REPORT TO THE PRESIDENT ON

SCHOOL-BASED OUTREACH FOR 

CHILDREN’S HEALTH INSURANCE

Submitted by the 

Secretary of Health and Human Services

July 2000

In Collaboration With

The Secretary of Agriculture 

The Secretary of Education 
REPORT TO THE PRESIDENT

SCHOOL-BASED OUTREACH

for

CHILDREN’S HEALTH INSURANCE

HHS LOGO

Submitted by the 

Secretary of Health and Human Services

July 2000

In Collaboration With

The Secretary of Agriculture 

The Secretary of Education 
-iiExecutive Summary

The lack of health insurance for millions of American children remains one of the great challenges facing

the nation. In 1997, President Clinton worked with Congress to create the bipartisan State Children’s

Health Insurance Program (SCHIP), the single largest expansion of children’s health insurance in 30

years. Every State and Territory has responded to this opportunity provided by SCHIP to expand

health insurance coverage to low-income children. SCHIP builds upon the Medicaid program, which

currently provides health coverage to very low-income children. States have broad flexibility to expand

Medicaid to cover more low-income children and 23 States have exercised this option, 18 States have

a combined Medicaid/SCHIP program and the remaining 15 States have separate State programs. As

of September 1999, nearly 2 million children who would otherwise be without health insurance were

enrolled in SCHIP and many more have also been enrolled in Medicaid as a result of increased

outreach efforts. 

Together, SCHIP and Medicaid could cover more uninsured, low-income children. There are still

many eligible but unenrolled children whom we need to reach. Barriers to enrollment persist, including

parents’ lack of knowledge about insurance options, cultural and language barriers, complicated

application and enrollment processes and the stigma associated with publicly-funded programs. 

Because most of the nation’s children can be found in schools (including preschool, Head Start and

child care), a natural place for outreach efforts to increase health insurance enrollment is in our schools. 

On October 12, 1999, the President directed the Secretaries of Health and Human Services (HHS),

Education (ED) and Agriculture (USDA) to develop specific recommendations to encourage and

integrate Medicaid and SCHIP outreach and enrollment for children in school settings. Over the past

several months, a cross-Departmental workgroup gathered information about school-based outreach

from national, regional, state and local health and education sources and held a National Summit to find

promising outreach practices.

Our findings indicate that school systems and early childhood programs are indeed the critical link in

successful outreach for children’s health insurance programs in many States. In communities across the

country, schools are accepted by parents as a conduit for important and credible information. Many

schools already partner with States, community-based organizations or provider groups to conduct

outreach. Current school outreach activities vary widely, from providing information for children to

take home to directly assisting families with enrollment. 

There is widespread recognition; however, that schools face multiple barriers in these efforts. Schools

lack the funding, expertise or time it takes to conduct sustained outreach campaigns. Privacy issues

make sharing information between programs difficult. It is important to remove these barriers through

collaboration and partnerships around child health in order to build on and expand effective outreach

campaigns in schools across the country. 

There is a shared recognition at all levels that America’s children face many compelling educational,
-iiihealth and developmental challenges that affect their lives and their futures. The fields of education and

health must work together to give children the assistance they need to have bright and healthy futures.

At the request of the President, we have prepared a Report which outlines our findings, describing

barriers and promising approaches to school-based outreach and makes recommendations to ensure

that health insurance outreach for children becomes a customary part of school activity. The Report

also provides a Federal action plan for assisting States and schools in this effort. In addition, we are

developing “how to” school-based outreach guides for distribution to school districts and schools,

providers and community groups. Throughout this Report, we refer to schools in the broader sense to

include both schools and early childhood programs.

Recommendations for the Federal Government

Although States have used many creative approaches so far to reach out to uninsured children through

Medicaid and SCHIP, challenges to identifying and enrolling eligible children remain substantial. While

schools can participate in outreach and enrollment efforts under current law, the following proposals

would enhance their ability to increase outreach activities and enroll many more uninsured children. We

strongly support the President's fiscal year 2001 budget proposals to accelerate the enrollment of

Medicaid and SCHIP eligible children through 

schools and are pleased with the recent passage of legislation by Congress and signed by the President

which will increase the coordination between Medicaid, SCHIP and the National 

School Lunch Program. Additionally, we recommend the Federal government act 

on the following recommendations:

‘Facilitate coordinated enrollment activities between Medicaid, SCHIP and other public

programs with similar eligibility criteria, such as the National School Lunch Program.

‘Provide technical assistance and support to help States, communities, health care

providers and schools implement school-based outreach and enrollment activities for

Medicaid and SCHIP. 

‘Encourage new or additional school-based outreach and enrollment efforts by

helping States and schools identify and maximize funding opportunities.

Promising State Practices 

Almost every State enlists the support of schools in its outreach and enrollment strategies for reaching
-ivchildren. In the most effective examples, State agencies’ participation have been integral to successful

outreach. The State provides leadership, enacts enabling legislation or promulgates effective regulations

and procedures, and makes available the essential resources. Without these elements, school-based

enrollment may not be successful or sustainable. 

The promising State practices included in this Report are based on models where States exercised their

leadership and used their resources to achieve successful school-based outreach and enrollment. 

Simplification is central to the success of outreach and enrollment strategies. The Administration is

doing much to encourage simplification, and most States are making efforts to simplify their enrollment

systems further. While simplification is critical to successful enrollment efforts, this section of the Report

focuses on school-based recommendations and strategies. States can use these promising practices

and those that follow for schools to develop or expand their State-specific strategies and plans of

action.

While many of the descriptions of the practices refer solely to schools, these same approaches have

also shown promise for early child care/education program settings.

Promising Practices for School Districts and Schools

Because of their unique role in local communities, schools are effective in identifying and educating

uninsured families and motivating them to seek health insurance and utilize health services for their

children. Families believe school organizations associated with school systems provide credible and

reliable information. Several State officials report that schools are one of the primary sources of health

insurance information identified by callers to State eligibility centers. 

Our research on current outreach activities in schools highlighted a wide array of successful techniques

to identify and help enroll uninsured children in children’s health insurance programs. In part, the

continuum of successful outreach includes: identifying and understanding eligible children and their

families; educating individuals about the programs; motivating people to take action; facilitating actions

needed to enroll children in the programs; following-up with families and State agencies on the status of

applications; and evaluating the outreach strategy. While schools can actively participate in all five steps

described in the outreach continuum, many schools have fully participated in identifying, educating and

motivating families to enroll their uninsured children.

Recommendation for Evaluation

An important step in implementing the recommendations in this Report is to develop evaluation

strategies that the Federal government, States and schools can use to determine the success of their
-vschool-based outreach efforts. Designing an evaluation component during the planning stages of an

outreach project forces planners to specify the project’s desired outcomes. In SCHIP and Medicaid

outreach, the ultimate desired outcome is increased access to comprehensive health care especially

primary and preventive health services, through increased enrollment. However, focusing on evaluation

encourages planners to strategically identify incremental steps that must be accomplished to obtain the

ultimate desired outcome. 

In order to promote evaluation of school-based outreach activities, we propose the following

recommendation:

‘The Federal government should evaluate school-based outreach and enrollment in

partnership with States, communities and schools.

Summary

In summary, schools and early child care/education programs are a promising place to conduct

outreach for children’s health insurance. Most uninsured children can be found in these settings and

most parents look to schools and early childhood programs for information they can trust related to

their children. However, schools and early childhood programs face multiple barriers in conducting

health insurance outreach, including constraints on time, resources and expertise, as well as privacy

issues that limit information sharing. In order to facilitate school-based outreach for children’s health

insurance, the Federal Government, the States, schools and other partners must join together to break

down existing barriers and connect eligible children with the health coverage they need. This Report

proposes a set of recommendations that would greatly reduce the existing barriers that keep schoolbased outreach from becoming an integral part of school business. 
-viTable of Contents

Section 1: Background........................................................................ 1

Significance of the Problem of Uninsured Children

New Opportunities to Provide Health Insurance for Children

Importance of Outreach

President Clinton’s Executive Memorandum 

Departmental Response

Section 2: Summary of Findings........................................................ 9

Role of Schools in Reaching Uninsured Children

 Importance of Health Insurance for Children

Motivating Schools to Adopt Outreach as Part of Their Mission

Constraints and Barriers

Keys to Success

Funding School-Based Outreach

Section 3: Recommendations for Federal Action............................ 15

Federal-level Recommendations

Models That Work: Spotlight on Northern Virginia

Section 4: Promising Practices - Innovative Outreach Approaches 

for States and Schools ............................................ 26

Part 1: Promising State Practices

Models That Work: Spotlight on San Diego

Models That Work: Spotlight on Chicago Public Schools

Part 2: Promising Practices for School Districts, Schools and 

Early Child Care/Education Programs

Models That Work: Spotlight on Florida

Section 5: Evaluation.......................................................................... 42

Completed Evaluations of Outreach to Increase Enrollment

Evaluation Recommendations

Summary................................................................................................. 47

Appendix A: Executive Memorandum
 United States Department of Commerce, www.census.gov/hhes/hlthins98.html. 1

1

Appendix B: Federal Action Plan

REPORT TO THE PRESIDENT ON SCHOOL-BASED 

OUTREACH FOR CHILDREN’S HEALTH INSURANCE

On October 12, 1999, the President directed the Secretaries of Health and Human Services (HHS),

Education (ED) and Agriculture (USDA) to develop a set of recommendations to integrate outreach

efforts to enroll children in Medicaid and the State Children’s Health Insurance Program (SCHIP) as a

regular part of school business. (See Appendix A, Executive Memorandum). In response to this

directive, a cross-Departmental workgroup has gathered information from national, regional, State and

local health and education sources. This Report outlines their findings, describes barriers and promising

approaches to school-based outreach, gives recommendations to make health insurance outreach for

children a customary part of school activity and suggests strategies to evaluate these efforts. The

Report also provides a Federal action plan for assisting States and schools in this effort. (See

Appendix B, Federal Action Plan).

Significance of the Problem of Uninsured Children

Despite unprecedented economic growth and record low unemployment in recent years, in 1998 there

were more than 11 million children under the age of 18 who lacked health insurance coverage in the

United States. Children represent approximately 25 percent of all uninsured. Two out of three of these 1

children, or over 7 million, live in families with household incomes below 200 percent of the Federal

Poverty Level (FPL). 

New Opportunities to Provide Health Insurance for Children

Lack of health insurance for millions of American children remains one of the great challenges facing the

nation. In 1997, President Clinton worked with Congress to create the bipartisan State Children’s

Health Insurance Program (SCHIP), the single largest expansion of children’s health insurance in 30
2

years. The 1997 Balanced Budget Act allocates $24 billion over 5 years to extend health care

coverage to millions of uninsured children in working families. SCHIP is a Federal/State partnership

that gives States three options for covering uninsured children: designing a new children’s health

insurance program; expanding its current Medicaid program; or a combination of both strategies. 

Every State and Territory has responded to the opportunity provided by SCHIP to expand health

insurance coverage to low-income children. 

SCHIP builds upon the Medicaid program, which currently provides health coverage to most very

low-income children. Changes have also transformed the Medicaid program. Prior to 1996, many

low-income families were eligible for Medicaid through the Federal cash assistance program Aid to

Families with Dependent Children. The Personal Responsibility and Work Opportunity Reconciliation

Act of 1996 replaced the old cash assistance programs with a new State-run Temporary Assistance for

Needy Families (TANF) program and ended the automatic link between eligibility for cash assistance

and eligibility for Medicaid. To preserve Medicaid coverage for low-income families with children, the

welfare reform law created a new Medicaid eligibility category. Under the new provision, families who

would have qualified for Medicaid under a State’s old cash assistance program are currently eligible for

Medicaid now, regardless of whether or not they currently receive TANF assistance. The law also

made available to States $500 million in enhanced matching funds to support system changes and

outreach necessary to address the effects of “delinking” Medicaid from welfare. States were also

provided with broad flexibility to expand Medicaid to cover more low–income families as an option. A

number of the States have exercised this option. 

Together, SCHIP and Medicaid could cover most uninsured children. However, increased outreach

efforts are necessary to identify and enroll these eligible children.

The Importance of Outreach

Outreach for children’s health insurance is a dynamic process of identifying eligible children and families,

and educating and enrolling them in Medicaid or SCHIP. The Federal government has worked in

partnership with States to find and enroll eligible children in both SCHIP and Medicaid. In 1999,

President Clinton and the National Governors’ Association launched the Insure Kids Now! campaign

which includes a national toll-free number (1-877 KIDS-NOW) and web site

www.insurekidsnow.gov. The Insure Kids Now! hotline is a toll-free number that connects callers

automatically to their own State agency that conducts enrollment activities for Medicaid and SCHIP. 

To date, over a quarter of a million calls have been placed through this number. The website has

information on eligibility requirements for families and ongoing outreach efforts. Federal efforts

continue to support State efforts to inform, identify and enroll children in their SCHIP or Medicaid

programs. Many States have implemented aggressive outreach and enrollment campaigns that use
 Smith, Vernon K., Eileen Ellis and Health Management Associates, “Medicaid Enrollment in 21 States: 2

 June 1997 to June 1999,” Prepared by the Kaiser Commission on Medicaid and the Uninsured, 

 April 2000.

