example, in one State the initial greeting is consumer 
hotline and another State uses State resource line. 
Of 14 States that provide any renewal information on their State SCHIP web sites, 
only one State includes a sample renewal form and instructions 
State SCHIP web sites emphasize enrolling new children in SCHIP but lack information about 
renewing eligibility for an already enrolled child.14 At the time of our review, three States 
SCHIP web sites were unavailable. Fourteen15 of 47 States provided SCHIP renewal 
information on the web sites.  Of those 14 States SCHIP web sites, on average, it took passing 
through four to five web pages to reach the renewal information. 
In reviewing the 14 States SCHIP renewal information on their SCHIP web sites, we found: 
<	 1 State provides comprehensive SCHIP renewal information, including renewal forms 
and user friendly instructions. 
<	 1 State provides a renewal form under a Documents and Forms section but it is 
difficult to access the form without prior knowledge of the exact web address or the 
name and number of the form. 
<	 2 States only provide the following information about renewal: the client is enrolled for 
12 months, and the client must re-enroll after one year. 
<	 10 States simply mention that the client will be notified by mail when it is time to renew; 
this information is included either in a section on Frequently Asked Questions or as 
part of an on-line manual. 
Offering renewal information on the States SCHIP web site can be valuable to other interested 
entities, such as community health centers, community-based organizations, hospitals or private 
health care providers for their own information as well as for providing assistance to parents. 
Also, the Internet can be a very useful resource for those parents who have access to it. 
Conclusions 
Renewing SCHIP coverage can be difficult for parents.  We encountered difficulties obtaining 
information when we simulated parental contact even though we have greater knowledge of the 
system and are, therefore, better equipped to negotiate it.  We identified problems with 
readability levels of renewal instructions and usability of forms. We noted the absence of written 
notification for parents regarding the outcome of the eligibility renewal process and helpful 
SCHIP information on SCHIP cards in some States.  In addition, we identified problems with 
obtaining general renewal information from SCHIP customer service telephone lines and State 
SCHIP web sites.  The SCHIP renewal process could be improved by making small 
modifications. Some States may already have implemented the recommended action or are 
planning on implementing it in the future. 
12 
SCHIP Renewal Process  OEI-06-01-00370  O P P O R T U N I T I E S  F O R  I M P R O V E M E N T  
The Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services 
Administration (HRSA) are the two main agencies responsible for the SCHIP program.  We 
offer to CMS and HRSA the following steps, which could improve the SCHIP renewal process. 
CMS could: 
<	 Take steps to ensure that States comply with the Federal regulatory requirement 
(42 CFR  457.340) to issue final outcome notices if children are disenrolled. 
<	 Complete and issue the CMS report for model application forms and notices. These 
models would assist States to develop forms and notices that meet the Federal 
regulatory requirement. 
CMS and HRSA could encourage States to: 
Continue to make the renewal process easier for parents. 
<	 Use systematic guidelines to create forms that are written in plain language, offer 
adequate space for filling in information, provide easily read print size, and minimize 
duplicate information. 
<  Include SCHIP beginning and ending coverage dates on the SCHIP card. 
<	 Include the unique SCHIP program name on the SCHIP card and on renewal 
correspondence - - or, at least, use one name consistently for easy recognition. 
Provide parents easier access to needed renewal information. 
<	 Add a telephone menu option specifically for SCHIP renewal to their automated 
telephone systems. 
<	 Encourage caseworkers to leave a message on their voice mail so that they will accept 
incoming calls during a specified time period convenient for them. 
<  Include specific renewal sections in State SCHIP web sites. 
13 
SCHIP Renewal Process  OEI-06-01-00370  E N D N O T E S 
1.  Centers for Medicare & Medicaid Services website, www.CMS.gov. 
2.	 Genevieve Kenney, Jennifer Haley. Why Arent More Uninsured Children Enrolled in 
Medicaid or SCHIP? Washington, D.C.: The Urban Institute. Assessing the New 
Federalism Policy Brief B-35. 
3.	 Mathematica Policy Research, ASPE SCHIP evaluation announcement. 
http://www.mathematica-mpr.com 
4.	 In 2000, CMS awarded a contract to the Maximus Center for Health Literacy and 
Communications Technologies to develop English and Spanish model applications and notices 
for States that are beneficiary-based.  CMS was scheduled to make these notices available to 
