Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

Inspector General 

September 2002 

OEI-06-01-00370 

STATE CHILDREN’S HEALTH 

INSURANCE PROGRAM (SCHIP) 

RENEWAL PROCESS 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services (HHS) 

programs, as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by the following operating components: 

Office of Audit Services 

The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the department. 

Office of Evaluation and Inspections 

The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the department, the 

Congress, and the public. The findings and recommendations contained in the inspections 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

Office of Investigations 

The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

unjust enrichment by providers. The investigative efforts of OI lead to criminal convictions, 

administrative sanctions, or civil monetary penalties. The OI also oversees state Medicaid fraud 

control units, which investigate and prosecute fraud and patient abuse in the Medicaid program. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 

rendering advice and opinions on HHS programs and operations and providing all legal support 

in OIG's internal operations. The OCIG imposes program exclusions and civil monetary 

penalties on health care providers and litigates those actions within the department. The OCIG 

also represents OIG in the global settlement of cases arising under the Civil False Claims Act, 

develops and monitors corporate integrity agreements, develops model compliance plans, 

renders advisory opinions on OIG sanctions to the health care community, and issues fraud 

alerts and other industry guidance. 
September 20, 2002 

/s/ 

Debra Robinson 

Director, Regional Operations 

Office of Evaluation and Inspections 

OIG Memorandum Report: “State Children’s Health Insurance Program (SCHIP) Renewal

Process,” OEI-06-01-00370

Thomas A. Scully

Administrator

Centers for Medicare & Medicaid Services

Elizabeth M. Duke, Ph.D.

Administrator

Health Resources and Services Administration

Attached is a memorandum report that examines the State Children’s Health Insurance Program

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

improvement. 

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

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

renew SCHIP eligibility is with mail-in forms (42 States) that typically are not user-friendly. Thirtythree States provide SCHIP renewal instructions that are difficult to read and understand. Parents

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

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

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

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

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

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

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

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

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

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

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

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

option, and web site access to general SCHIP renewal information. 
Page 2 

You are welcome to provide comments but are not required to do so, since the report contains no 

recommendations. 

If you have any questions about this report or would like a meeting to discuss more detailed 

information, please contact Elise Stein, Director, Public Health and Human Services at 

(202) 619-2686. 

Attachment 
EXECUTIVE SUMMARY 

OBJECTIVE 

To evaluate the State Children’s Health Insurance Program (SCHIP) renewal process from the 

parents’ perspective and identify opportunities for improvement. 

BACKGROUND 

The State Children’s Health Insurance Program (SCHIP) allows States to expand health 

insurance coverage to certain low-income children. By September, 2001, more than 4.6 

million children who would otherwise be without health insurance were enrolled in SCHIP. 

Despite this progress, previous research suggests that eligible children are unintentionally 

disenrolled because their parents encounter difficulties navigating State SCHIP renewal 

processes, leaving them without health insurance. 

Our study examines the renewal process by simulating how parents might navigate that process. 

We collected renewal materials sent to parents from all 50 States. In addition, we accessed 

and evaluated telephone customer service lines and State SCHIP web sites. Our review of 

these information sources provides insight into limitations within the SCHIP renewal process. 

FINDINGS 

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

2 Require In-Person Interviews 

< 42 States require parents to complete and return forms by mail. Of these 42 States, 10 

States provide user-friendly forms, e.g. plain language, adequate space and print size, 

minimal duplicate information. 

< 6 States instruct parents to self-report any changes in family status. Four of the six 

States require parents to respond only if there are changes. Two States require parents 

to sign and return a pre-printed form if there are no changes in family status, or to 

update, sign and return the form if there are changes in status. 

< 2 States require in-person interviews to renew SCHIP. 

SCHIP Renewal Process i OEI-06-01-00370 
States Are Required To Send A Notice For Disapproval Of SCHIP Renewal, But 20 

States Do Not 

SCHIP regulations (42 CFR § 457.340) require States to send parents a written notice if 

eligibility is denied, suspended or terminated. We found that seven States send disapproval 

notices only, nine States send approval notices only, and 11 States do not send a final outcome 

notice. 

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

Expiration Date On The Card 

The coverage dates on the card alert parents that SCHIP coverage must be renewed at the end 

of the eligibility period. It is an important reminder for parents who did not receive renewal 

materials in time, and prompts them to contact their SCHIP offices. 

Parent Access To SCHIP Renewal Information Via Telephone Customer Service 

And The Internet Is Limited 

Fifty-four percent of telephone calls to SCHIP customer services resulted in obtaining general 

SCHIP renewal information. Twenty-eight percent of the calls reached a person who was 

unable to provide the renewal information and/or told us to contact the case worker. Eighteen 

percent of calls resulted in either voice mail, a busy signal, or being on hold longer than 10 

minutes. Thirty-four States use automated telephone menu systems for SCHIP customer 

service lines, but none of the automated telephone systems have a menu option for SCHIP 

renewal information. 

While 47 States have SCHIP web sites, 14 provide SCHIP renewal information. Only one 

State web site offers detailed information about the renewal process, including a sample form. 

CONCLUSIONS 

Renewing SCHIP coverage can be difficult for parents. We encountered difficulties obtaining 

information when we simulated parental contact even though we have greater knowledge of the 

system and are, therefore, better equipped to negotiate it. We identified problems with 

readability levels regarding renewal instructions and usability of forms. We noted the absence 

of written notification for parents regarding the outcome of the eligibility renewal process and 

helpful SCHIP information on SCHIP cards in some States. We also identified problems with 

obtaining general renewal information from SCHIP customer service telephone lines and State 

SCHIP web sites. 

SCHIP Renewal Process ii OEI-06-01-00370 
OPPORTUNITIES FOR IMPROVEMENT 

We encourage the Centers for Medicare & Medicaid Services (CMS) and the Health 

Resources and Services Administration (HRSA) to work with States to incorporate the 

following: 

< Take steps to ensure that States comply with the Federal regulatory requirement 

(42 CFR § 457.340) to issue final outcome notices if children are disenrolled. 