3

radio, television and print media to inform families about the States’ programs, provide a toll-free

hotline, outstation eligibility workers in local 

communities, and involve schools, employers, health care providers, community-based organizations

and the business community. 

As a result of these and other outreach efforts, nearly two million children who would otherwise be

without health insurance coverage were enrolled in SCHIP during Federal fiscal year 1999. This is

twice the number reported for the first full year of the program. The new enrollment figures were

released by HHS Secretary Donna Shalala in January 2000 and are based on State-by-State reported

data on the number of children who had access to health insurance from October 1, l998 to September

30, 1999. Of the nearly two million children covered during Federal fiscal year 1999, States reported

that more than 1.2 million were in the new State-designed children’s health insurance program and

almost 700,000 were enrolled in Medicaid expansion plans. These figures represent only those

children for whom States received SCHIP funding; many children have also been enrolled in Medicaid

as a result of increased outreach efforts. The study of Medicaid enrollment in 21 States, recently

reported by the Kaiser Commission on Medicaid and the Uninsured, suggests an upward trend in

Medicaid enrollment in 12 States as of June 1999, thus reversing an earlier decline. 2

Despite these encouraging figures, millions of children are still eligible for Medicaid and SCHIP but are

not enrolled. Approximately 3 million low-income uninsured children are eligible for SCHIP and

approximately 4 million are potentially eligible for Medicaid but are not enrolled. Barriers to enrollment

persist, including parents’ lack of knowledge about insurance options; cultural and language barriers;

special fears among immigrant families; complicated application and enrollment processes; and the

“stigma” associated with so-called welfare programs. Intensified outreach is needed to overcome these

barriers. 

President’s Executive Memorandum

Most uninsured children can be found in schools (or in preschool, Head Start and child care programs)

and since most parents consider schools a trusted conduit for important information, schools are a

critical link in outreach. Recognizing the important role that schools can play in outreach for health

insurance programs, President Clinton, on October 12, 1999, issued an Executive Memorandum

directing the Secretaries of Health and Human Services, Agriculture, and Education to recommend

specific actions to encourage and integrate health insurance outreach and enrollment for children in
 Memorandum for the Secretary of Health and Human Services, the Secretary of Education, and the Secretary 3

of Agriculture, Subject: School-Based Health Insurance Outreach for Children; The White House, Office of the

Press Secretary, October 12, 1999. See Appendix A. 

4

school settings. The memorandum asks for short and long-term recommendations on administrative 3

and legislative actions for making school-based outreach to enroll children in SCHIP and Medicaid an

integral part of school business. These actions may include: 

• Technical assistance and other support to school districts and schools that engage in outreach;

• Suggestions on how to effectively use the school lunch program application process to promote

enrollment in health insurance programs; 

• Lists of practices that have proven effective, such as integration of outreach and enrollment

activities into school events; and 

• Model SCHIP and Medicaid policies and plans for school-based outreach.

Finally, the President asked for a summary of key findings from national and regional conferences on

school-based outreach and for recommendations on methods to evaluate SCHIP and Medicaid

outreach strategies in schools. The President directed the Department of Health and Human Services

to serve as coordinating agency in the development of these recommendations and asked the Secretary

of Health and Human Services report back to him in six months.

In the interim, the Administration has continued to work through public and private efforts to improve

children’s health coverage. The President’s Budget for Fiscal Year 2001 includes several proposals

that would facilitate outreach and enrollment, including extending coverage by creating a new “Family

Care” program that would build on SCHIP to extend coverage to uninsured parents of low-income

children and expand State options to insure children through age 20. The President also proposed

accelerating enrollment of eligible Medicaid and SCHIP children through programs that promote

enrollment simplification, expansion of enrollment sites, and information sharing between the school

lunch program and Medicaid. In addition, the President proposed giving States the option to insure

legal immigrant children and pregnant women in Medicaid and SCHIP regardless of their date of entry

into this country.

Departmental Response

To implement the Executive Memorandum, the three Departments established a workgroup with
5

representatives from HHS’s Office of the Secretary, Health Care Financing Administration (HCFA),

Health Resources and Services Administration (HRSA), and Administration for Children and Families

(ACF); the Department of Agriculture (USDA); and the Department of Education (ED). The

Department of Justice (DOJ) and Corporation for National Service (CNS) also participated on the

workgroup.

A number of activities were completed in response to the President’s Executive Memorandum and

form the basis of the recommendations in this Report. These included the following: 

• Regional Meetings

HHS’s HCFA, with HRSA, USDA and ED, sponsored a series of seven regional

telephone conference calls between October 26, 1999 and November 1, 1999. More

than 1,200 call participants representing 36 States discussed State and local issues

surrounding school-based enrollment, identified key concerns, and shared successful

approaches to outreach. In addition, ED and USDA worked with HHS to sponsor

regional conferences on school-based outreach in New York, Philadelphia and San

Francisco. The summary of regional meetings is available at

www.insurekidsnow.gov/childhealth/outreach/interim.pdf.

• National Summit on School-Based Outreach

On November 17-18, 1999, HRSA, with HCFA, ED, USDA, and DOJ hosted a

two-day National Summit on School-Based Outreach for Children’s Health Insurance

Programs in Washington, D.C. The conference was attended by more than 300

individuals representing teams of States’ Education and SCHIP/Medicaid agencies and

outreach workers, Federal agencies and national advocacy organizations. The National

Summit opened with remarks from HHS Secretary Shalala, Education Secretary Riley,

Agriculture Secretary Glickman and Attorney General Reno. The Summit featured

plenary and breakout sessions to identify successful school-based health insurance

outreach and enrollment strategies and to discuss ways in which such school-based

strategies could become a routine school practice. The National Summit Proceedings

are posted at www.insurekidsnow.gov/childhealth/outreach/summit.pdf.

• Consultation with Professional Organizations
6

The Department of Education called two meetings to solicit suggestions and feedback

from national health, nutrition and education organizations. On November 18, 1999, at

the National Summit, many of these groups came together in a breakout session to

discuss some of the current practices and challenges in school-based outreach. On

February 24, 2000, ED hosted a follow-up meeting to continue this dialogue. Groups 

in attendance included the Council of Chief State School Officers, the Council of Great

City Schools, the National Center for School Health Nursing, the National School

Boards Association, the Association of State and Territorial Health Organizations,

American School Counselors Association, the AFL-CIO, American School Food

Service Association, the Public Education Network and the National Association of

Social Workers. 

• Contract

HCFA contracted with the Barents Group, LLC and the Academy for Educational

Development (AED) to collect and synthesize information on school-based health

insurance outreach and enrollment strategies. Sources of information included State and

Federal government documents and reports, reports by foundations and nonprofit

organizations, articles published in peer-review journals and information from relevant

websites, and direct contact with 32 State SCHIP/Medicaid representatives. This

information assisted in the preparation of 

this report and “how to” guides on school-based outreach for school districts, health

providers and State Medicaid, SCHIP and education agencies. 

These activities built on other current efforts already underway to support school-based outreach,

including:

• Using the free and reduced price school lunch program

This critical program can provide information to families and help to enroll children in

health programs. Many school districts have provided families with information about

free and low-cost health insurance at the same time they distributed the free and

reduced price school meal application. Also, many districts included a check off box

on the school meal application, or a separate form so families could request health

insurance information. 

On April 30, 1999, USDA issued a comprehensive Prototype Free and Reduced Price
Web address is http://www.fns.usda.gov/cnd/translations/default.htm 4

 Schools were asked to pledge to take at least one step to help enroll children in health insurance. Possible 5

steps were: contact the State and/or regional SCHIP/Medicaid outreach coordinator for forms or

assistance; distribute information to families about children’s health insurance programs; help integrate

health insurance enrollment into school activities; help get other organizations involved by having ED

contact them about how they could help, or conduct another type of school-based outreach/enrollment

activity.

7

Meal Application for use in schools and day care facilities. The prototype application

package included a separate form for households to request information about

Medicaid and SCHIP. Additionally, these materials were recently translated into 12

different languages and distributed to State agencies that administer the Federallyassisted feeding programs for children in schools and day care facilities. These forms

are also available on the agency's website. USDA encourages the use of the prototype 4

school lunch application forms. The applications were translated into other languages

so that households with limited English reading skills can apply for free and reduced

price meals and can authorize the sharing of information from their free and reduced

price meal application for health insurance purposes.

• Back-to-School campaigns

The Department of Education launched a campaign entitled Insure Kids Now!

Through Schools. On August 9, 1999, ED sent letters to all 15,575 school

superintendents around the country inviting them to join a national coalition to

encourage schools and communities to work together to identify uninsured children for

enrollment into SCHIP and Medicaid. A packet of information accompanied the letter,

including an activity sheet describing how schools can target and enroll eligible children,

a list of State-specific contacts and a pledge form soliciting schools’ commitment to

outreach. With the support of the National Association of Elementary School 5

Principals and the National Association of Secondary School Principals, a similar letter

went to 27,000 elementary and 42,000 secondary school principals and

representatives. As of February 2000, 890 school and school district representatives

had returned pledge forms, approximately 60 percent from principals, 20 percent from

superintendents and 20 percent from an unspecified source. 

HHS, DOJ, ED along with several national nonprofit organizations conducted an Insure

Kids Now! National Back-To-School Campaign in Fall 1999. From September 22

to October 2, 1999, HHS-funded radio announcements to raise awareness about

children’s health insurance programs in local communities. Forty-five events in more
Covering Kids, a national health access initiative for low-income uninsured children sponsored by the 6

Robert Wood Johnson Foundation, is providing $47 million to help increase the number of eligible children

who benefit from health insurance coverage programs. The three-year grants support 50 Statewide and 167

local coalitions in conducting outreach initiatives and working towards enrollment simplification and

coordination of health coverage programs for low-income children. Many of the Covering Kids grantees

and their pilot sites are pursuing targeted school-based outreach initiatives. 

8

than 25 communities were conducted in partnership 

with local United Way offices, schools, and community partners, including many of the

Robert Wood Johnson Foundation’s Covering Kids’ grantees.6

In November 1999, the Administration for Children and Families (ACF) at HHS

mailed packets to encourage Head Start programs to become active in Medicaid and

SCHIP outreach. Nationwide, 1,513 grantees received materials for dissemination to

all 15,872 Head Start programs. The package included an information memorandum

with ideas on how to get involved, a Head Start/Medicaid/SCHIP partnership guide

developed jointly with HCFA and a pledge form for programs to commit to new or

continued outreach efforts. ACF is acknowledging these pledges with Insure Kids

Now! Coalition certificates and providing follow-up as appropriate through HHS’s

Regional Offices. 
 Perry, Michael, page 3. 7

9

Section 2: Summary of Findings

The Interdepartmental Workgroup examined the information gathered from the national and regional

conferences, review of current literature, discussions with State Medicaid, SCHIP and education

agencies, and meetings with school officials. These findings are summarized below and were used in

the development of recommendations put forward in this Report. 

The findings indicate that school systems are the critical link in successful outreach for children’s health

insurance programs in many States. Successful efforts to enroll children in Medicaid and SCHIP are

often school-based, because schools are accepted by parents as a conduit for important, reliable

information. School outreach activities vary widely, from providing information for children to take

home, to direct on-site enrollment assistance. Many schools partner with States, community-based

organizations or provider groups to conduct outreach. However, there is widespread recognition that

many schools face multiple constraints in these efforts. Schools often lack the funding, expertise or time

it takes to conduct sustainable outreach campaigns. State Medicaid and SCHIP agencies can maximize

the use of public resources for targeting outreach by jointly partnering and supporting those outreach

strategies that schools offer to carry out most efficiently and effectively. To build sustainable

campaigns in schools, it is important to reduce these constraints through collaboration and partnerships

around child health. Yet at all levels, there is a shared recognition that America’s children face many

compelling educational, health and developmental challenges that affect their lives and their futures. To

help children meet these challenges, the fields of education and health must work together.

The Importance of Health Insurance for Children

Literature reviews indicate clear relationships among health insurance, health outcomes and school

performance. Children without health insurance suffer more from asthma, ear infections and vision

problems, all treatable conditions that interfere with classroom participation. Uninsured children and

adolescents are less likely to visit a doctor for routine and preventive care or to have a usual source of

care. Uninsured children are more likely to make doctors’ visits in the emergency room. Parents of

uninsured children are more likely to postpone health care or to not fill a prescription for their child. 7
 Newacheck, Paul W., DrPH, Claire D. Brindis, DrPH, Courtney Uhler Cart, MSW, MPH, Kristen Marchi, MPH, 8

Charles E. Irwin and Jr, MD. “Adolescent Health Insurance Coverage: Recent Changes and Access to Care,”

Pediatrics 1999 August; 104(2), pp. 195-202.

Americ an Academy of Pediatrics. Year 2000 Projection of U.S. Children’s Health Status and Program

9

Eligibility, 1999, www.aap.org/advocacy/schipef.html. 