States in the Spring of 2002. In addition to the models, Maximus is also developing guidelines 
to assist States in creating effective written communications.  These guidelines build upon the 
Writing and Designing Print Materials for Beneficiaries guide, released in 1999. 
5.	 We did not include the District of Columbia, Puerto Rico, American Samoa, Commonwealth of 
Northern Mariana Islands, Guam, or Virgin Islands in this inspection. 
6.	 Florida did not provide a renewal application form.  Rhode Island and Virginia did not provide 
sample SCHIP cards. 
7.	 There are six Combination Program Type States (CA, IA, IL, MI, ND, TX) that utilize two 
offices to handle SCHIP (Medicaid expansion and a Separate component of SCHIP) and that 
also use two separate forms for renewal. We only reviewed the Separate SCHIP Program 
Type component for these States. The Medicaid expansion program forms are not included in 
the analysis. 
8.  Chi Square test result was not significant. 
9.	 The 10 States that have user-friendly forms are AK, IA, ID, IL, KS, LA, NE, TX, UT and 
WA. 
10.	 This percentage is calculated based on number of children ever enrolled in SCHIP during the 
year 2001 in the 42 States that use forms for renewal. This information was obtained from the 
State Childrens Health Insurance Program Annual Enrollment Report, Federal Fiscal Year 
(FFY) 2001: October 1, 2000 - September 30, 2001, Centers for Medicare & Medicaid 
Services, February 2002. 
11. 	 Texas is the one State out of the group with user-friendly forms that is also one of the ten most 
populous States in terms of children ever enrolled in SCHIP. The ten most populous SCHIP 
enrollee States in FFY 2001 were CA, FL, GA, MA, MD, MO, NY, OH, PA and TX. This 
14 
SCHIP Renewal Process  OEI-06-01-00370  information was obtained from the State Childrens Health Insurance Program Annual 
Enrollment Report, Federal Fiscal Year (FFY) 2001: October 1, 2000 - September 30, 2001, 
Centers for Medicare & Medicaid Services, February 2002. 
12.  Virginia and Rhode Island have SCHIP cards, but they did not send us a sample card. 
13.	 We obtained the case workers telephone number from the following initial sources: 10 States 
were from SCHIP cards, 3 States were from renewal materials and 6 States from SCHIP web 
sites. 
14.	 We initially surveyed State web pages during the last week of August 2001 and then again in 
December 2001 to determine if we could find SCHIP renewal information on these web sites. 
In both August and December, one State did not have an SCHIP web site and one States web 
page was under construction. In December, an additional States web page was under 
construction.  All other States had web pages for SCHIP - of these 48 States, in August, 12 
States web sites specifically mentioned the renewal process in some form. In December, 14 
States mentioned the renewal process in some form, representing a slight gain over a three-
month period. 
15.	 The 14 States are AK, CA, CT, IN, KY, MN, MT, NJ, NC, ND, OH, TX, WV and WY. 
Alaska provides the most comprehensive web site for SCHIP renewal information. 
15 
SCHIP Renewal Process  OEI-06-01-00370  A P P E N D I XA   
SCHIP Forms at Renewal Time 
(August 30 - September 30, 2001) 
Type of  Approach at  Content*  Analysis Measures 
SCHIP  Renewal Time 
Program  Readability (a)  Usability (b) 
Ease Scale  Grade level 
(0-100 best)  (7th - 8th is standard) 
AK  Medicaid  Renewal form  Pre-print  46.6  11  good 
AL  Combination  Renewal form  Blank  58.3  10.3  fair 
AR  Medicaid  Renewal form  Blank  43.9  10  fair 
AZ  Separate  Renewal form  Blank  57.9  8.9  fair 
CA  Combination  Renewal form  Blank  47.7  11.5  fair 
CO  Separate  Original form  Blank  64.1  8.3  fair 
CT  Combination  Original form  Blank (c)  62.2  8.3  fair 
DE  Separate  Original form  Blank  33.5  12 good 
FL  Combination  Continued  ( No Info) 
GA  Separate  Continued  N/A  55.6  9  n/a 
HI  Medicaid  Original form  Blank  30.7  12  fair 
IA  Combination  Renewal form  Pre-print  80.2  5.2 good 
ID  Medicaid  Renewal form (d)  Pre-print  83  5.5  good 
IL  Combination  Renewal form  Pre-print  43.4  12  good 
IN  Combination  Renewal form (e)  Blank  59.6  9.9  fair 
KS  Separate  Original form  Blank  66.2  7  good 
KY  Combination  In-person  N/A  55.4  10.2 n/a 
LA  Medicaid  Renewal form  Blank  68.5  7  good 
MA  Combination  Original form  Blank  62.3  9.6  fair
MD  Combination  Original form  Blank  64.3  8.5  fair 
ME  Combination  Renewal form  Blank  54.8  8.8  fair 
MI  Combination  Renewal form  Pre-print  58.9  9.8  good 
MN  Medicaid  Renewal form  Blank  61.3  8.4  fair 
MO  Medicaid  Renewal form  Blank  43.3  10  fair 
MS  Combination  Continued  N/A  55.6  9  n/a 
MT  Separate  Original form  Blank  40.5  11.8 poor 
NC  Separate  Renewal form  Blank  56.9  10  fair 
ND  Combination  Renewal form  Pre-print  56.2  9.1  fair
NE  Medicaid  Renewal form  Blank  70.3  7  good 
NH  Combination  Original form  Blank  49.6  11.3  fair 