< Adopt user-friendly forms: offer plain language, adequate space and print size, and 

minimize duplicate information. 

< Include SCHIP coverage dates on the SCHIP card. 

< Add a telephone menu option specifically for SCHIP renewal in those States that use 

automated telephone systems. 

< Provide specific renewal sections on State SCHIP web sites. 

SCHIP Renewal Process iii OEI-06-01-00370 
TABLE OF CONTENTS 

PAGE

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

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

FINDINGS

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

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

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

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

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

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

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

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

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

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

APPENDIX 

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

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

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

SCHIP Renewal Process OEI-06-01-00370 
I N T R O D U C T I O N 

OBJECTIVE 

To evaluate the State Children’s Health Insurance Program (SCHIP) renewal process from the 

parents’ perspective and identify opportunities for improvement. 

BACKGROUND 

In 1997, Congress enacted the State Children’s Health Insurance Program (SCHIP) as Title 

XXI of the Social Security Act to expand health insurance coverage for certain low income 

children. A low-income child is generally defined in section 2110(b)(1) of the Act as a child 

whose family income exceeds the applicable Medicaid income level by not more than 50 

percent, or 200 percent of the federal poverty level (FPL), whichever is higher. SCHIP is a 

State-run program that entitles States to approximately $40 billion in Federal funds through 

2007. Like Medicaid, SCHIP is a joint State and Federal program; however, the Federal 

match for SCHIP is higher than that for the Medicaid Program. States have three options for 

covering uninsured children under Title XXI: to create a separate SCHIP program, expand 

Medicaid, or to combine the two approaches. 

Enrollment and Disenrollment for SCHIP-eligible Children 

By 2000, all 50 States and the District of Columbia had received approval from the Centers for 

Medicare & Medicaid Services (CMS) to expand public health insurance coverage for children 

through SCHIP. By September 2001, CMS reported that more than 4.6 million children who 

would otherwise be without health insurance coverage were enrolled in SCHIP.1 

Despite the progress of SCHIP, eligible children still lack health care coverage. A July 2001 

report2 by the Urban Institute indicated that their analysis had “also identified a sizable subgroup 

of low-income uninsured children (18 percent) who were uninsured at the time of the survey but 

who had been enrolled in Medicaid or SCHIP in the past year.” In other words, these children 

had dropped out of the program. The report also indicated that there are many reasons for 

parents not enrolling or discontinuing their children in public health insurance programs. 

Reasons include administrative difficulties associated with enrollment and renewal, parents’ lack 

of knowledge about public health insurance programs, not wanting public insurance for their 

children, or feeling such insurance is not needed. According to the State Annual Reports, 

numerous States cited that many parents never responded to the SCHIP renewal notices. 

Children may also become ineligible for coverage because of changes in family income, 

coverage by private insurance, moving out of State, or aging out of the program. 

SCHIP Renewal Process 1 OEI-06-01-00370 
SCHIP Evaluation Efforts 

Different agencies within the Department of Health and Human Services (HHS) have been 

conducting studies regarding SCHIP disenrollments. The Assistant Secretary for Planning and 

Evaluation (ASPE) of HHS is conducting a congressionally mandated SCHIP evaluation to 

assess enrollment and disenrollment dynamics and to analyze the program’s affect on 

beneficiary access, service, and satisfaction in 10 States.3 The Agency for Healthcare 

Research and Quality (AHRQ) conducts SCHIP research through the Child Health Insurance 

Research Initiative (CHIRI). In one study by CHIRI, “The Consequences of States’ Policies 

for SCHIP Disenrollment,” a major finding was that the renewal process generates large 

disenrollments; about half of children previously enrolled are disenrolled at renewal time, but as 

many as 25 percent return within two months. The Centers for Medicare & Medicaid Services 

(CMS) is in the process4 of completing a project for model application forms and notices for 

SCHIP and Medicaid. In addition, several non-profit foundations published reports that mainly 

provided useful information regarding the mechanics of the renewal process, but they lacked 

information about what parents and/or guardians might experience when they navigate that 

process. 

The Office of Inspector General has issued nine SCHIP-related inspection reports in the last 

three years. The three most recent reports are: “State Children’s Health Insurance Program: 

Ensuring Medicaid Eligibles are not Enrolled in SCHIP” (OEI-05-00-00241), “State 

Children’s Health Insurance Program: Assessment of State Evaluation Reports” (OEI-05-00-

00240), and “Federally Funded Health Centers and Low Income Children’s Health Care: 

Improving SCHIP Enrollment and Adapting to a Managed Care Environment” (OEI-06-98-

00321). None of the previous OIG work examined the renewal process. 

METHODOLOGY 

Study Focus 

In this report, we described what parents of SCHIP-enrolled children in all 50 States5 may 

experience when they renew their children’s SCHIP eligibility. We focused on evaluating 

SCHIP renewal notices and application forms and accessing renewal information through 

SCHIP customer services. 

Data Collection and Analysis 

We used both qualitative and quantitative approaches to focus on three distinct aspects of the 

renewal process to: 1) describe States’ program type and renewal process approach; 

2) review State SCHIP renewal materials and information sent to parents; and 3) assess States’ 

SCHIP customer service via the telephone and the Internet. Our contacts with States’ SCHIP 

policy staff initially included requests for renewal materials and information; we also contacted 

them later in the study on an as-needed basis to clarify policy or questions raised by our data. 