 Lavin, AT, Shaprio GR, and Weill KS, “Creating an Agenda for School-Based Health Promotion: A Review 10

of Twenty-five Selected Reports.” Journal of School Health, 1992; 62(6): 212-228.

10

Uninsured adolescents, compared to their insured counterparts, were five times as likely to lack a usual

source of care, four times as likely to have 

unmet health needs and twice as likely to go without a physician contact during the course of the year. 8

Children without health insurance are absent from school more frequently than their peers. Access to

health care contributes to a child’s academic achievement and success by reducing the number and

length of school absences. With 11 million uninsured children, there are too many students whose

educational experience is continually interrupted by episodes of preventable illness. In a 1999 survey

conducted by the American Academy of Pediatrics, teachers reported that 12 percent of their students,

up to 18 percent in urban areas, had health problems that impede their academic performance. 9

As we strive for high standards in every school and classroom, it is essential that we help families ensure

that their children arrive at school ready to learn. Good health is a prerequisite for learning and

"unhealthy children are children with impaired learning.”10

The Role of Schools in Reaching Uninsured Children and Families

Schools are a natural setting to conduct outreach for children’s health insurance programs, because

schools and early child care/education programs are where most of the uninsured children are. State

Medicaid and SCHIP agencies seeking the best return on outreach investments often find that working

with schools simplifies targeting audiences (e.g., parents of adolescents, Spanish-speaking families),

distributing information, reaching families and enrolling children. Other factors that make schools a

logical and successful site for outreach efforts include:

• Promoting the healthy development of children contributes to their academic achievement and

success. This supports schools’ missions for learning.

• Schools have well-developed systems for information dissemination, and parents expect to

learn about programs for their children from schools.
 “Healthy Kids, Healthy Schools,” Consumers Union, 1999. 11

11

• Many schools and Head Start programs already have a school nurse, health coordinator or

other health care provider (e.g. staff of a school-based health center, community health care

provider, etc.) who connects children and their families with health services. In these settings,

there is already a connection between health and school.

• Because schools routinely distribute information, they already know and understand

communication problems and other concerns of the families in their community. 

• Families trust school officials, school teachers, nurses and other school personnel and the

information they impart.

• Many schools already have a strong connection to community networks. These networks can

assist schools in conducting outreach.

• Schools are commonly viewed by families as a familiar and comfortable setting within the

community.

• Schools have experience in related outreach and education efforts regarding health, such as

anti-smoking, anti-drug and improved nutrition campaigns.

• Many schools provide health services to eligible children through school-based health clinics.

Motivating School Districts and Schools to Participate

Schools are primarily held accountable for educational outcomes not health-related measures, so

schools’ limited resources are naturally focused on the mission of educating students. Many schools

recognize that they can play an important role in improving the health and well-being of students as well. 

To encourage schools to engage in health insurance outreach, it is critical to highlight that healthy

children perform better in school. Children with health insurance are less likely to be absent from

school and are more prepared for classroom learning. In addition, there is a link between health

insurance, healthy children and resources; student absences are lower among insured children, thus

boosting schools’ Average Daily Attendance (ADA) and available funding for schools. These 11

potential benefits can motivate schools to become involved in health insurance outreach. To achieve the

maximum participation, schools need to be able to 

count on support from local and State partners so that outreach efforts can be minimally burdensome
12

and highly effective. 

School officials who have engaged in school-based outreach identified other strategies as important, if

less quantifiable “motivators.” For example, schools welcome recognition, either in the media or

through personal contact from State and local officials (e.g., Governor, Mayor) for their successful

outreach efforts. It is important to provide feedback to schools and reward their efforts in highly visible

ways. Also, seeing a respected peer such as another superintendent or principal take time to persuade

a colleague of the importance of their participation can motivate other school officials. Many schools

providing outreach and enrollment assistance to parents saw increased parental involvement in the

schools as a positive outcome. Finally, since schools’ time and resources are already limited, providing

schools with the additional resources for outreach also serves as a strong motivator.

Constraints and Barriers

Principal barriers to school-based outreach include: inadequate resources and administrative support;

difficult enrollment processes; and problems in data sharing. Most schools do not have the funding,

staffing and space to make a sustained commitment to outreach. Other schools lack administrative

support to engage in outreach, especially if principals view it to be a significant burden. Sharing

personally identifiable information from the free and reduced price meal applications or from emergency

contact cards requires parental consent, therefore schools may encounter problems in data sharing. 

Finally, some States have not worked with their schools to address existing barriers and States with

lengthy and complicated health insurance enrollment processes undermine outreach.

Key Factors in Successful Outreach Programs

The information gathered about school-based outreach suggests that there are some straightforward

“keys to success” that apply in most schools. Successful outreach strategies generally facilitate schoolbased outreach by providing information, resources and staff; and they simplify the application process

(e.g., shorter forms, reducing verification) and make it easier for all types of outreach to succeed. 

Although most agree that what works in one school district might not necessarily work in another, there

are some common elements in successful programs. 

For example, many schools cited funding for trained outreach workers and school nurses who assist in

enrollment and provide follow-up with parents as critical to their success. In addition, a "dedicated"

private space to meet with families about insurance that is outfitted with computers to track applications

and enrollments, informational materials, consent forms and applications, and portable copy machines

were identified as helpful. A number of school officials noted that having an internal champion who
13

promotes outreach and encourages colleagues to participate was critical to their success. School

officials noted that “piggybacking”on other outreach efforts is helpful, such as through immunization

programs and the free or reduced price meals program. Finally, minimizing disruptions by building on

already scheduled activities was important. School officials suggested taking advantage of natural

opportunities for face-to-face meetings with parents, e.g., providing information during back-to-school

night, report card distribution days, PTA meetings and in English as a second language classes for

parents. Providing feedback to schools about the enrollment of children from that school will help to

motivate schools and their outreach partners to continue their efforts by showing them the positive

results for children. 

Schools asked that States take measures to simplify the application process. Reducing the length of the

application and excessive documentation is critical. A simplified process enables the limited resources

of schools and their partners to go much further and make parents’ completion of the enrollment

process more likely. States noted that it is helpful to monitor schools’ needs and provide technical

assistance, as well as other resources. States that stay in touch with school-based efforts can be ready

for a surge in applications as a result of outreach activities. 

A description of four promising approaches to school-based outreach are highlighted throughout this

Report as “Models that Work.”

Sources of Outreach Funding

The most significant source of program funding for SCHIP and Medicaid outreach are administrative

funds provided to States. In SCHIP, States’ administrative spending is limited to 10 percent of their

total expenditures; however, there is no such limit in Medicaid. Some States have suggested that it

would be helpful to raise the 10 percent cap on the use of SCHIP funds while programs are getting “up

and running” and creating public awareness. However, this policy change would require Congressional

action. States can also use their allocations of the $500 million Federal fund available under section

1931 of the Social Security Act, in accordance with guidance issued in the January 6, 2000 letter to

State officials and the May 14, 1997 Federal Register notice, or State Maintenance of Effort funds for

outreach and training activities for Medicaid and SCHIP. In several States, Federal Medicaid funds

are used to match the administrative expenditures incurred by States for the costs of salaries of school

nurses who perform outreach activities. Finally, in a number of States, tobacco settlement funds are

being considered as a source for outreach funding.

Some States provide additional public funding through either the States’ Department of Education or

the Department of Health Services. State funds are accessible to schools in several ways. Several

States disseminate funds through mini-grants which support local outreach activities and several of the
14

grantees are school districts. In a few States, application fees are paid to individuals or organizations

under contract with the State for each completed and approved application. These application

assistance fees in most States come from SCHIP and Medicaid administrative funds. Other sources of

funding available to help schools with outreach include private foundations (e.g., the Robert Wood

Johnson Foundation’s Covering Kids Initiative and local foundations), businesses and schools districts.

The schools themselves provide an in-kind contribution to outreach through staff time, school space,

and access to school equipment and supplies. 

Partnerships with health care providers can bring additional funds and resources. Children who have

insurance are more likely to seek preventive services and have a regular source of primary care. They

are less likely to seek more expensive care in hospital emergency rooms and less likely to incur unpaid

medical bills.
15

Section 3: Recommendations for Federal Action 

The following are our recommendations to the Federal government for making outreach and enrollment

for children’s health insurance programs an integral part of school business. This structure for making

recommendations acknowledges the key players who can take action to make school-based outreach

and enrollment effective - the Federal government, the State Agencies, school districts, schools and

early child care/education providers. This information derives from what the Workgroup has learned

from States and communities at the National Summit, during the regional conference calls and meetings

and through the research conducted. The President also asked for both short and long-term Federal

strategies; the Action Plan (Appendix B) provides those details. 

The population of uninsured children eligible for Medicaid and SCHIP is increasing for a variety of

reasons. Although States have used many creative approaches to reach out to uninsured children

through Medicaid and SCHIP programs, challenges to identify and enroll eligible children remain

substantial. While it is possible for schools to participate in outreach and enrollment efforts under

current law, these proposals will enhance their ability to do so. In addition to strongly supporting

the President’s fiscal year 2001 budget proposals to accelerate the enrollment of Medicaid/SCHIP

eligible children through schools, we recommend the Federal government act on the following

recommendations:

1. Facilitate outreach and enrollment activities between Medicaid/SCHIP and other

public programs with similar eligibility criteria, such as the National School Lunch

Program (NSLP).

The National School Lunch Program (NSLP) is an excellent vehicle to market health

insurance and to target outreach efforts to children potentially eligible for SCHIP and

Medicaid. About 96 percent of all public and nonprofit private schools participate in the

National School Lunch Program. Traditionally, eligibility for free and reduced price meals

is based on households’ gross income as reported by the household on the free and

reduced price meal application. The eligibility limit for free meals is 130 percent of the

Federal poverty guidelines and 131 to 185 percent for reduced price meals. 

The Federal government should assist in promoting the use of the NSLP through the
16

following actions:

1.1Implement the provisions in the Agricultural Risk Protection Act of 2000 that

amend the National School Lunch Act (NSLA) to allow for sharing of children’s

free and reduced price school meal eligibility information with Medicaid and

SCHIP.

On June 20, 2000, the President signed the Agriculture Risk Protection Act of 2000. Prior

to this legislation, the statute for the lunch program permitted the sharing of information

about children eligible for free and reduced price meals without parental consent with some

programs. However, school officials could not release individual names to SCHIP or

Medicaid agencies without parental consent. 

Beginning October 1, 2000, schools can share information about children eligible for free

and reduced price meals with Medicaid and SCHIP. Schools must notify parents prior to

sharing the information with health insurance programs and must give parents the

opportunity to elect not to have their information shared with the Medicaid and SCHIP

agencies. Both the State Child Nutrition Agency and the district's school food service must

agree to do this and there must be a written agreement between the school and the State or

local agency or agencies administering health insurance programs for children. The three

Federal Departments will work together to distribute information on this important

legislative change.

1.2 Use the National School Lunch Program to increase awareness about

Medicaid/SCHIP and identify potential enrollees.

USDA and HHS should annually encourage the distribution of State-developed health

insurance information and should provide the State Child Nutrition Agencies with the name

of a SCHIP/Medicaid contact person. SCHIP/Medicaid directors and School Districts,

including local food service directors, should coordinate to distribute health insurance

information or health insurance applications (especially in high-eligibility areas) as part of the

schools enrollment process or during the NSLP’s free and reduced price meal application

process. 

USDA and HCFA should encourage State Child Nutrition Directors and State

Medicaid/SCHIP Directors to develop a plan to coordinate the transfer of school lunch

eligibility information to SCHIP/Medicaid for appropriate follow-up. HHS and USDA

should develop and share model Memoranda of Understanding to help facilitate this

process.
17

2.Provide technical assistance and support to help States, communities, health care

providers and schools implement school-based outreach and enrollment activities

for Medicaid/SCHIP.

Many options are already available to States and local school districts to work in

partnership to increase enrollment and retention in SCHIP and Medicaid. However,

these options are not currently utilized to their fullest potential. Therefore, we

recommend several actions be undertaken by the three Federal Departments to make

schools, States and communities aware of types of school-based outreach and

enrollment activities and “how to” carry out these activities and promote their

effectiveness. In order for school-based enrollment to work, the application and

enrollment process must be simple. To this end, we are also recommending that we

continue to work with States to further simplify enrollment and redetermination

processes and enlist schools as partners in this endeavor. By facilitating new

partnerships, improving forums for information sharing, working with States and other

partners and providing other types of technical assistance, HHS, ED and USDA can

make an impact on outreach and enrollment activities within the current legislative and

regulatory guidelines. The Departments have been working to educate States and other

entities about ways to make outreach and enrollment processes more effective within

the current guidelines, but these efforts must be expanded.

2.1Develop and disseminate “how to” guides for States, school districts,

schools and health care providers on conducting school-based outreach and

enrollment.

HHS has contracted with Barents Group LLC and the Academy for Educational

Development (AED) to develop three “how to” guides; one targeted to school districts,

schools and early child care/early education programs; one to health care providers;

and one to SCHIP, Medicaid and State education agencies. By design, the guides will

address the roles and interests of each target audience and provide them with the tools

to facilitate their participation in school-based outreach and enrollment. HHS, USDA,

and ED have been involved in the conceptualization and design of these guides. All

three guides will be distributed nationally and will be available on

www.insurekidsnow.gov in the Summer 2000.