NJ  Combination  Continued (f)  Pre-print  41.9  12  good 
__________ 
16 
SCHIP Renewal Process  OEI-06-01-00370  Type of  Approach at  Content*  Analysis Measures 
SCHIP  Renewal Time 
Readability (a)  Usability (b) 
Program 
Ease Scale  Grade level 
(0-100 best)  (7th - 8th is standard)
NM  Medicaid  Original form (g)  Blank  39.3  11.9  good 
NV  Separate  Continued (f)  Pre-print  63.4  8.2  good 
NY  Combination  Original form  Blank  56.1  9.9  fair 
OH  Medicaid  Original form  Blank  45.4  11.4  fair
OK  Medicaid  Renewal form  Blank  48.1  10.3  poor 
OR  Separate  Original form  Blank  68.3  7  fair
PA  Separate  Renewal form  Blank  52.2  9.7  good 
RI  Medicaid  Renewal form  Blank  63.6  7.7  fair 
SC  Medicaid  Continued  N/A  68  8  n/a 
SD  Combination  Renewal form  Blank  43.5  11.4  fair 
TN  Medicaid  In-person  Blank  69.7  7.8  poor 
TX  Combination  Renewal form  Pre-print  66.5  8.4  good 
UT  Separate  Renewal form  Pre-print  61.1  8.7 good 
VA  Separate  Original form  Pre-print  50.1  12  good 
VT  Separate  Original form  Blank  54.6  9.7  fair
WA  Separate  Original form  Blank  64.3  8.2  good 
WI  Medicaid  Original form  Blank  46  11.1 good 
WV  Separate  Renewal form  Pre-print  69.1  7.1  poor 
WY  Separate  Renewal form  Pre-print  47.4  10.9  fair 
*Content: States using pre-printed information contain most recent application and account information on the 
client. If the information is still correct, the parent is required to sign and date the form and send it back. However, 
if the information has changed, parents are instructed to cross out and write in new information and return the form. 
(a) Readability is an objective measure using the Microsoft Word readability program which provides scores 
using the Flesch Reading Ease Scale and the Flesch-Kincaid Index. 
(b) Usability of the form was rated according to white spaces on the form, readability of font size, and adequacy of 
the fields for information requested. See Methodology section of the report. 
(c) CT has very little pre-printed information provided on form. It is mostly blank. 
(d) ID uses multiple methods. A form is required if changes in circumstances and will allow continued eligibility. 
(e) IN uses renewal forms, but encourages in-person office visit. They also allow clients to renew over the 
telephone and update new information. 
(f) NJ and NV use a continued automatic approach unless the parents report changes to their circumstances, 
although parents must respond with a signature to continue coverage. These States have a renewal form, however, 
it is not required unless the parent has a change of circumstances. 
(g) NM requires the form or an in-person renewal visit. 
__________ 
17 
SCHIP Renewal Process  OEI-06-01-00370  B  I  B  L  I  O  G  R  A  P  H  Y 
The Center for Health Literacy and Communication Technologies.  Simplifying Medicaid/SCHIP 
Enrollment and Retention Forms (SMERF). What People are Saying About Notices and Apps. -
English, Maximus. 
Cunningham, Peter J.  Targeting Communities with High Rates of Uninsured Children, Health Affairs, pp. 
20-29. 
Dick, Andrew R., Andrew Allison, Susan G. Haber, Cindy Brach, Elizabeth Shenkman.  The Consequences 
of States Policies for SCHIP Disenrollment, 2002, The Child Health Insurance Research Initiative. 
The George Washington University Center of Health Policy and Research, Room to Grow: Promoting Child 
Development Through Medicaid and CHIP, The Commonwealth Fund, July 2001. 
Health Care Financing Administration (CMS), Outreach & Eligibility Division, Model Application and Best 
Practice Guide, GS-23F-9796H, 2000. 
Kannel, Susan, Michael Perry, Trish Riley, Cynthia Pernice, What Parents Say: Why Eligible Children Lose 
SCHIP, June 2001, National Academy for State Health Policy. 
Kenney, Genevieve, Jennifer Haley. Why Arent More Uninsured Children Enrolled in Medicaid or SCHIP? 
Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief B-35. 
Kenney, Genevieve, Jennifer Haley, Lisa Dubay How Familiar Are Low-Income Parents with Medicaid and 
SCHIP? Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief B-34. 
Kenney, Genevieve, Jennifer Haley, Frank Ullman, Most Uninsured Children Are in Families Served by 
Government Programs Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief 
B-4. 
Kaiser Commission on Medicaid and the Uninsured. 2000. Making it Simple: Medicaid and CHIP Income 
Eligibility Guidelines and Enrollment Procedures, Prepared by Donna Cohen and Laura Cox. Washington, 
D.C.: Center on Budget and Policy Priorities, 2000. 
Kaiser Commission on Medicaid and the Uninsured. 2000. CHIP Program Enrollment: June 2000, 
Prepared by Vernon K. Smith Ph.D. Lansing, MI: Health Management Associates, 2001. 
Letter to The Honorable Christopher S. Bond, dated July 25, 2001. Subject: Childrens Health Insurance: 
SCHIP Enrollment and Expenditure Information, signed by Kathryn G. Allen, Director, Health Care-Medical 
and Private Health Insurance Issues, U.S. Government Accounting Office. 
__________