SCHIP Renewal Process 2 OEI-06-01-00370 
SCHIP program types and renewal approach: We extracted SCHIP renewal information 

from the State Annual Evaluation, CMS’ web site, individual State SCHIP web sites, and 

recent publications by the Urban Institute, Kaiser Family Foundation, National Academy for 

State Health Policy, and other research institutes. These sources provided us with information 

about the SCHIP program plan and characteristics for each State. We constructed simple 

frequencies for program types (separate, combined, or Medicaid expansion programs) and for 

States’ approaches to the SCHIP renewal process itself. 

SCHIP Renewal Materials: From August 30 to September 30, 2001, we collected SCHIP 

renewal materials directly from individual State SCHIP offices including SCHIP renewal 

applications, renewal notices and follow-up letters, SCHIP cards, and any other relevant 

SCHIP renewal materials that the States were using at the time of our data collection. We 

received responses from all 50 States although three States did not provide all materials.6 We 

analyzed the content of all SCHIP renewal instructions received for readability by using the 

“Readability Statistics” tool in Microsoft Word. In addition, we developed a check list of 

criteria for systematically rating usability of the forms for renewal. 

Readability – The “Readability Statistics” tool uses both the Flesch-Kincaid Index and Flesch 

Reading Ease Scale. The Flesch-Kincaid Index measures the school-grade writing level. 

Materials written at the 7th to 8th grade reading level are the standard for what is readable by 

and suitable for the general public. The Flesch Reading Ease Scale provides scores based on 

sentence and word length: a score of 100 is “very easy to read”, 0 is “extremely difficult to 

read”, and 65 equates to “plain English”. 

Usability – We rated usability of the forms used at renewal time based on the form’s general 

appearance, adequacy of fields for information requested, and print size. The criteria for rating 

usability of forms were: 

C Good: Form has ample ‘white space’ (so the form is not crowded), font size is 

readable without difficulty, field size is large enough for writing in requested 

information. 

C Fair: A mixed rating, with some of the elements rated ‘good’ and some rated ‘poor’. 

C Poor: Appearance of form is crowded/cluttered, font size is small and difficult to read, 

fields size is too small for writing in information requested. 

SCHIP cards: We also reviewed SCHIP cards to determine if the card displayed coverage 

dates and the States’ unique SCHIP program names. These cards are directly issued from the 

State or the Managed Care Organization that is under contract with the State to provide 

SCHIP services. 

Parent access for SCHIP renewal via telephone and the Internet: Individual SCHIP 

customer service telephone lines in all 50 States were evaluated from two aspects. First, we 

examined success rates in obtaining renewal information using telephone 

SCHIP Renewal Process 3 OEI-06-01-00370 
numbers shown in renewal materials that the States sent us; we also noted whether customer 

service representatives were helpful and courteous when we requested assistance or 

information. Second, we analyzed types of telephone systems with particular emphasis on 

renewal information as an option on automated menus. 

From October 24th to November 26th, 2001, we called individual State SCHIP customer 

service telephone numbers obtained from the following sources: States’ SCHIP renewal 

materials, SCHIP cards, and States’ SCHIP web sites. We created a structured protocol for 

telephone calls to systematize this portion of the data collection. This protocol included a set of 

questions asked of all customer service representatives, an assessment of telephone systems 

(automatic vs. live person), and the helpfulness of the person who answered the phone. To 

minimize bias, we systematically made multiple calls to each State using different days and times 

of day. We made at least four telephone calls to an SCHIP telephone number for each State. 

The telephone calls were unannounced, and we did not reveal our identity or research intention. 

As part of the simulation, we tried to proactively obtain information about renewing SCHIP as 

if we were parents who needed SCHIP renewal information. We asked their help for a variety 

of reasons, ranging from not understanding the process, to having lost information sent by the 

State or its contracted agency. 

To obtain SCHIP renewal information from individual State’s SCHIP web sites, we visited 

each State’s web site twice - - once during the last week of August 2001 and again during the 

first week of December 2001. For each visit to the web sites, we searched for renewal 

information only; we did not examine any other aspect of States’ SCHIP web sites. If we 

could locate renewal information, we also examined it for usefulness to the parent; that is, how 

much information about renewal would a parent know after reviewing the renewal information 

on the web site. 

Definition of Terms 

Individual States use slightly different terminology to describe the SCHIP renewal processes. 

In this report, we will use ‘renewal’ to represent similar terms such as re-enrollment, recertification, and redetermination. We use the term ‘parent’ to include any person with legal 

authority to act on behalf of the SCHIP-enrolled child, and we use ‘child’ to mean one or more 

children. 

Limitations 

State SCHIP programs are continuously evolving so the findings for this report are limited to 

the time period when we completed data collection for the study (August 27 to December 5, 

2001). In addition, our findings may understate challenges that parents experience when 

renewing their children’s SCHIP coverage. We may have been more determined to deal with 

the SCHIP system when difficulties arose, and we are probably more knowledgeable about the 

SCHIP program than parents whose experience we were trying to simulate. Furthermore, even 

though we were able to approach other aspects of renewal as if we were a parent dealing with 

SCHIP Renewal Process 4 OEI-06-01-00370 
the system, we, of course, did not have the specific child case information needed to examine 

the exchanges between case workers and parents in those States where case workers handle 

the renewal process. Also, we did not examine the actual re-enrollment rates that are 

associated with the various SCHIP renewal approaches, application forms, and notices that 

States use for SCHIP renewal. 

This study was conducted in accordance with the Quality Standards for Inspections issued by 

the President’s Council on Integrity and Efficiency. 

SCHIP Renewal Process 5 OEI-06-01-00370 
F I N D I N G S 

To evaluate the States’ SCHIP renewal process from the parent’s perspective and identify 

opportunities for improvement, we analyzed all 50 States’ renewal application forms and 

instructions, notices, SCHIP cards, States’ telephone customer services, and State SCHIP 

web sites. We encountered difficulties obtaining information when we simulated parental 

contact with renewing agencies. Because we have a wider knowledge of the system and are, 

therefore, better equipped to navigate it, we believe that parents can find the system a greater 

challenge to negotiate than we did. We identified problems with readability levels of renewal 

instructions and usability of forms. We noted the absence of written notification for parents 

regarding the outcome of the eligibility renewal process and helpful SCHIP information on 

SCHIP cards in some States. In addition, we identified problems with obtaining general 

renewal information from SCHIP customer service telephone lines and State SCHIP web sites. 