2.2Work in partnership with private/public organizations to support up to three

regional community-based training centers to prepare school and community

staff to participate in outreach activities. 
18

These centers would provide training materials to support school personnel activities in

outreach and organize relevant seminars, workshops and conferences for school and

health agency partners interested in beginning or already engaged in joint outreach

efforts.

HHS will identify model, school-based outreach locations to serve as regional-level

training centers. HHS will work with private and public organizations to secure

sustained funding for these regional training centers and to create the training materials. 

The “how to” guide will be used as a resource.

2.3Support passage of an amendment to the Medicaid statute to include all

schools engaged in outreach and enrollment activities as “qualified entities”

(entities allowed, at the State option, to determine presumptive eligibility under

Federal Medicaid statute). 

This proposal is included in the President’s FY 2001 budget. By including all schools

as qualified entities to determine presumptive eligibility (State option) and not just those

schools who are already Medicaid providers, schools with trained staff will be able to

make initial determinations about eligibility in SCHIP and Medicaid and temporarily

enroll children pending final approval. Since schools are seen as trusted entities by

families, parents may be more inclined to pursue application in a school environment. 

Should an amendment pass, HHS and ED will work together to gather best practices in

instituting presumptive eligibility in schools that are and are not Medicaid providers and

disseminate those on the school-based outreach website and listserv.

2.4Work with HHS Regional Offices to use current SCHIP monitoring visits to

provide technical assistance to States as they continue to work with schools to

enroll children. Regional Offices can identify best practices that can be shared

with other States.

HCFA Regional offices have the lead on planning the SCHIP monitoring visits in

coordination with HRSA, ACF and the Office of Civil Rights staff. Central Office staff

will work with Regional staff to encourage States during the monitoring visits to support

school-based outreach. Regional office staff will gather information on best practices

from the visits and make it available to other States and schools through the

www.insurekidsnow.gov website.

2.5Work with national education organizations, advocacy groups and other
19

education leaders to promote school-based outreach and enrollment. 

The three Departments convened an initial meeting of education, school nutrition and

health groups during the National Summit in November 1999. The groups met again in

February 2000 to continue to discuss the Departments efforts to promote school-based

outreach and enrollment. These stakeholder meetings will continue to be convened by

the Department of Education on an ad hoc basis as a venue for promoting schoolbased outreach and enrollment. 

2.6Work with States to encourage the development and evaluation of projects

that simplify SCHIP and Medicaid enrollment for children enrolled in other

Federal programs. 

Several States and local school districts are interested in developing projects or pilots

that would simplify SCHIP and Medicaid enrollment for children already enrolled in the

school lunch program, Head Start and subsidized child care. We recommend that the

Federal Departments assist interested States in the development and evaluation of these

pilots. School Food Service, Head Start, child care and SCHIP/Medicaid officials can

work together to improve coordination in planning and implementing these models. 

They can also ensure that families who give consent to receive health insurance

information do receive sufficient follow-up. The Federal government can also identify

and share best State practices.

Additionally, HCFA will award approximately five grants of roughly $80,000 to State

Medicaid and SCHIP agencies during a one year project called “Medicaid and SCHIP

Eligibility Pilots.” The purpose of this project is to identify new and effective ways to

simplify the application and enrollment process by piloting innovative efforts on a small

scale. State agencies who receive an award will work closely with other stakeholders,

including schools, during the project implementation and evaluation. As a result of this

grant project, HCFA will provide support to States as they continue to explore ways of

simplifying the application process and encourage States to adopt effective mechanisms

to remove one or more steps a family would otherwise have to complete to enroll their

eligible children in Medicaid or SCHIP.

 2.7Create an inter-Departmental electronic mail listserv to facilitate

communication, problem solving and exchange of timely information from

schools, health agencies and community groups partnering in outreach and

enrollment. Share appropriate and timely information related to program

implementation, policy development and legislative changes of Federally-
20

funded programs.

HHS will establish a listserv function to notify interested organizations and individuals of

new developments. HHS will use the school-based outreach page on the

www.insurekidsnow.gov website to post new information. The Departments of

Agriculture and Education will take responsibility for providing HHS with timely and

relevant information for the site or with relevant links to their websites.

2.8Hold regular telephone conferences with electronic mail listserv subscribers

from schools, health agencies and community groups to share information about

initiating efforts, maintaining efforts, funding sources, promising practices,

evaluating efforts and managing barriers. Post summaries or highlights

electronically on the www.insurekidsnow.gov website.

HHS, USDA and ED will coordinate scheduling telephone conferences with listserv

subscribers as a method for information sharing. Summaries of all conference calls and

any other pertinent information will be posted on the www.insurekidsnow.gov

website. All Departments will be responsible for supplying HHS with information for

the webpage and listserv.

2.9Provide additional targeted technical assistance to interested States that

have not taken advantage of options available under current law for

streamlining and simplifying SCHIP and Medicaid enrollment and

redetermination processes.

Several activities are currently underway to reduce barriers which deter enrollment and

reenrollment in Medicaid and SCHIP. These activities range from program practices to

caseworker retraining. HCFA is working with States to identify existing barriers,

promote promising practices, develop model application language to assist States in

reducing the reading/literacy level of applications and identify models of simplified, userfriendly Medicaid and SCHIP beneficiary notices on eligibility actions. In addition,

HHS is working with States to develop school-based outreach pilots. 

Although not specifically a school-based technical assistance resource, HRSA currently

funds and partners with HCFA on the implementation of CompCare, a four-year

technical assistance program that makes assistance available to each State over the life

of the project. The technical assistance will be tailored to the system improvement

needs articulated by each State and designed to support the achievement of Statespecific child health outcome objectives including linking eligible children with the
Letters posted on: 12

www.hcfa.gov/medicaid/wrdl1600.htm 

http://www.hcfa.gov/medicaid/wrdl514.htm#A3

21

SCHIP and Medicaid programs. Streamlining and simplifying enrollment and

redetermination processes could be one activity.

Likewise, with the ongoing outreach and enrollment activities and related grassroots

experiences provided by the Robert Wood Johnson Foundation’s Covering Kids

grantees, there are numerous possibilities to work closely with State agencies in further

refining and simplifying the enrollment and redetermination processes. Partnerships at

all levels enhance the possibilities of continuous improvements for publicly-funded

children’s health insurance programs.

Other types of technical assistance could include low-cost site visits, meetings or

conferences convened specifically around school-based outreach and enrollment. The

SCHIP monitoring visits and State evaluations due March 31, 2000 are both ways to

identify technical assistance needs and interests of the States and best practices. 

3.Encourage new or additional school-based outreach and enrollment efforts by

assisting States and schools to identify and maximize funding opportunities.

To launch a significant effort such as nationwide school-based outreach and enrollment,

States and schools need to work together to identify the sources of funding that are

available and how to obtain these funds. This implies private as well as public sources.

3.1Encourage State Medicaid agencies to utilize the special $500 million

fund set aside for Medicaid outreach following welfare reform to fund

school-based outreach and enrollment activities, in accordance with Federal

guidance.

The January 6, 2000, HCFA letter to State officials and the May 14, 1997 Federal

Register Notice provide guidance to States on using this fund for Medicaid and 12

SCHIP outreach. HCFA will continue to work with the State Medicaid agencies

to identify remaining funds set aside for

 Medicaid outreach and assist States in using these resources to support 

school-based outreach activities. 
The guide is available on: www.hcfa.gov/medicaid/schools/machmpg.htm. 13

22

3.2Develop guidance letters, workshops and other forms of technical

assistance detailing options available under current law for States to

receive Federal match for reimbursing schools and other entities that are

conducting outreach and enrollment activities. Guidance on how school

districts and schools can contract with State Medicaid/SCHIP agencies to

get reimbursed for their outreach and enrollment work should be a priority. 

Include guidance and sample Memoranda of Understanding to assist State

Child Nutrition Directors, food service personnel, school district personnel

and others whose commitment to carrying out outreach activities is

contingent on reimbursement for the costs associated with these efforts.

In addition to the letter to State officials and the Federal Register notice already

providing guidance on the continued availability of the $500 million special fund,

HCFA is currently in the process of reviewing

 public comments on its Draft School-Based Administrative Claiming Guide . This 13

Guide will provide information for schools, State Medicaid Agencies, HCFA staff

and other interested parties on the existing requirements for claiming Federal funds

under the Medicaid program for the costs of administrative activities, such as

Medicaid outreach, that are performed in the school setting. 

3.3Develop a model Memorandum of Understanding (MOU) that can be

used by Medicaid/SCHIP agencies in collaborating with State Education

Agencies, Federally-funded grantees, foundation grantees and school

districts for conducting and funding outreach and enrollment activities.

HCFA Central Office will draft and disseminate a model MOU to help States

better collaborate with State Education Agencies. As States implement

Memoranda of Understanding with other agencies and entities that assist in schoolbased outreach, it is important that they include local outreach workers in the

execution of school-based enrollment. Including local eligibility workers is

important to successfully streamline, simplify and coordinate a system for child

health insurance coverage. Their involvement provides schools with resources to

carry through with outreach to the point of enrollment. 

3.4Facilitate partnerships between public and private entities to identify
23

new and innovative funding streams to pay for school-based outreach and

enrollment.

HHS and ED will continue to meet with foundations and private organizations

to learn about funding options for States. The Departments will meet with

national organizations that represent integrated health systems, hospitals, and

managed care organizations to identify potential areas of interest in promoting

and funding school-based outreach and enrollment activities consistent with

federal policies. All findings will be disseminated via the list serv and the

www.insurekidsnow.gov website.

Spotlight: Models That Work

Partnership between Schools and a Health System in Virginia

Inova Health System, a large not-for-profit health care organization in Northern Virginia, works in partnership

with Fairfax County public schools and community-based organizations (CBOs) to conduct outreach and

enrollment in elementary schools. The goals of the partnership are to:

• identify children who do not have a medical home or health insurance coverage;

• refer/enroll all eligible uninsured children in Medicaid, the Children’s Medical Security Insurance Plan

(CMSIP, which is Virginia’s SCHIP), or other health care programs;

• provide follow-up with families; and

• monitor and report on outcomes.

The partnership was initiated in 1993 by the health system's Board of Trustees’ task force on community health. 

A community needs assessment identified children’s preventive health and children’s access to health care

services as two of the most pressing child health concerns in Fairfax County. The impetus for this effort was

and is the health system's commitment to provide quality care and to improve the health of the diverse

communities they serve. Inova strives to increase the number of previously underserved children receiving
Fairfax County Schools are divided into three areas, each of which has a superintendent. 14

24

primary care and preventive services to ultimately optimize the value of each dollar spent on caring for the

underserved. Schools also benefit because their students receive health insurance coverage, obtain health care

services and are ultimately healthier students.

After two years of planning and collecting baseline data, the health system created a program, Partnership for

Healthier Kids (PHK), with local community organizations including Fairfax County Public Schools and Northern

Virginia Family Service. The school district has participated as a “partner” since PHK’s inception, actively

providing input every step of the way. One Fairfax County superintendent embraced the health system’s 14

initiative and identified a school and its enthusiastic principal, a person well respected by other principals in the

district, to pilot the outreach program. From the outset, the superintendent made school participation in the

program voluntary. To encourage school participation, she described the shared benefits of the program for

schools, providers and families. This superintendent was the catalyst in linking the health system to the

schools.

Once the school decides to participate in the program, the PHK staff host introductory workshops and

individual school training sessions to two or three school representatives (usually the principal, secretary,

assistant principal, public health nurse, parent liaison or guidance counselor). PHK educates them on the

importance of school-based outreach and works with the staff to develop a school specific outreach plan. PHK

staff provide a procedural manual, consent forms, letters and educational materials–flyers, posters, newsletter

articles, tent cards- to schools to distribute and display around the school.

Most materials are translated into the five most common languages in the county. PHK and the schools take the

following steps to identify and help uninsured children:

• Designated school staff identify potential eligible children through a review of the emergency contact forms

that are completed by parents. Forms lacking information on insurance or a doctor are earmarked as

potential referrals to PHK.

• The school principal motivates families to respond by sending a personal letter to each family who has

missing information on the emergency contact sheet. Information on obtaining free or low cost health

insurance through the PHK, a parental consent form and a self-addressed, business reply envelope that

parents can use to return the form to the schools are also included in this packet.

• As parents or guardians return consent forms, the PHK outreach coordinator collects, reviews, logs data

and forwards forms to PHK case workers. Professional case workers, contracted by Inova from Northern

Virginia Family Service, then complete telephone and/or personal interviews with families, conduct a needs

assessment, prepare a CMSIP/Medicaid application and help compile the required documentation. 

Ineligible children are referred to a local, public primary care provider.

• The PHK case workers follow-up with the Fairfax County Department of Family Services on the status of

applications. Family follow-up sessions are conducted with referred/enrolled families four times over a 12-

month period to ensure that the new insurance and medical provider meet their health care needs.
25

• Results of the outreach activities are reported and shared with the schools.