18 
SCHIP Renewal Process  OEI-06-01-00370  Lipsey, Mark, David Wilson, Practical Meta-Analysis, Applied Social Research Methods Series, 
Vol. XX, Thousand Oaks, CA, Sage Publications, Inc. 
National Governors Association (NGA), Retention and Reenrollment of Children in SCHIP and 
Medicaid, available at http://www.nga.org. 
National Governors Association (NGA), Strategies for Retention and Reenrollment of Children in 
SCHIP and Medicaid, available at http://www.nga.org. 
Office of Inspector General, Department of Health and Human Services, The Childrens Health Insurance 
Program: State Application and Enrollment Processes: An Early Report from the Front Lines, OEI-05-
98-00310, 1999. 
Office of Inspector General, Department of Health and Human Services, State Childrens Health Insurance 
Program: Assessment of State Evaluations Reports, OEI-05-00-00240, 2001. 
Pernice, Cynthia, Kirsten Wysen, Trish Riley, Neva Kaye, Charting SCHIP: Report of the Second 
National Survey of the State Childrens Health Insurance Program, National Academy for State Health 
Policy, July 2001. 
Ross, Donna Cohen, Laura Cox, Medicaid for Children and CHIP Income Eligibility Guidelines and 
Enrollment Procedures, Center on Budget and Policy Priorities, October 2000. 
Urban Institute, Parents Reasons for Not Obtaining Public Health Insurance for Children More Complex 
Than Once Thought, http://www.urban.org/news/pressrel/p010702.html, July, 2, 2001. 
Wooldridge, Judith, Brenda Cox, Mary Harrington, Lorenzo Moreno, Christopher Trenholm, Welmoet van 
Kammen, Will Black, Amy Zambrowski, Design Report: Congressionally Mandated Evaluation of the State 
Childrens Health Insurance Program, Mathematica Policy Research, Inc. Contract number HHS-100-01-
0002, 2001. 
__________

19 
SCHIP Renewal Process  OEI-06-01-00370  A C K N O W L E D G M E N T S  
This report was prepared under the direction of Judith V. Tyler, Regional Inspector General for Evaluation and

Inspections in Dallas. Other principal Office of Evaluation and Inspections staff who contributed include:

Nancy H. Juhn, Ph.D., Team Leader  Alan Levine, Program Specialist

Marnette E. Dhooghe, Program Analyst  Joan Richardson, Program Specialist

Gina Collins, Program Analyst

Lisa White, Administrative Officer

__________

20 
SCHIP Renewal Process  OEI-06-01-00370