The SCHIP renewal process could be improved by making small modifications. 

42 States Renew SCHIP By Mail; 6 Continue Coverage Based On 

Self- Reports; 2 Require In-Person Interviews 

Mail-in forms (42 States) — Forty-two States7 send SCHIP renewal application forms to 

parents and require them to complete and return them to continue SCHIP coverage for their 

children. Mail-in forms generally appear to be burdensome; parents may experience difficulty 

in completing them because of length, lack of pre-printed information previously submitted, or 

unclear instructions. (See full discussion of forms starting on page 8). States may provide 

parents with other options, such as allowing parents to call in the information via telephone or 

make in-person visits to their case workers to complete renewal forms. Appendix A provides 

detailed information. 

Continued coverage for unchanged eligibility status (6 States) — Six States 

automatically renew SCHIP eligibility unless there is a change in status. The States send 

parents letters or forms that typically provide pre-printed information about household members 

and income/expenses supplied by the parents on their initial application. These States also 

provided parents the clearest and easiest to read SCHIP renewal materials. Of the six States, 

four send a letter and require the parent to respond, only if there is a change in income or family 

status. The other two States require slightly more effort -- the parent receives a renewal form 

that is pre-printed with previously submitted information and which must be signed and 

returned. In addition, if there is a change in eligibility status, the parent must update the 

information on the form. 

In-person interviews (2 States) — Only two States require an in-person interview for 

parents to renew their child’s SCHIP eligibility. One State sends notices to parents 

SCHIP Renewal Process 6 OEI-06-01-00370 
with a preset appointment time and requires parents to come to the office for the scheduled 

time. This State does not send any forms for SCHIP renewal prior to the in-person interview. 

The other State sends parents forms to be completed and brought with them to the in-person 

interview and gives the parent a 90-day period to schedule the interview at their convenience. 

SCHIP renewal process approaches do not differ between the States’ SCHIP 

program types 

The three types of SCHIP programs are Medicaid expansion, separate program, and a 

combination of Medicaid expansion and separate program. Our findings indicate that there is 

no relationship between SCHIP renewal process approaches and SCHIP program types.8 

(See Table 1.) 

Table 1: SCHIP Program Types by Renewal Process Approaches 

SCHIP PROGRAM TYPES 

MAIL-IN FORMS 

(n = 42 States) 

CONTINUED 

ELIGIBILITY 

(n = 6 States) 

IN-PERSON 

INTERVIEW 

(n = 2 States) 

COMBINED (19) 15 3 1 

MEDICAID EXPANSION (15) 13 1 1 

SEPARATE PROGRAM (16) 14 2 0 

States send prior notification postcards, follow-up notices and return envelopes 

to assist parents in the SCHIP renewal process 

Eight States send pre-notification postcards or letters to the parent to let them know that they 

will be receiving forms for renewing SCHIP coverage. Twenty-one States send follow-up 

notices to parents to remind them to return their forms and documentation. State follow-up 

notices range from a simple reminder to instructions for providing specific missing information 

and/or documents, the date SCHIP coverage will expire if they do not provide the 

information/documents, and how to contact State SCHIP offices if they need help. 

Fourteen States send the parent a return envelope with the form. These envelopes minimize 

non-response by reminding parents to return the forms and providing the proper address. One 

State marks important SCHIP mail in a special way. This State includes a bright neon-yellow 

sticker on the outside of the envelope to help ensure that the parent identifies it as important 

SCHIP renewal information. States such as California, Texas, and Minnesota with diverse 

populations have an instructional SCHIP renewal handbook that is available in several other 

languages to better serve parents with limited English proficiency. 

SCHIP Renewal Process 7 OEI-06-01-00370 
SCHIP Renewal Instructions And Forms Can Be Difficult To 

Understand And Use 

Thirty-three States provide parents renewal instructions that are difficult to read 

Despite different renewal approaches, all 50 States send written SCHIP renewal instruction 

notices to parents. According to the Flesch-Kincaid Index, materials written at the 7th and 8th 

grade reading level are the standard for what is readable by, and suitable for, the general public. 

In 26 States, written instructions received by parents for SCHIP renewal were at the more 

difficult reading levels of 10th to 12th grade. Seven States were at the 9th grade reading level, 

which is marginal for readability according to the standard (see Table 2). 

Table 2: Readability of Instructions Provided at Renewal Time 

GRADE LEVEL 5 - 6th 7 - 8th 9th 10th 11th 12th 

STATES (n =49 States)* 2 14 7 12 6 8 

*We did not receive the material from one State. 

Using the Flesch Reading Ease Scale of 0 to 100, 100 being “very easy to read” and 65 

equated with “plain English,” we found that 49 States’ renewal instructions had an average 

reading scale of 56, i.e., close to plain English. Fifteen of the 49 States fell into ‘the more 

difficult to read’ category of below 50 on the reading scale. 

Of the 42 States requiring mail-in forms, 25 States created a form specifically for 

renewal; 17 States require parents to re-complete the original application form 

Of the 25 States with renewal forms specifically created for renewal, 12 States pre-print some 

sections with SCHIP eligibility information previously submitted by the parent at the initial 

enrollment. Thus, parents do not have to provide the same information again. Of the 17 States 

that require parents to re-complete the original application form, only one State provides a preprinted form. The original application forms used for renewal were not distinctly marked to 

indicate that they were being used for renewal purposes. In comparison, we found that forms 

created for renewal purposes only were more user-friendly than the original application forms. 

Table 3 shows this comparison. (See Methodology and Appendix A for details.) 