Inova has hired an external organization to evaluate the partnership program. The first year evaluation summary

reported that, "The partnership between a major health system and local school system, coupled with methods

of case finding and referral, make this one of the most innovative projects in the country." Partnership for

Healthier Kids has developed effective methods of conducting individualized, school-based outreach without

violating the privacy rights of students or unduly burdening school administration.
26

Section 4: Promising Practices

Innovative Outreach Approaches for States and Schools

The following is a series of promising practices for States and schools for making outreach and

enrollment for children’s health insurance programs an integral part of school business. This

structure for highlighting promising practices acknowledges the key players who can take action

to make school-based outreach and enrollment effective - the Federal government, the State

Agencies, school districts, schools and early child care/education providers. This information

derives from what was learned from States and communities at the National Summit, during

regional conference calls and meetings, and through research. The promising practices for

States and schools represent successes across the country. This section is divided into two

parts: Promising State Practices and Promising School Practices. 

Part 1: Promising State Practices

Almost every State enlists the support of schools in their outreach and enrollment strategies for

reaching children. Various State models have produced successes. In the most effective

examples, the State agencies themselves have been integral to successful outreach. The State

provides leadership, enacts enabling legislation or promulgates regulations and procedures and

makes available the essential resources. Without these elements, school-based enrollment may

not be as successful or sustainable. 

The promising State practices that follow are based on models where States exercised their

leadership and used their resources to achieve successful school-based outreach and

enrollment. Simplification is central to the success of outreach and enrollment strategies. The

Administration is doing much to encourage simplification, and most States are making efforts to

simplify their enrollment systems further. While simplification is critical to successful enrollment

efforts, this section focuses on school-based recommendations and strategies. States can use

these promising practices and those that follow for schools to develop or expand their Statespecific strategies and plans of action. While many of the descriptions of the practices refer

solely to schools, these same approaches have also shown promise for early child

care/education program settings.
27

Promising State Practice #1: Make schools and early child care/education programs 

a priority for conducting outreach and enrolling eligible children.

Most uninsured children are in schools and early child care/education programs. Many

school aged children (age 5-18) have only recently become eligible for public health

insurance programs. Children of working families with incomes above the poverty level

may also be newly eligible. Moreover, as States expand eligibility to higher income groups

and older children, the schools are where these children are most easily located and

informed about potential eligibility.

States that have used school settings for outreach report the effectiveness of this approach. 

Their experiences have ranged from surges in applications following school information

distribution drives to phone callers indicating that schools were the prime source of

information on the health insurance programs.

While evaluation of school-based outreach is not yet complete, school-based outreach is a

logical and practical solution to finding the parents of most of the uninsured children. Thus,

it should be a major emphasis for outreach funding.

Promising State Practice #2: Involve school officials and officials administering the

school nutrition programs at all levels in planning and carrying out school-based

outreach activities.

When States forge partnerships with schools, they gain entrée into the communities where

they need to focus their outreach efforts. Schools understand the target audience on a

deeper level because of their knowledge of and ties to the community. States that use the

expertise of school officials expand their reach and access to the target community and

increase their credibility with the community. By working with school health and nutrition

officials, States build upon existing, trusted relationships and programs.

Strategy 1: Develop a plan to coordinate sharing of school lunch information

through the National School Lunch Program's free and reduced price school meal

application process.

The National School Lunch Program is an excellent vehicle to educate households

about the availability of health insurance for children and to target potentially eligible

children for Medicaid/SCHIP enrollment. The lunch program operates in about 96

percent of all public and nonprofit private schools and serves free and reduced price
28

meals to children from households at or below 185 percent of 

poverty. Many of these children are uninsured and would be eligible for Medicaid or

SCHIP. 

At the beginning of the school year, most schools are required to distribute a letter and

an application to all households notifying them of the availability of free and reduced

price school meals. Many schools have included information about health insurance, a

contact person or phone number for more information, along with the school meal

application materials. This is an effective way to 

educate all families in the school, regardless of their income, about the health insurance

options for low-income households. 

USDA had issued several model free and reduced price school meal applications that

were used by schools to target households for health insurance who were applying for

free and reduced price meals. Depending on the model, parents could either consent to

have their names and addresses shared with Medicaid/SCHIP officials to get more

information about health insurance or they could consent to share all their free and

reduced price school meal eligibility information with Medicaid/SCHIP officials to

determine their eligibility for free or low-cost health insurance. 

Beginning October 1, 2000, because of new legislation enacted June 20, 2000, schools

can share free and reduced price eligibility information with Medicaid and SCHIP

unless the parent/guardian tells the school that they do not want their information

shared. The school must notify parents prior to sharing the information with health

insurance programs and must give parents the opportunity to elect not to share their

information. Both the State Child Nutrition Agency and the district's school food

service must agree to do this and there must be a written agreement between the school

and the Medicaid/SCHIP agencies prior to the transfer of eligibility information.

Another way to use the free and reduced price application process is to send

Medicaid/SCHIP information or a Medicaid/SCHIP application with the notification of

approval or denial of household's eligibility for free and reduced price meals.

Regardless of the method used, Medicaid/SCHIP agencies and Child Nutrition

agencies should develop a plan for the transfer of information and follow-up with

households that have expressed interest in health insurance.

While some suggest linking school lunch and health insurance applications, the program

eligibility requirements are sufficiently different to pose some potential risks and

problems for the National School Lunch Program. Apart from different household and

income definitions, the school lunch program differs by not requiring children’s Social
 “Fostering a Close Connections: Report to Covering Kids on Options for conducting Child Health 15

Insurance Outreach Enrollment Through the National School Lunch Program,” prepared for Covering Kids

by Donna Cohen Ross of the Center for Budget and Policy Priorities;

www.coveringkids.org/outr-DCRossFostConn1-2K.html

29

Security numbers or citizenship status - requirements considered especially sensitive for

children of immigrant families. Because requiring this additional information on the

school lunch application could indeed deter participation in the school lunch program,

States and school districts should pursue linking strategies that minimize this risk - such

as requesting citizenship status or Social Security numbers through an alternative

method.

The Center on Budget and Policy Priorities recently prepared a report for the Covering

Kids project on promising strategies for using the school lunch program for outreach 15

and enrollment. A survey of State practices is currently underway.

Whatever the approach, it is important for Medicaid/SCHIP and Child Nutrition State

and local agencies to work together to design appropriate and cost-effective

procedures for distributing insurance information to households using the free and

reduced price application process or for sharing school lunch eligibility information to

Medicaid/SCHIP. Presumptive eligibility for health insurance using eligibility for free

and reduced price school meals is also an option to consider. 

Spotlight: Models That Work
30

Certified Application Assistants Working in San Diego School Districts

Pilot school districts in San Diego County are participating in an outreach program that uses certified

application assistants (CAAs) in schools to enroll children in State health insurance programs. The CAA

program provides grant funding to support trained CAAs who work full time at participating schools for a

specific time period. CAAs follow-up on filed applications or with families who have been identified by the

school as eligible for State health insurance programs. For example, a CAA assigned to Chollas Elementary

School will spend about eight weeks at the school, following up to see if families who send in applications

are enrolled in the health insurance program and if they have signed up with a provider. The State of

California requires completion of an eight-hour CAA training program and pays them $50 for each

successful application. The State provides entity numbers to schools and districts for billing purposes.

School nurses are critical links in this program. The school nurse, a trusted individual from the school,

works with the certified application assistant and provides feedback from parents. For example, the school

nurse may tell the CAA which families have not yet received word on their insurance program applications.

The CAA is considered a school district employee (though funded by outside agency funding) and as such

is allowed access to home telephone numbers of those students who may not have health insurance. 

Once students are enrolled, the school nurse serves as a “focal point” between children/parents, the

insurance program and the providers. Parents feel that having a school nurse to assume this role helps to

reduce barriers and provides optimal case management. When the CAA leaves to do follow-up at another

participating school, parents from the Chollas Elementary School are given a central number at the district

that they can use to locate the CAA. Parents also have the name and phone number of the school nurse to

assist in follow-up.

The Chollas Elementary School’s principal believes that parents are motivated to participate in these

programs by the low premiums and through “word of mouth” referrals. The school motivates children to

return completed application forms by using incentives, such as certificates for snacks.
31

Promising State Practice #3: Provide technical assistance and ongoing support to

school districts, schools and early child care/education programs for outreach and

enrollment. 

School districts and schools can be more effective given the right combination of technical

assistance and adequate funding. While schools may not be experts in all aspects of outreach

due to program complexity and time considerations, there are many strategies initiated by

States to support school-based outreach. The strategies below have been used by States to

support schools.

Strategy 1: Establish a single point of contact at the State or local level for school

personnel to call to obtain information about their State’s programs (e.g., eligibility

criteria, brochures, flyers) and the status of applications that have been submitted.

State and school partnerships work best when there is a single point of contact to

answer questions, provide information and arrange for staff visits, when appropriate. 

Schools also need a single point of contact to follow-up on the status of applications

when the school is providing enrollment assistance.

Strategy 2: Provide schools with culturally appropriate materials and applications. 

Schools prefer materials that are sensitive to the cultural backgrounds of their students

and are consistent with their education role. States have developed marketing materials

in multiple languages and designed the message consistent with the school’s mission. 

States have partnered with schools and community groups to understand the

socioeconomic, demographic, cultural, linguistic and social characteristics of the

community. 

Schools with large immigrant populations also need information on the issue of “public

charge” for their student population. Immigrant parents are reluctant to sign up their

eligible children for any public program because of fear that this will have a negative

impact on their own immigration status. States can take advantage of existing materials

that have been collected at the Federal level.
32

Strategy 3: Train superintendents, principals, teachers, school nurses, schoolbased health center providers, counselors, child nutrition directors and other school

personnel on the State’s insurance programs and how schools can assist in the

effort. 

Schools identified the need for training on how to give presentations, motivate parents

and track applications and enrollments. They want to know more about cultural

relevance and be able to tailor outreach approaches to their own situations. They want

to know how to answer frequently asked questions about State programs. 

It is also important to stress the benefits to schools in conducting outreach. Increased

attendance, fewer days lost due to illness and healthier children who learn better are

substantial incentives for schools to become involved. Unexpected benefits included

increased involvement of parents in the schools and improved community relationships. 

Using school colleagues to deliver these messages increased the credibility of the

message.

Some States found it productive to initially target their efforts on school districts with the

highest rates of uninsured children. If school district level information is not readily

available, the State can also use proxy measures such as targeting schools with the

highest rates of children eligible for free or reduced meals.

Promising State Practice #4: Provide feedback to schools on the impact of their

efforts in identifying and enrolling uninsured children.

Schools maintain their enthusiasm for outreach activities when they see the results of their

activities. Schools that are advised on the results of their efforts are more interested in

continuing their effort. Even feedback on unsuccessful outreach attempts is valuable, so

schools will know that their approach needs to be changed. 

Recognition of the leadership and achievements of schools who do an outstanding job in

outreach deserves public acclaim.

Promising State Practice #5: Maximize schools’ ability to conduct outreach and 

enrollment by funding such activities, providing staff resources or identifying other

funding sources.

In general, schools lack the necessary resources to take on a significant new workload

involving health insurance outreach. States have used a variety of methods to dedicate
33

funding to school-based outreach. Some reimburse schools directly for conducting

outreach, fund community-based organizations to conduct outreach in schools or hire

dedicated state staff to work in the schools. States have used the three strategies outlined

below. 

Strategy 1: Assist school districts by developing partnerships with communitybased organizations to provide application assistance in schools. Use mini-grants

or offer application assistance fees to community-based organizations to provide

enrollment assistance in schools. 

Partnerships between States, community-based organizations and schools have been

very successful. Community organizations have credibility with families and are also

trusted. States have funded these groups to work with schools to handle the major

workload of school-based outreach. 

Informing schools of the existence of these community organizations or community

providers and how they can utilize them to help enroll their students are helpful

practices important to schools and the overall outreach effort.

States have employed a variety of financial models to support school-based outreach. 

Some have provided mini-grants to community organizations while others have paid

schools or community organizations on the basis of successfully completed applications. 

In order to sustain outreach, it is important for the State to provide an ongoing source

of funding tied to performance. 

Strategy 2: Outstation State or local outreach employees in schools and early child

care/education centers. Arrange for training of school volunteers to provide

assistance.

Schools are a familiar setting for parents and they are more comfortable going to a

school than a public assistance office to enroll. Some States have funded dedicated

outreach workers for schools and child care/education centers. Likewise, they have

provided in-service training and materials. Schools assume responsibility for

publicizing the days, times and locations that workers will be available so parents can

plan to come to the school or community setting.

Strategy 3: Target dollars from the fund established to conduct Medicaid outreach

following welfare reform to school-based outreach and enrollment.
http://www.hcfa.gov/medicaid/wrdl1600.htm 16

http://www.hcfa.gov/medicaid/wrdl514.htm#A3

The outreach activities include: reproducing and mailing KidCare applications to targeted families’ 17

homes; creating flyers and information sheets about KidCare; using an automatic calling system to remind

parents of the Report Card Pick-Up Days and the availability of enrollment assistance; advertising the

outreach effort on ethnic radio stations, in newspapers, and at press conferences.

34

Some States have paid for school-based Medicaid outreach activities from the fund

established to conduct Medicaid outreach after the delinking of Medicaid and TANF. 

Permissible activities are addressed in the January 6, 2000 letter to State health officials

and the May 14, 1997 Federal Register notice.16

Spotlight: Models That Work

Partnership Between the State of Illinois, Chicago Public Schools and KidCare Application Agents to

Identify and Enroll Uninsured Children

Since October 1998, the State of Illinois and the Chicago Public Schools (CPS) have been partners in the

development and implementation of school-based outreach activities to enroll uninsured children into

KidCare, Illinois’ SCHIP. The CPS partnership uses mapping databases to geo-code demographic

variables that highlight geographic concentrations of CPS students appearing to be eligible for KidCare

based on their eligibility for free and reduced price meals under the National School Lunch Program (NSLP). 

They then target those schools with an amended NSLP application to include a consent section for families

to sign to release information to the Illinois Department of Public Aid and certified KidCare Application

Agents (KCAA) to follow-up with them about applying for KidCare. A separate flyer accompanying the

NSLP application explains the consent box.

One of the major activities has been Report Card Pick-Up Days in November 1998, April 1999 and November

1999 where families could get information on KidCare and application assistance. Report Card Pick-Up

Days were targeted because the CPS system requires parents to physically enter the school and personally

attend a teacher/parent conference to pick up their child’s report card. A diverse array of outreach

activities advertised the Report Card Pick-Up Days. At the school-level, each school principal designated 17

an individual to be a resident KidCare expert and coordinator, as well as to assist families in completing a

KidCare application. CPS personnel, with the Illinois Department of Public Aid, conducted a massive

training session of approximately 2,000 volunteers for the November 1998 Report Card Pick-Up Day. The

training has been refined over time to reflect lessons learned and to provide more advanced and accurate

enrollment information to volunteers in the schools. The Illinois Department of Public Aid provided a

$850,000 grant to CPS to cover the costs associated with the first two Report Card Pick-Up Days.

The State and CPS also worked together to implement a number of administrative simplification activities

that included CPS opening six regional centers in April 1999 where families can walk in to obtain information

and assistance; shortening the KidCare application in April 1999; implementing a mail-in application

option; implementing 12-month continuous financial eligibility for Medicaid children to match the 12-month
 Each of the selected KCAAs has a 70 to 80 percent acceptance of applications into KidCare.

18

35

continuous eligibility already available through KidCare; implementing a toll-free KidCare hotline and

certifying entities as KidCare Application Agents (KCAAs). Entities eligible to become KCAAs include

Federally Qualified Health Centers, Rural Health Centers, hospitals and community-based organizations

among others. Each entity undergoes training and signs an agreement with the Illinois Department of

Public Aid and is paid $50 for a successful application. In addition, the Illinois Department of Public Aid

has assigned a central contact person to each KCAA to resolve any outstanding KidCare application

issues.

The experience gained during the Report Card Pick-Up Day events has resulted in the implementation of a

pilot project where CPS, with the Illinois Department of Public Aid, is partnering with a selected group of

fourteen “corporate” KCAAs, representing over 100 sites in Chicago. The KCAAs are targeting 18

approximately 61,000 children whose parents signed the release waiver on the amended NSLP application at

the beginning of the 1999/2000 school year. In January 2000, CPS contacted the selected group of KCAAs

to invite them to join the pilot project whereby the KCAA partners “adopt” schools to conduct intensive

outreach and follow-up. Each adopted school’s listing of targeted students includes the student’s name,

parent/guardian’s name, address and phone number. In February 2000, CPS sent a letter to each principal of

an adopted school indicating the community-based agent that will be working to contact families of

targeted students in their school. CPS also sent a letter to parents indicating which community-based agent

would contact them. KCAAs began contacting families in March 2000. Each participating KCAA will

receive information about those individuals contacted under this pilot who are successfully enrolled into

KidCare and, for those not enrolled, the reasons why. Illinois uses State general funds and Federal

Medicaid matching funds for the grant to the CPS and for the payments to KCAAs.
36

Part 2: Promising Practices for School Districts, Schools and

 Early Child Care/Education Centers

Research on current outreach activities in schools highlighted a wide array of successful

techniques to identify and enroll children in the State’s health insurance programs. The

following activities comprise a continuum of successful outreach: identifying and understanding

who are the potentially eligible children and their families; educating individuals about the

program; motivating people to take action; facilitating actions needed to enroll in the programs;

following-up with families and with State agencies on the status of applications and evaluating

the effect of the outreach strategy. Schools are uniquely positioned to undertake several of

these outreach activities.

Because of their unique role in the community, schools are effective in identifying and educating

uninsured families and motivating them to seek health insurance for their children. Families trust

information provided by the school or under the aegis of the school. Several State agencies

report that schools are one of the primary sources of referral identified by callers to State

eligibility centers. 

There are many promising strategies for schools which are based on actual school activities. 

Schools have clearly taken into account their unique environments in implementing these

strategies.

Promising School Practice #1: Distribute information on the availability of children’s

health insurance programs. 

When schools provide information on the availability of health insurance, parents are more

likely to read it, believe it and act on it. Additionally, messages that are repeated multiple

times and conveyed in multiple ways are most likely to be heard. Sending a flyer home

once is not as effective as a multifaceted approach which could include distributing a flyer,

publishing a newsletter article and talking directly with parents through school nurses. 

Schools are well positioned to participate in the following types of outreach activities:
37

Strategy #1: Send health insurance information along with other information that

parents are likely to read (e.g., brochures sent home at the start of the school

year; flyers attached to report cards; printed information about the program on

school lunch menus; information from the school nurse, school-based health center

and/or school health service providers; items in school newsletters). 

Use of existing school structures and processes for conveying helpful information

minimizes the burden on schools and maximizes the likelihood that parents will read the

material. Distributing information at the start of the school year is effective as parents

are more attentive at this time of year and are more likely to read the information

provided. Similarly, when information is attached to documents of importance during

the year, such as report cards or messages from the school nurse on health concerns,

parents are more likely to notice and read them. It is more effective when the

information refers families to a state, community or school contact for follow-up. 

Strategy #2: Distribute information at well-attended school events (e.g., back-toschool night, report card pick-up day, sports events and enrollment for services of

a school-based health center). School staff, State or county outreach workers or

community volunteers should be available to talk with parents about health

insurance coverage at these events.

Building upon existing programs and events minimizes disruptions while providing

opportunities for face-to-face meetings with parents. Because school and family

schedules are hectic, it is important to take advantage of existing events to distribute

information and have community volunteers or state or county staff available to answer

questions or assist with applications.

Strategy #3: Send a letter to families from the principal or other key school official

about the school’s support for the children’s health insurance programs and the

importance of enrolling children.

The principal of a school or the superintendent of the school district is a recognized

leader in the community. School nurses and other school health care providers are also

trusted, key school officials. Various schools have sent personal letters from such

officials to the uninsured families to stress the importance of health insurance, healthy

children and learning and the availability of health insurance. The support of the school

leadership for these efforts can be critical to a family’s interest in the program.
38

Strategy #4: Distribute materials in languages other than English if children come

from families in which English is not the primary language. 

Schools know their student population and their families. They know which families

need foreign language materials, and if so, in what languages. Most States have

produced materials in a least Spanish and many have produced materials in multiple

languages. Community groups and USDA have also produced materials in multiple

languages and appropriate reading level for the community.

Strategy #5: Distribute applications, in addition to general brochures or flyers, if

most of the children who attend the school are likely to be eligible (e.g., in Title I,

ESEA schools with a high percentage of children eligible for free or reduced price

meals, Provision 2 or 3 schools under the National School Lunch Program, or Head

Start centers). Include information with applications on where they can get

assistance in completing the application.

Children who are in Title I, ESEA schools or Provision 2 or 3 schools will usually

qualify for one of the children’s health insurance programs because their family income

levels are low. Schools that have high proportions of these students found it cost

effective to send out applications to all students, rather than try to identify individuals

who might be eligible.

Strategy #6: Designate someone on the school staff, a parent volunteer or a

community volunteer for parents to contact if they have questions.

 Parents may be more comfortable initially contacting someone who they trust at the

school for more information, e.g., the school nurse, school-based health center staff,

teachers of English as a second language or community or parent volunteers. This

trusted person could assist the family in obtaining information or assistance.

Strategy #7: Ask staff to take advantage of teachable moments to educate

families about the importance of health insurance and its availability.

When a sick child is picked up from the school nurse or other school health care

provider or when a child is screened and a referral for a health problem is sent home,

the parent is focused on the health of that child and the need for medical care. 

Information on the importance of health insurance to a child’s health and
39

academic performance and the availability of free or low-cost health insurance is more

likely to be read and favorably received during such times.

Promising School Practice #2: Identify specific children who may be eligible and provide,

or arrange for, targeted assistance to their families.

Schools have a number of readily available methods to identify uninsured children potentially

eligible for enrollment in the State’s child health insurance program. This enables a school or its

partners to target resources on those most likely to be eligible.

Strategy #1: Ask a question about health insurance status on school forms that

parents are required to complete annually for each child. Follow-up with the family

if the child does not have insurance or insurance information is missing.

Many schools ask questions annually about health insurance on an emergency contact

form. A number of schools have used this approach as an easy method to identify

uninsured children. If the schools have the resources, they follow up by letter from a

school official or by calling families who did not have insurance or where insurance

information is missing. In cases where resources are limited, the schools obtained

consent from the parents and provided the names of uninsured children to outreach

workers or eligibility workers for follow-up. These workers agreed to contact the

families and provide them with information and assistance.

Strategy #2: Ask parents about health insurance status and discuss the availability

of insurance and offer information on application assistance on relevant occasions. 

Schools can request information on health insurance as a standard part of school

registration, registration for early child care/education, enrollment for services of a

school-based health clinic, follow-up to health screenings or sports registration. 

Occasions where parents are present provide a great opportunity for providing inperson information.

Strategy #3: Use school-based health centers and other health personnel to

educate all students and identify uninsured students as they seek services. 
40

School health personnel often have a significant role in school-based outreach efforts. 

School nurses and school-based health center staff can be the connection between

children/parents, the insurance program and health care providers. Some school clinics

are qualified providers for Medicaid and SCHIP services and help enroll children in the

appropriate insurance program. 

Promising School Practice #3: Partner with local community-based organizations, health

care providers and businesses for staffing or financial assistance in conducting outreach

and enrollment, especially for application assistance. 

While most agree that schools are ideal partners to build long, lasting mechanisms for sustaining

outreach to uninsured children, there are limits to what they can do without additional resources

or technical assistance. In addition to using State support, schools have successfully partnered

with community groups, health care providers and AmeriCorps volunteers to follow-up with

families. After schools have obtained permission of the uninsured families, community groups

and health care providers have contacted families by phone or in person and assisted them in

completing applications and following through on the application processing. Many community

groups have been actively engaged in trying to enroll children in health insurance programs and

would welcome the opportunity to work directly with schools. Local businesses have provided

schools with prizes or in-kind contributions, such as printing or copying material, for these

outreach efforts. 

Promising School Practice #4: Take advantage of the State Medicaid/SCHIP agencies’

point of contact for up-to-date materials, information on funding opportunities, training and

promising practices for conducting school-based outreach and enrollment. 

Some States have a State-wide model for outreach, while others have delegated the

responsibility to county or local level. States have been providing mini-grants or other funding

to grass roots organizations to conduct outreach. Some States are providing payments to

organizations for successful applicants while other States cover the administrative cost of

outreach (e.g., supplying postage paid envelopes and flyers).

There may be opportunities for local schools to obtain funding to conduct outreach activities. If

schools want to use their own materials, State or local officials can ensure that they are up to

date as programs are expanding in scope. Some States have also provided opportunities for

training on their State’s health insurance program as well as outreach techniques. School health

officials can acquire valuable information on the programs, as well as generic skills in

communicating with their community.
Healthy Kids Annual Report, February 2000. 19

Ibid. 20

Florida uses a direct application mailing to parents whose child(ren) was identified by a modified emergency 21

contact card as not having health insurance. Florida's dial-up computer system has the ability to dial homes and

give a pre-recorded message. 

 Coordinated School Health Programs: Health Services: Developing Funding Strategies, CCHI. 22

www.cchi.org/cgi-bin/cchi/doc.asp?ID+3729.

 Shenkman E., et al. The School Enrollment-Based Health Insurance Program: Socioeconomic Factors in

2 3

Enrollees' Use of Health Services. American Journal of Public Health, December 1996: Vol. 86: 1791-93.