SCHIP Renewal Process 8 OEI-06-01-00370 
Table 3: Comparison of Renewal Forms and Original Applications 

for Renewing SCHIP Eligibility By Mail 

FORM CHARACTERISTICS RENEWAL FORMS 

(n = 25 States) 

RE-COMPLETE ORIGINAL 

APPLICATIONS 

(n = 17 States) 

USES PREPRINTED INFORMATION 

Yes 

No 

48% 

52% 

(12) 

(13) 

16% 

84% 

(1) 

(16) 

AVERAGE FORM LENGTH 2 pages 4 pages 

READING GRADE LEVEL 

Easy (5th - 8th)) 

Fair (9th - 10th) 

Difficult (11th - 12th) 

32% 

48% 

20% 

(8) 

(12) 

(5) 

29% 

23% 

47% 

(5) 

(4) 

(8) 

USABILITY 

Good 

Fair 

Poor 

40% 

52% 

8% 

(10) 

(13) 

(2) 

35% 

59% 

6% 

(6) 

(10) 

(1) 

INCLUDES OF RIGHTS AND 

RESPONSIBILITIES* 

Yes 

No 

64% 

36% 

(16) 

(9) 

88% 

12% 

(15) 

(2) 

*“Rights and Responsibilities” certify that parents understand and authorize the conditions of eligibility. 

Of the 42 States, 10 States9 have user-friendly forms, which we defined as having at least three 

of four form characteristics listed in Table 3: pre-printed information, shorter lengths, easy 

reading grade levels, and good usability. The 10 States have only 21 percent of the SCHIP 

children ever enrolled during the year 2001, which indicates that the majority of parents are 

faced with forms that are difficult to use.10 Only one of the 10 States belongs to the top 10 most 

populous States for SCHIP enrollees.11 

Parents Are Not Always Notified Of Final Renewal Outcomes 

States are required to send a notice for disapproval of SCHIP renewal, but 20 

States do not 

SCHIP eligibility must be renewed at least every 12 months. If eligibility is denied, suspended, 

or terminated, SCHIP regulations at 42 CFR § 457.340 require States to send parents a written 

notice. We found that States take the following actions: 

• 23 States send approval or disapproval notices to parents depending on the 

outcome of the renewal. 

• 7 States send disapproval notices only. 

• 9 States send approval notices only. 

• 11 States do not send a final outcome notice. 

SCHIP Renewal Process 9 OEI-06-01-00370 
The 11 States that do not send a final outcome notice instead send two or more follow-up 

notices that inform parents that SCHIP coverage will be discontinued if parents do not complete 

required renewal actions by a certain deadline. Without an outcome notice that clearly indicates 

disapproval or approval at the end of the renewal process, parents may make erroneous 

assumptions about whether their child is still eligible for SCHIP coverage. In addition, 

disenrollment information explains the reasons a case may have been discontinued, whether the 

parent can provide more information in order to show eligibility, or how to contest a 

disenrollment decision. 

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

States Include An Expiration Date On The Card; 24 States Do Not 

Include The State SCHIP Program Name 

Including coverage dates on SCHIP cards can be a powerful reminder to parents that SCHIP 

must be renewed and may prompt parents to contact their SCHIP offices if they do not receive 

renewal materials in a timely fashion. Despite all 50 States providing these cards12 to enrolled 

children, only 12 States show both the effective and expiration dates of SCHIP coverage on the 

card. Nine States just show the effective date of the coverage on the card but not the expiration 

date. 

States typically select a unique SCHIP program name that can appear on the card and help 

build program recognition. Unique SCHIP program names, such as Husky, MIChild, LaChip 

and Badger Care, help to reduce the perceived stigma of seeking public assistance. These 

unique SCHIP names also help parents identify correspondence related to the program. 

Although these unique names appear on renewal materials, only 24 States printed their 

designated SCHIP program name on the SCHIP card. Parents may be confused if the program 

name that appears on their card is different from the name on the renewal materials that they 

receive in the mail. In such situations, when parents receive SCHIP renewal materials and do 

not recognize the SCHIP name, they may simply disregard them. 

SCHIP Renewal Process 10 OEI-06-01-00370 
Parent Access To SCHIP Renewal Information Via Telephone 

Customer Service And The Internet Is Limited 

Obtaining SCHIP renewal information through States’ SCHIP customer service 

telephone lines is challenging 

Using telephone numbers obtained from renewal forms and notices, SCHIP cards, and State 

SCHIP web sites, we made a total of 257 telephone calls, with a minimum of four to each State. 

The results of our telephone calls to all 50 States’ SCHIP customer service lines were: 

< 54 percent of calls resulted in obtaining requested general SCHIP renewal 

information. Based on our experiences, persons who provided us with the 

renewal information were almost always courteous and helpful. 

< 28 percent of the calls reached a person who was unable to provide general 

SCHIP renewal information and/or who told us to contact the case worker. 

< 18 percent of the calls resulted in a busy signal (7 percent), being on hold longer 

than 10 minutes (3 percent), or reaching a voice mail box (8 percent). 

As indicated in the methodology section, we simulated parents’ experiences, but we did not 

have a specific child’s information nor could we reveal our identity. When we reached voice 

mail we were, therefore, unable to leave a message. Consequently, we were not able to 

determine if the telephone calls that reached voice mail (8 percent) would result in calls being 

returned to us. 

We found that 19 States rely on case workers for the renewal process. In these States, case 

workers are the primary source for obtaining renewal information. Of the calls made to these 19 

States, 55 percent resulted in obtaining requested SCHIP renewal information.13 In 26 percent 

of these calls, case workers would not provide us with renewal information, even general 

information, without specific identifying information for a child, such as a social security number. 

The remaining 19 percent of these calls resulted in reaching voice mail. We did not receive any 

returned calls from the case workers because we did not leave any messages on their voice 

mails. 