41

Spotlight: Models That Work

A State Legislative Approach to School-Based Outreach

In the late 1980s, State officials in Florida identified school-based enrollment for health insurance as one way to

reduce the high number of uninsured children in the State. This recognition led State leaders to launch an

ambitious experiment called the "Healthy Kids Corporation Act" in 1990 to implement a comprehensive health 19

insurance program for uninsured children using school-based strategies. In this approach, "school systems

would be used as the mechanism for creating large risk pools of people to cover participants the way large

businesses did. Coverage could be offered to families with children enrolled in school and benefits would be

designed specifically for them.” Schools would also be used for outreach, distribution of applications and 20

marketing of the Healthy Kids program. With the creation of SCHIP, Florida built upon the experience of the

Healthy Kids program and expanded the number of programs it offers to families with uninsured children. 

KidCare was the name assigned to the array of programs available to families of which Healthy Kids is a major

component.

Florida's 10 years of experience with school-based outreach have shown that the most effective strategy is

getting an application into the hands of everyone identified as not having insurance. Florida supplements its 21

strategy with activities to raise awareness and educate families about its programs, including multi-media

marketing, involving community-based organizations and providers in regional outreach projects, the use of a

toll-free hotline and information dissemination. 

The State has played a significant role in initiating and endorsing the school-based outreach initiative. However,

Florida recognizes that the power to effectively implement strategies in the schools is located at the district level

among school boards. In Florida, schools' willingness to participate and to conduct outreach is extremely

important. The State works with schools to ensure that they are actively engaged in outreach and to help ensure

that outreach becomes an integral part of their day-to-day business. By August 1999, 94,344 students in 41 of

Florida's 62 counties received health insurance coverage through the Healthy Kids Program. During the 1995-96 22

school year, hospitals in Healthy Kids communities reported a 30 percent decrease in pediatric charity work and a

70 percent decrease in pediatric emergency department visits. Findings from surveys conducted by the 23
 Shenkman, E., H. Steingraber, and C. Bono. Op. Cit. 24

 National Institutes of Health, Making Health Communication Programs Work: A Planner’s Guide, 25

NIH Publication No. 92-1493, April 1992.

42

Institute for Child Health Policy indicated that schools were the primary way new enrollees learned about

KidCare. The percentage of families reporting that they heard about it from the schools ranged from 50-59

percent, depending on the racial and ethnic group.24

Section 5: Evaluating School-Based Outreach

An important step to implementing the recommendations in this Report is developing evaluation

strategies that the Federal government, States and schools can use to determine the success of their

school-based outreach efforts. Designing an evaluation component during the planning stages of an

outreach project forces planners to specify the project’s desired outcomes. In SCHIP and

Medicaid outreach, the ultimate desired outcome is increased access to health care through

increased enrollment. However, focusing on evaluation encourages planners to strategically identify

incremental steps that must be accomplished to obtain the ultimate desired outcome. 

Evaluations of outreach interventions require a combination of advanced planning, methodological

expertise, data collection instruments, data bases, personnel to collect and compile information and

computer tracking systems to bring disparate pieces of information together. These elements can be

expensive and may compete with the outreach activities themselves for scarce resources. 

It is important to note that the SCHIP statute required States to submit to the Department of Health

and Human Services a State evaluation of their State Children’s Health Insurance Program by

March 31, 2000. However, since all States implemented their programs at different times over the

past two to three years, some may not have sufficient information to produce a comprehensive

evaluation at this time. 

Types of Evaluation

The Department of Health and Human Services’ National Institutes of Health provide valuable

insight to evaluating outreach in their Making Health Communication Programs Work: A Planner’s

Guide. Two types of evaluation that are particularly pertinent to school-based outreach are 25

process and outcome evaluation. Process evaluation examines the procedures and tasks involved in

implementing outreach activities. For school-based outreach, process evaluation measures might
Barents Group, Final Report on “Outreach for Public Insurance, prepared for the Agency for Healthcare 26 

Research and Quality, February 2000.

43

track how many applications were distributed through schools or how many parents checked a box

on a school lunch application. Outcome evaluation is used to obtain descriptive data on a project

and to document short-term results. These results might

include knowledge or attitude changes; expressed intentions of the target audience; or intermediate

behavior changes.

Completed Evaluations of Outreach to Increase Enrollment

The Department of Health and Human Services’ Agency for Healthcare Research and Quality

(AHRQ) and Office of the Assistant Secretary for Planning and Evaluation (OASPE) recently

commissioned a review of the literature on outreach interventions intended to increase enrollment in

public health insurance programs. The researches report that few rigorous evaluations of outreach

interventions have been completed. They found nine evaluations that met the criteria for inclusion 26

in their review. Four of these examined the impact of simplified application procedures on Medicaid

enrollment, two examined approaches for increasing awareness of public health insurance programs,

one focused on the effect of positioning Medicaid as “private-type” insurance, and two utilized case

management and beneficiary advocacy to increase enrollment. Case management and advocacy

programs encompass a range of outreach steps and a large number of activities. These evaluations

were focused on the “intervention package,” not the specific interventions. 

While none of these completed evaluations focused specifically on school-based outreach strategies,

school-based outreach evaluation could share similar evaluation measures, including: awareness of

the SCHIP/Medicaid program; source of knowledge about the SCHIP/Medicaid program; reason

enrollees report for joining the program; number of potentially eligible people contacted either oneon-one or in a group setting; number of inquiries based on public information activities; number of

people referred; number of people who applied; number of people who enrolled by race/ethnicity. 

On-going Evaluations of Outreach to Increase Enrollment

Even though most of the outreach evaluations currently underway are not focused solely on activities

linked to schools, the interventions may be useful in designing school-based outreach evaluation. 

This section highlights a few on-going outreach evaluations that are particularly relevant to schoolbased outreach. These evaluations are organized by the name of the program, author of the
 Barents Group, Final Report on “Outreach for Public Insurance,” prepared for the Agency for 27

Healthcare Research and Quality, February 2000.

44

evaluation, intervention focus, and outcomes to be measured. 27

Evaluation of the First Things First Initiative: University of California, Berkeley School of

Public Health, Center for Health Management Studies, in collaboration with the Institute for Health

Policy Studies, University of California at San Francisco; contact Thomas G. Rundall, U.C.

Berkeley School of Public Health. Study focuses on the efforts of ten community coalitions to

reduce Medicaid barriers. 

 • Process evaluation measures in ten sites include:

< Number of potential applicants contacted by the project.

< Number of applications completed and submitted to Medi-Cal.

< Number of applicants contacted who were found to be eligible.

< Number of applicants denied and reasons for denials (including referral to other

programs).

< Number of Medi-Cal recipients disenrolled and reasons for disenrollment.

• Outcome evaluation measures:

< Monthly enrollments of children in Medi-Cal in ten communities from 4/1/96-

9/30/99.

< Number of applicants in ten communities contacted who were enrolled for the first

time.

< Number of re-enrollments facilitated by the program.

Evaluation of the Seek-Find-Enroll Initiative: Jack Wheeler, School of Public Health,

University of Michigan, and Gary Freed, Division of Pediatrics, University of Michigan Medical

Center. The focus is on 14 community coalitions targeting diverse populations using a variety of

outreach methods. Some school- and church-based activities will be included. Measures include:

• Enrollment rates in MIChild and Healthy Kids.

• Enrollments in MIChild and Healthy Kids from the community coalitions.

• Process measures: Number of individuals contacted, number of flyers. distributed,

number of presentations given, number of clients provided with application

assistance, number of completed applications, among others.
45

Evaluation of Four Pilot Projects to Increase SCHIP and Medicaid Enrollment in

Pennsylvania Under the Children’s Health Coverage Campaign: Consumer Health Coalition

(Pennsylvania’s Partnership for Children); contact Ann Bacharach. Focus is on assessing three

different coalition-building approaches: a fee-per-application approach, an approach relying on

volunteers, and an approach using a “community health worker.” Schools are among the best

possible sites for meeting with families. Measures include:

• SCHIP and Medicaid enrollments tied to each approach/project site. 

• Barriers to enrollment.

• Problems with the enrollment process.

Evaluation of the Health-Insurance Access Through Schools: “HATS” Project: School Health

and Community Pediatrics Division, University of California-San Diego; contact Dr. Howard Taras. 

The focus is on assessing the use of schools for reaching children eligible for SCHIP and Medicaid

and developing a “formula” that can be replicated in other school districts. Measures include:

• Number of hours of outreach work and number of visits or calls by outreach

workers required to complete an application.

• Proportion of parents who begin, but do not complete the application process, and

reasons for non-completion.

• Number of applications completed.

• Number of children enrolled in Medicaid or SCHIP.

Ongoing Evaluations of Outreach to Increase Access to Care

Two ongoing school-based outreach evaluations are looking explicitly at the effects of enrollment on

access to and utilization of services. Steven Horam of Community Health Resource Center is evaluating

the Inova Health System’s Partnership for Healthier Kids in Northern Virginia. During the 1998-99

school year, 5,000 emergency medical information cards were audited, 820 families were contacted and

487 children were referred to a “medical home.” The evaluation of 1999-2000 school year activities

is underway and will include an expansion from ten to an estimated 50 schools. Eventually, the

evaluators would like to be able to determine, by using a survey, the number of primary care, prevention
 Szilagyi, Peter and colleagues (2000) studied the Child Heatlh Plus program (CHPlus) which became the 28

model for SCHIP in New York State. Their objective was to examine changes in access to care, utilization of

services and quality of care for children after they enrolled in CHPlus. They found statistically significant

increases in access to a medical home and a usual source of preventive care after enrollment. However,

there was not a significant difference in emergency department services associated with enrolling in

CHPlus.

46

and emergency room services used by newly insured and referred families. 28

Dr. Howard Taras’ evaluation of the Health-Insurance Access Through Schools (HATS) Project

will go even further. In addition to measuring change in enrollment and change in access to health

services, Dr. Taras intends to evaluate pre- and post-enrollment school absenteeism rates and

school performance of the newly insured children. 

Evaluation Recommendations

Given the importance of evaluation to informed decision making, evaluation should be a key

component of the Federal, State and school-level recommendations found earlier in this report. In

instances where outcome evaluation measures are not feasible due to financial resources or other

confounding factors, outreach planners should at least integrate process evaluation measures as part

of specific outreach strategies. 

In order to promote evaluation of school-based outreach activities, we propose the following

recommendations:

4. The Federal government should evaluate school-based outreach and enrollment in

partnership with States, communities and schools.

4.1 Create and disseminate tools for States and schools to use to evaluate the

impact and effectiveness of their outreach efforts.

4.2 Establish clear and simple performance measures and reporting guidelines for

States to share their evaluation results with the Federal government and other States.

4.3 Create and implement a tool for evaluating the impact of Federal initiatives to

increase Medicaid/SCHIP enrollments through school-based outreach efforts.

4.4 Gather and make available information on the results of outreach evaluation

efforts.

In addition, we strongly encourage that HHS, in conjunction with ED, USDA, State and school
47

partners, support studies to examine the link between health insurance and educational performance. 

Many schools already recognize the important role they can play in linking children with health

insurance. However, schools also recognize that they are primarily held accountable for educational

outcomes, not health-related measures. For sustainability of school-based outreach and enrollment,

it is important to demonstrate the link between health insurance, healthy children and educational

performance.

While there are a number of challenges to designing evaluation tools for school-based outreach, the

benefits far outweigh the costs. The outreach and enrollment landscape is an evolving one with

multiple activities frequently directed at the same family. This confounds and complicates efforts to

understand which outreach strategies are more effective. However, evaluation is the key to spending

outreach dollars as wisely as possible. By choosing the most effective outreach strategies based on

informed decision making, scarce resources can be maximized and more of America’s children can

be served. 

Summary 

In summary, schools are the promising place to conduct outreach for children’s health insurance. 

Evidence, both from States and local communities, supports the impact that schools can have in

reaching millions of uninsured children. However, at the present time, and despite the extraordinary

outreach effort involving thousands of schools throughout the nation, barriers often prevent schools

from building a sustainable outreach program. This Report puts forth a set of recommendations that

address the resources needed to make outreach to uninsured children an integral part of school

business. It calls for a partnership between the public and private sectors, and close collaboration

among the health, education and nutrition agencies at the Federal, State and local levels. 
48

APPENDIX A
49

THE WHITE HOUSE 

 

 Office of the Press Secretary

 _______________________________________________________________

 For Immediate Release October 12, 1999

 

 

October 12, 1999

 

 

MEMORANDUM FOR THE SECRETARY OF HEALTH AND HUMAN SERVICES

THE SECRETARY OF EDUCATION

 THE SECRETARY OF AGRICULTURE 

 

SUBJECT: School-Based Health Insurance Outreach for Children

 

The lack of health insurance for millions of Americans remains one of the great challenges facing this

Nation. To help address this issue, I worked with the bipartisan Congress to create the Children's

Health Insurance Program (CHIP), the single largest expansion of children's health insurance in 30

years. The 1997 Balanced Budget Act allocated $24 billion over 5 years to extend health care

coverage to millions of uninsured children in working families. CHIP builds on the Medicaid

program, which currently provides health coverage to most poor children, and together, these

programs could cover most uninsured children.

 

Yet too few uninsured children eligible for CHIP or Medicaid participate. Barriers to enrollment

include parents' lack of knowledge about the options; cultural and language barriers; complicated

application and enrollment processes; and the "stigma" associated with so-called welfare 

programs. The Vice President and I have made removing these barriers to enrollment a high

priority. In 1997, I launched a major public-private outreach campaign called "Insure Kids Now." 

Foundations, corporations, health care providers, consumer advocates, and others have participated

through activities such as setting up enrollment booths at supermarkets and promoting the national

toll-free number (1-877-KIDS NOW) on grocery bags, TV and radio ads, and posters. In

addition, we created a Federal Interagency Task Force on Children's Health Insurance Outreach in

February 1998, which has implemented over 150 new activities to educate and train Federal

workers and families nationwide about the availability of Medicaid and CHIP.

 

Today I am directing the Secretaries of Health and Human Services, Education, and Agriculture to

focus children's health insurance outreach on a place where we know we can find uninsured children: 

schools. State experience indicates that school systems are an ideal place to identify and

enroll uninsured children in Medicaid or CHIP because schools are accepted by parents as a

conduit for important information. In addition, health insurance promotes access to needed health
50

care, which experts confirm contributes to academic success. We have learned that children without

health insurance suffer more from asthma, ear infections, and vision problems -- treatable conditions

that frequently interfere with classroom participation; and children without health insurance are

absent more frequently than their peers. As we strive for high standards in every school and

classroom, it is essential that we help families ensure their children come to school ready to learn.

 

Therefore, I hereby direct you, in consultation with State and local agencies, to report to me a set of

recommendations on specific actions to encourage and integrate health insurance enrollment and

outreach for children into schools, consistent with the mission of your agency. This report shall

include: 

 

• Specific short- and long-term recommendations on administrative and legislative actions for

making school-based outreach to enroll children in Medicaid and CHIP an integral part of

school business. These may include technical assistance and other support to school districts

and schools engaged in outreach; suggestions on how to effectively use the school lunch

program application process to promote enrollment in health insurance programs; lists of

practices that have proven effective, such as integration of outreach and enrollment activities

into school events such as registration, sports physicals, and vision and hearing testing; and

model State CHIP and Medicaid policies and plans for school-based outreach.

 

• A summary of key findings from the national and regional conferences scheduled for this fall

on the topic of school-based outreach. These conferences will bring together national and

State education officials, Medicaid and CHIP directors, public policy experts, and 

community-based organizations to examine the use of schools to facilitate the enrollment of

children in Medicaid and CHIP; evaluation tools to monitor the effectiveness of current

school-based outreach efforts; and best practices in school-based outreach and enrollment

for children's health insurance.

 

• Recommendations on methods to evaluate CHIP and Medicaid outreach strategies in

schools. Performance measures should be an integral part of school-based CHIP and

Medicaid outreach strategies, as they can inform policy-makers on the effectiveness of these

strategies, as well as help to identify areas of improvement.

 

I direct the Department of Health and Human Services to serve as the coordinating agency to assist

in the development and integration of recommendations and to report back to me in 6 months. The

recommended actions should be consistent with Medicaid and CHIP rules for 

coverage of appropriate health- and outreach-related activities. They should be developed in

collaboration with State and local officials as well as community leaders and should include

recommendations on fostering effective partnerships between education and health agencies. 

These recommended activities should be complementary, aggressive, and consistent with my

Administration's overall initiative to cover uninsured children.
51

 

 

 WILLIAM J. CLINTON

 

 # # # 

 

APPENDIX B
52

REPORT TO THE PRESIDENT ON SCHOOL-BASED OUTREACH 

Recommendation 1: Facilitate outreach and enrollment activities between Medicaid/SCHIP and other public programs with

similar eligibility criteria, such as the National School Lunch Program (NSLP).

Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

1.1 Implement the provisions in the 1.1.1 Send letter to SCHIP/Medicaid agencies HHS Summer

Agriculture Risk Protection Act of explaining the changes to information sharing with

2000 that amend the National NSLP and encouraging collaboration with their Child

School Lunch Act. Nutrition Agency.

1.1.2 Send letter to Child Nutrition State agencies

encouraging cooperation with SCHIP/Medicaid and

identifying a SCHIP/Medicaid coordinator. Explain

the criteria and conditions for disclosing free and

reduced price eligibility information with

SCHIP/Medicaid.

1.1.3 Distribute to Child Nutrition State Directors

two USDA developed prototype forms:

 1) Agreement for sharing eligibility 

 information between local school food 

 service and other agencies, including 

 SCHIP/Medicaid; and

 2) Prototype notification to parents about 

 potential disclosure of their free and 

 reduced price eligibility information and 

their option to refuse disclosure.

USDA July 2000

USDA Summer

2000

2000
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

53

1.2 Use the National School Lunch 1.2.1 Recommend that State Child Nutrition USDA March 3.2

Program to increase awareness Directors encourage local food service directors to annually

about Medicaid/SCHIP and include health insurance outreach materials with

identify potential enrollees. school lunch package distributed to all households at

the beginning of the school year.

1.2.2 Encourage food service and State Medicaid/

SCHIP staff to work together to develop a plan for

the transfer of school lunch eligibility information to

SCHIP/Medicaid eligibility workers for 

follow-up.

1.2.3 Keep State Child Nutrition Directors updated

on SCHIP/Medicaid through electronic transmissions

and presentations at Federal/State Child Nutrition

meetings.

1.2.4 Identify model information exchange 

programs and publicize on website.

USDA

HCFA

USDA

USDA

HCFA

Ongoing

Ongoing

Ongoing
54

Recommendation 2: Provide technical assistance and support to help States, communities, health care providers and schools

implement school-based outreach and enrollment activities for Medicaid/SCHIP.

Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

2.1 Develop and disseminate “how 2.1.1 Let contract for guide. HHS/ED/ Summer 3.2

to” guides for States, school 2.1.2 Receive, publish, distribute deliverable. 2000

districts, schools and health care 2.1.3 Post guides to the Insure Kids Now! 

providers on conducting school- website.

based outreach and enrollment. 

USDA

2.2 Work in partnership with 2.2.1 Identify model, school-based outreach HCFA Sept. 2.1, 2.7,

private/public organizations to locations. 2000 2.8

support up to three regional 2.2.2 Establish partnerships to help fund centers.

community-based training centers 2.2.3 Create training materials.

to prepare school and community 2.2.4 Advertise availability of training through 

staff to participate in outreach listserv, conference calls and webpage. Begin training

activities. program.

Ongoing

Ongoing

Sept.

2000

2.3 Support passage of an 2.3.1 Gather best practices from States that use HHS Ongoing

amendment to the Medicaid presumptive eligibility to enroll children in 

statute to include all schools schools. 

engaged in outreach and 2.3.2 Disseminate this information via the 

enrollment activities as “qualified listserv, webpage and conference calls.

entities” (entities allowed, at the 2.3.3 Develop legislative language for President’s

State option, to determine FY 2001 budget.

presumptive eligibility under 2.3.4 Meet with interested groups on language to 

Federal Medicaid statute). assure confidentiality/privacy concerns are 

addressed.
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

55

2.4 Work with HHS Regional Offices 2.4.1 Discuss school-based outreach issues at HHS Ongoing

to use current SCHIP monitoring Regional/Central Office meetings regarding 

visits to provide technical SCHIP monitoring visits.

assistance to States as they 2.4.2 Encourage Regional Offices to share best 

continue to work with schools to practices following monitoring visits.

enroll children. Regional Offices

can identify best practices that

can be shared with other States.

2.5 Work with national education 2.5.1 Continue to convene established ED Ongoing 2.7, 2.8

organizations, advocacy groups stakeholder group.

and other education leaders to 2.5.2 Identify national offices of community 

promote school-based outreach based organizations providing application 

and enrollment. assistance.

2.5.3 Contact national offices.

2.5.4 Disseminate results of contacts on listserv, 

website.

2.5.5 Develop collaboration between national and 

local partners. 

HHS/ED/ Ongoing

USDA

HHS/ED/ Ongoing

USDA

HHS/ED/ Ongoing

USDA

2.6 Work with States to encourage 2.6.1 Assist States in developing projects that HHS Ongoing

 the development and evaluation simplify Medicaid/SCHIP enrollment by 

of projects that simplify SCHIP coordination with other public programs.

and Medicaid enrollment for 

children enrolled in other 

Federal programs.

2.6.2 Identify new and effective ways to simplify 

the application and enrollment process by 

piloting and evaluating innovative efforts on a

small scale.

HCFA Sept 2000
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

56

2.7 Create an inter-Departmental 2.7.1 Develop listserv capability on Internet page. HHS/ED/ July 2000

electronic mail listserv to facilitate 2.7.2 Develop address list for listserv.

communication, problem solving 2.7.3 Post information as appropriate.

and exchange of timely

information from schools, health

agencies and community groups

partnering in outreach and

enrollment. Share appropriate

and timely information related to

program implementation, policy

development and legislative

changes of Federally-funded

programs.

USDA July 2000

Ongoing

2.8 Hold regular telephone 2.8.1 Work with States, providers, school HHS Ongoing 

conferences with electronic mail officials and community organizations to 

listserv subscribers from schools, identify topics for conference calls.

health agencies and community 2.8.2 Advertise conference calls through listserv.

groups to share information about 2.8.3 Update school-based webpage on 

initiating efforts, maintaining www.insurekidsnow.gov website.

efforts, funding sources, promising 2.8.4 Link webpage to USDA/FNS and ED 

practices, evaluating efforts and websites.

managing barriers. Post 2.8.5 Post conference call summaries and 

summaries or highlights highlights to webpage.

electronically on the

www.insurekidsnow.gov

website.

HHS Ongoing

HHS

USDA/ED July 2000

HHS Ongoing
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

57

2.9 Provide additional targeted 2.9.1 CompCare contract with Health Systems HRSA Through

 technical assistance to Research, Inc. is available to provide technical FY 2004

 interested States that have not assistance. All states will have an opportunity to

taken advantage of options receive technical assistance under this contract.

available under current law for 2.9.2 Conduct low-cost site visits, meetings or 

streamlining and simplifying conferences around school-based outreach 

SCHIP and Medicaid issues.

enrollment and redetermination 2.9.3 Utilize monitoring visits and 03/31/00 State 

processes. evaluations to determine technical 

assistance needs and interests.

HCFA

HHS

HHS

Ongoing

Ongoing
58

Recommendation 3: Encourage new or additional school-based outreach and enrollment efforts by assisting States and schools

to identify and maximize funding opportunities.

Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

3.1 Encourage State Medicaid 3.1.1 To the extent possible, information about HCFA Ongoing

agencies to utilize the special state by state expenditures and balances will be

$500 million fund set aside for disseminated regularly by HCFA.

Medicaid outreach following 3.1.2 Encourage HHS Regional Directors to HHS/IGA Ongoing

welfare reform to fund school- continue to discuss the availability of the fund in their

based outreach and enrollment regions. USDA/ED June 2000

activities, in accordance with 3.1.3 Provide RO staff with a list of State 

Federal guidance. education and nutrition contacts that they can share

 with the State Medicaid/SCHIP staff to partner and

discuss the use of the remaining funds.
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

59

3.2 Develop guidance letters, 3.2.1 Guidance on the continued availability of HCFA Completed

workshops and other forms of the $500 million delinking fund has already been

technical assistance detailing distributed by HCFA to States.

options available under current

law for States to receive Federal

match for reimbursing schools and

other entities that are conducting

outreach and enrollment activities. 

Guidance on how school districts

and schools can contract with

State Medicaid/SCHIP agencies

to get reimbursed for their

outreach and enrollment work

should be a priority. Include

guidance and sample Memoranda

of Understanding to assist State

Child Nutrition Directors, food

service personnel, school district

personnel and others whose

commitment to carrying out

outreach activities is contingent on

reimbursement for the costs

associated with these efforts.

3.2.2 Develop a guide on Administrative 

Claiming for School-Based Services.

3.2.3 Develop and distribute guidance to State 

Child Nutrition Directors about reimbursement 

for the costs of outreach for food service offices.

3.2.4 Develop guidance on issues raised by 

States on conference calls.

HCFA Summer

HCFA/

USDA

HHS

2000

Sept 2000

Ongoing 
Strategy: Action Steps: Dept/ Time Related

Agency Line Strategies

60

3.3 Develop a model Memorandum 3.3.1 Regional Office staff will share with HHS June 2000 2.7, 2.8

of Understanding (MOU) that can Central Office any already existing MOUs that exist

be used by Medicaid/SCHIP in States to help develop the model.

agencies in collaborating with

State Education Agencies,

Federally- funded grantees,

foundation grantees and school

districts for conducting and

funding outreach and enrollment

activities.

3.3.2 Develop and disseminate model MOU. HHS July 2000

3.4 Facilitate partnerships between 3.4.1 Meet with foundations and others to learn HHS/ED Ongoing 2.5, 2.9

public and private entities to about funding options for States.

identify new and innovative

funding streams to pay for schoolbased outreach and enrollment.

3.4.2 Meet with national organizations for 

integrated health systems, hospitals, managed care

organizations.

3.4.3 Disseminate findings on listserv, website.
61

For additional copies of this Report, please call:

1-888-ASK HRSA
62

or visit

www.insurekidsnow.gov