Of the 34 States with automated telephone menus, none offered specific SCHIP 

renewal menu options 

Our telephone calls reached one of the following three venues: an operator (16 States), an 

automated system with an operator (32 States), and an automated system with no operator (2 

States). For those calls that reached an automated system, none offered specific renewal 

information or procedures, although eight of 34 States included a menu option for verifying 

eligibility status. Also, at times we were not sure if we had reached the SCHIP customer service 

telephone line since the initial greeting message from the automated 

SCHIP Renewal Process 11 OEI-06-01-00370 
system or operator was not clear. For example, in one State the initial greeting is “consumer 

hotline” and another State uses “State resource line.” 

Of 14 States that provide any renewal information on their State SCHIP web sites, 

only one State includes a sample renewal form and instructions 

State SCHIP web sites emphasize enrolling new children in SCHIP but lack information about 

renewing eligibility for an already enrolled child.14 At the time of our review, three States’ 

SCHIP web sites were unavailable. Fourteen15 of 47 States provided SCHIP renewal 

information on the web sites. Of those 14 States’ SCHIP web sites, on average, it took passing 

through four to five web pages to reach the renewal information. 

In reviewing the 14 States’ SCHIP renewal information on their SCHIP web sites, we found: 

< 1 State provides comprehensive SCHIP renewal information, including renewal forms 

and user friendly instructions. 

< 1 State provides a renewal form under a “Documents and Forms” section but it is 

difficult to access the form without prior knowledge of the exact web address or the 

name and number of the form. 

< 2 States only provide the following information about renewal: “the client is enrolled for 

12 months,” and “the client must re-enroll after one year”. 

< 10 States simply mention that the client will be notified by mail when it is time to renew; 

this information is included either in a section on “Frequently Asked Questions” or as 

part of an on-line manual. 

Offering renewal information on the State’s SCHIP web site can be valuable to other interested 

entities, such as community health centers, community-based organizations, hospitals or private 

health care providers for their own information as well as for providing assistance to parents. 

Also, the Internet can be a very useful resource for those parents who have access to it. 

Conclusions 

Renewing SCHIP coverage can be difficult for parents. We encountered difficulties obtaining 

information when we simulated parental contact even though we have greater knowledge of the 

system and are, therefore, better equipped to negotiate it. We identified problems with 

readability levels of renewal instructions and usability of forms. We noted the absence of written 

notification for parents regarding the outcome of the eligibility renewal process and helpful 

SCHIP information on SCHIP cards in some States. In addition, we identified problems with 

obtaining general renewal information from SCHIP customer service telephone lines and State 

SCHIP web sites. The SCHIP renewal process could be improved by making small 

modifications. Some States may already have implemented the recommended action or are 

planning on implementing it in the future. 

SCHIP Renewal Process 12 OEI-06-01-00370 
OPPORTUNITIES FOR IMPROVEMENT 

The Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services 

Administration (HRSA) are the two main agencies responsible for the SCHIP program. We 

offer to CMS and HRSA the following steps, which could improve the SCHIP renewal process. 

CMS could: 

< Take steps to ensure that States comply with the Federal regulatory requirement 

(42 CFR § 457.340) to issue final outcome notices if children are disenrolled. 

< Complete and issue the CMS report for model application forms and notices. These 

models would assist States to develop forms and notices that meet the Federal 

regulatory requirement. 

CMS and HRSA could encourage States to: 

Continue to make the renewal process easier for parents. 

< Use systematic guidelines to create forms that are written in plain language, offer 

adequate space for filling in information, provide easily read print size, and minimize 

duplicate information. 

< Include SCHIP beginning and ending coverage dates on the SCHIP card. 

< Include the unique SCHIP program name on the SCHIP card and on renewal 

correspondence - - or, at least, use one name consistently for easy recognition. 

Provide parents easier access to needed renewal information. 

< Add a telephone menu option specifically for SCHIP renewal to their automated 

telephone systems. 

< Encourage caseworkers to leave a message on their voice mail so that they will accept 

incoming calls during a specified time period convenient for them. 

< Include specific renewal sections in State SCHIP web sites. 

SCHIP Renewal Process 13 OEI-06-01-00370 
E N D N O T E S 

1. Centers for Medicare & Medicaid Services website, www.CMS.gov. 

2. Genevieve Kenney, Jennifer Haley. “Why Aren’t More Uninsured Children Enrolled in 

Medicaid or SCHIP?” Washington, D.C.: The Urban Institute. Assessing the New 

Federalism Policy Brief B-35. 

3. Mathematica Policy Research, ASPE SCHIP evaluation announcement. 

http://www.mathematica-mpr.com 

4. In 2000, CMS awarded a contract to the Maximus Center for Health Literacy and 

Communications Technologies to develop English and Spanish model applications and notices 

for States that are beneficiary-based. CMS was scheduled to make these notices available to 

States in the Spring of 2002. In addition to the models, Maximus is also developing guidelines 

to assist States in creating effective written communications. These guidelines build upon the 

Writing and Designing Print Materials for Beneficiaries guide, released in 1999. 

5. We did not include the District of Columbia, Puerto Rico, American Samoa, Commonwealth of 

Northern Mariana Islands, Guam, or Virgin Islands in this inspection. 

6. Florida did not provide a renewal application form. Rhode Island and Virginia did not provide 

sample SCHIP cards. 

7. There are six Combination Program Type States (CA, IA, IL, MI, ND, TX) that utilize two 

offices to handle SCHIP (Medicaid expansion and a Separate component of SCHIP) and that 

also use two separate forms for renewal. We only reviewed the Separate SCHIP Program 

Type component for these States. The Medicaid expansion program forms are not included in 

the analysis. 

8. Chi Square test result was not significant. 

9. The 10 States that have user-friendly forms are AK, IA, ID, IL, KS, LA, NE, TX, UT and 

WA. 

10. This percentage is calculated based on number of children ever enrolled in SCHIP during the 

year 2001 in the 42 States that use forms for renewal. This information was obtained from the 

State Children’s Health Insurance Program Annual Enrollment Report, Federal Fiscal Year 

(FFY) 2001: October 1, 2000 - September 30, 2001, Centers for Medicare & Medicaid 

Services, February 2002. 

11. Texas is the one State out of the group with user-friendly forms that is also one of the ten most 

populous States in terms of children ever enrolled in SCHIP. The ten most populous SCHIP 

enrollee States in FFY 2001 were CA, FL, GA, MA, MD, MO, NY, OH, PA and TX. This 

SCHIP Renewal Process 14 OEI-06-01-00370 
information was obtained from the State Children’s Health Insurance Program Annual 

Enrollment Report, Federal Fiscal Year (FFY) 2001: October 1, 2000 - September 30, 2001, 

Centers for Medicare & Medicaid Services, February 2002. 

12. Virginia and Rhode Island have SCHIP cards, but they did not send us a sample card. 

13. We obtained the case worker’s telephone number from the following initial sources: 10 States 

were from SCHIP cards, 3 States were from renewal materials and 6 States from SCHIP web 

sites. 

14. We initially surveyed State web pages during the last week of August 2001 and then again in 

December 2001 to determine if we could find SCHIP renewal information on these web sites. 

In both August and December, one State did not have an SCHIP web site and one State’s web 

page was ‘under construction.’ In December, an additional State’s web page was under 

construction. All other States had web pages for SCHIP - of these 48 States, in August, 12 

State’s web sites specifically mentioned the renewal process in some form. In December, 14 

States mentioned the renewal process in some form, representing a slight gain over a threemonth period. 

15. The 14 States are AK, CA, CT, IN, KY, MN, MT, NJ, NC, ND, OH, TX, WV and WY. 

Alaska provides the most comprehensive web site for SCHIP renewal information. 

SCHIP Renewal Process 15 OEI-06-01-00370 
APPENDIX A 

SCHIP Forms at Renewal Time 

(August 30 - September 30, 2001) 

Type of Approach at Content* Analysis Measures 

SCHIP Renewal Time 

Program Readability (a) Usability (b) 

Ease Scale Grade level 

(0-100 best) (7th - 8th is standard) 

AK Medicaid Renewal form Pre-print 46.6 11 good 

AL Combination Renewal form Blank 58.3 10.3 fair 

AR Medicaid Renewal form Blank 43.9 10 fair 

AZ Separate Renewal form Blank 57.9 8.9 fair 

CA Combination Renewal form Blank 47.7 11.5 fair 

CO Separate Original form Blank 64.1 8.3 fair 

CT Combination Original form Blank (c) 62.2 8.3 fair 

DE Separate Original form Blank 33.5 12 good 

FL Combination Continued ( No Info) 

GA Separate Continued N/A 55.6 9 n/a 

HI Medicaid Original form Blank 30.7 12 fair 

IA Combination Renewal form Pre-print 80.2 5.2 good 

ID Medicaid Renewal form (d) Pre-print 83 5.5 good 

IL Combination Renewal form Pre-print 43.4 12 good 

IN Combination Renewal form (e) Blank 59.6 9.9 fair 

KS Separate Original form Blank 66.2 7 good 

KY Combination In-person N/A 55.4 10.2 n/a 

LA Medicaid Renewal form Blank 68.5 7 good 

MA Combination Original form Blank 62.3 9.6 fair

MD Combination Original form Blank 64.3 8.5 fair 

ME Combination Renewal form Blank 54.8 8.8 fair 

MI Combination Renewal form Pre-print 58.9 9.8 good 

MN Medicaid Renewal form Blank 61.3 8.4 fair 

MO Medicaid Renewal form Blank 43.3 10 fair 

MS Combination Continued N/A 55.6 9 n/a 

MT Separate Original form Blank 40.5 11.8 poor 

NC Separate Renewal form Blank 56.9 10 fair 

ND Combination Renewal form Pre-print 56.2 9.1 fair

NE Medicaid Renewal form Blank 70.3 7 good 

NH Combination Original form Blank 49.6 11.3 fair 

NJ Combination Continued (f) Pre-print 41.9 12 good 

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SCHIP Renewal Process 16 OEI-06-01-00370 
Type of 

SCHIP 

Program 

Approach at 

Renewal Time 

Content* Analysis Measures 

Readability (a) Usability (b) 

Ease Scale Grade level 

(7th - 8th (0-100 best) is standard)

NM Medicaid Original form (g) Blank 39.3 11.9 good 

NV Separate Continued (f) Pre-print 63.4 8.2 good 

NY Combination Original form Blank 56.1 9.9 fair 

OH Medicaid Original form Blank 45.4 11.4 fair

OK Medicaid Renewal form Blank 48.1 10.3 poor 

OR Separate Original form Blank 68.3 7 fair

PA Separate Renewal form Blank 52.2 9.7 good 

RI Medicaid Renewal form Blank 63.6 7.7 fair 

SC Medicaid Continued N/A 68 8 n/a 

SD Combination Renewal form Blank 43.5 11.4 fair 

TN Medicaid In-person Blank 69.7 7.8 poor 

TX Combination Renewal form Pre-print 66.5 8.4 good 

UT Separate Renewal form Pre-print 61.1 8.7 good 

VA Separate Original form Pre-print 50.1 12 good 

VT Separate Original form Blank 54.6 9.7 fair

WA Separate Original form Blank 64.3 8.2 good 

WI Medicaid Original form Blank 46 11.1 good 

WV Separate Renewal form Pre-print 69.1 7.1 poor 

WY Separate Renewal form Pre-print 47.4 10.9 fair 

*Content: States using pre-printed information contain most recent application and account information on the 

client. If the information is still correct, the parent is required to sign and date the form and send it back. However, 

if the information has changed, parents are instructed to cross out and write in new information and return the form. 

(a) Readability is an objective measure using the Microsoft® Word readability program which provides scores 

using the Flesch Reading Ease Scale and the Flesch-Kincaid Index. 

(b) Usability of the form was rated according to ‘white spaces’ on the form, readability of font size, and adequacy of 

the fields for information requested. See Methodology section of the report. 

(c) CT has very little pre-printed information provided on form. It is mostly blank. 

(d) ID uses multiple methods. A form is required if changes in circumstances and will allow continued eligibility. 

(e) IN uses renewal forms, but encourages in-person office visit. They also allow clients to renew over the 

telephone and update new information. 

(f) NJ and NV use a continued automatic approach unless the parents report changes to their circumstances, 

although parents must respond with a signature to continue coverage. These States have a renewal form, however, 

it is not required unless the parent has a change of circumstances. 

(g) NM requires the form or an in-person renewal visit. 

__________ 

SCHIP Renewal Process 17 OEI-06-01-00370 
B I B L I O G R A P H Y 

The Center for Health Literacy and Communication Technologies. Simplifying Medicaid/SCHIP 

Enrollment and Retention Forms (SMERF). What People are Saying About Notices and Apps. -

English, Maximus. 

Cunningham, Peter J. “Targeting Communities with High Rates of Uninsured Children”, Health Affairs, pp. 

20-29. 

Dick, Andrew R., Andrew Allison, Susan G. Haber, Cindy Brach, Elizabeth Shenkman. The Consequences 

of States’ Policies for SCHIP Disenrollment, 2002, The Child Health Insurance Research Initiative. 

The George Washington University Center of Health Policy and Research, Room to Grow: Promoting Child 

Development Through Medicaid and CHIP, The Commonwealth Fund, July 2001. 

Health Care Financing Administration (CMS), Outreach & Eligibility Division, Model Application and Best 

Practice Guide, GS-23F-9796H, 2000. 

Kannel, Susan, Michael Perry, Trish Riley, Cynthia Pernice, What Parents Say: Why Eligible Children Lose 

SCHIP, June 2001, National Academy for State Health Policy. 

Kenney, Genevieve, Jennifer Haley. “Why Aren’t More Uninsured Children Enrolled in Medicaid or SCHIP?” 

Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief B-35. 

Kenney, Genevieve, Jennifer Haley, Lisa Dubay “How Familiar Are Low-Income Parents with Medicaid and 

SCHIP?” Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief B-34. 

Kenney, Genevieve, Jennifer Haley, Frank Ullman, “Most Uninsured Children Are in Families Served by 

Government Programs” Washington, D.C.: The Urban Institute. Assessing the New Federalism Policy Brief 

B-4. 

Kaiser Commission on Medicaid and the Uninsured. 2000. Making it Simple: Medicaid and CHIP Income 

Eligibility Guidelines and Enrollment Procedures, Prepared by Donna Cohen and Laura Cox. Washington, 

D.C.: Center on Budget and Policy Priorities, 2000. 

Kaiser Commission on Medicaid and the Uninsured. 2000. CHIP Program Enrollment: June 2000, 

Prepared by Vernon K. Smith Ph.D. Lansing, MI: Health Management Associates, 2001. 

Letter to The Honorable Christopher S. Bond, dated July 25, 2001. Subject: Children’s Health Insurance: 

SCHIP Enrollment and Expenditure Information, signed by Kathryn G. Allen, Director, Health Care-Medical 

and Private Health Insurance Issues, U.S. Government Accounting Office. 

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SCHIP Renewal Process 18 OEI-06-01-00370 
Lipsey, Mark, David Wilson, Practical Meta-Analysis, Applied Social Research Methods Series, 

Vol. XX, Thousand Oaks, CA, Sage Publications, Inc. 

National Governor’s Association (NGA), Retention and Reenrollment of Children in SCHIP and 

Medicaid, available at http://www.nga.org. 

National Governor’s Association (NGA), Strategies for Retention and Reenrollment of Children in 

SCHIP and Medicaid, available at http://www.nga.org. 

Office of Inspector General, Department of Health and Human Services, The Children’s Health Insurance 

Program: State Application and Enrollment Processes: An Early Report from the Front Lines, OEI-05-

98-00310, 1999. 

Office of Inspector General, Department of Health and Human Services, State Children’s Health Insurance 

Program: Assessment of State Evaluations Reports, OEI-05-00-00240, 2001. 

Pernice, Cynthia, Kirsten Wysen, Trish Riley, Neva Kaye, Charting SCHIP: Report of the Second 

National Survey of the State Children’s Health Insurance Program, National Academy for State Health 

Policy, July 2001. 

Ross, Donna Cohen, Laura Cox, Medicaid for Children and CHIP Income Eligibility Guidelines and 

Enrollment Procedures, Center on Budget and Policy Priorities, October 2000. 

Urban Institute, “Parents’ Reasons for Not Obtaining Public Health Insurance for Children More Complex 

Than Once Thought”, http://www.urban.org/news/pressrel/p010702.html, July, 2, 2001. 

Wooldridge, Judith, Brenda Cox, Mary Harrington, Lorenzo Moreno, Christopher Trenholm, Welmoet van 

Kammen, Will Black, Amy Zambrowski, “Design Report: Congressionally Mandated Evaluation of the State 

Children’s Health Insurance Program,” Mathematica Policy Research, Inc. Contract number HHS-100-01-

0002, 2001. 

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SCHIP Renewal Process 19 OEI-06-01-00370 
ACKNOWLEDGMENTS 

This report was prepared under the direction of Judith V. Tyler, Regional Inspector General for Evaluation and

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

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

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

Gina Collins, Program Analyst

Lisa White, Administrative Officer

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SCHIP Renewal Process 20 OEI-06-01-00370