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States concerned about improving outreach efforts to enroll eligible children in health insurance programs are looking at the National School Lunch Program as a possible source of leads, if not outright enrollments. Since the income eligibility guidelines to obtain free or reduced-price meals through the program are similar to or more restrictive than the income eligibility guidelines for children’s health coverage in most states, a child who is eligible for school lunch benefits is likely to be eligible for health coverage through the Medicaid or Children’s Health Insurance Program (CHIP).
The Agricultural Risk Protection Act of 2000 included provisions to make it easier to disclose information from a school lunch application. States and school food authorities were given an option to disclose children’s free and reduced-price meal eligibility data to Medicaid and CHIP agencies without first obtaining parental consent.
To protect confidentiality, school food authorities are required to tell families that the information will be shared and give them an opportunity to opt out of the disclosure.
The Center on Budget and Policy Priorities in Washington, DC, conducted a survey to determine how state child nutrition agencies and local school districts responded to the call to explore using the school lunch program for effective health care outreach.
It also looked at the extent to which the U.S. Department of Agriculture’s (USDA) multiuse school lunch application and waiver forms were used during the 1999-2000 school year. To assist with health insurance outreach for children, the USDA developed and distributed several prototype forms that could be used to obtain parental consent to disclose children’s free and reduced-price meal eligibility information for the purpose of identifying and enrolling children in Medicaid and CHIP.
The prototypes are available either as a check-box on a multiuse school lunch application or as a separate waiver form that could be attached to an application.
The survey found that most state school lunch agencies issued either the USDA prototype multiuse school lunch application or waiver form to local school districts in the 1999-2000 school year. Most states that did not use either the form or the waiver used other means to tell families about availability of free and low-cost children’s health care coverage, including enclosing flyers or other promotional materials with school lunch applications.
More than half the states that used the prototype forms included a cover letter encouraging school districts to use the materials or providing instructions on how to use them, or both.
Strategies for sorting out school lunch applications or waivers on which families had checked the consent box appeared to vary from state to state and even school district to school district.
Many state child nutrition directors did not know how applications with boxes checked off were being sorted. State child nutrition directors also were not familiar with how the information was being communicated to health insurance agencies or how those agencies responded.
The directors had mixed opinions of the prototype application and waiver forms, and said the key factors for successful implementation of a multiuse application or waiver were a strong partnership between relevant state agencies and the availability of Medicaid or CHIP staff to help implement transfer and follow-up procedures.
The greatest obstacles to successful implementation of the multiuse school application or waiver appeared to include inadequate availability of school staff to implement procedures and a lack of clear procedures for handling the multiuse application or waivers. Cost of implementation was not mentioned as a significant concern.
Donna Cohen-Ross, center analyst, tells State Health Watch the survey revealed a significant amount of interest in exploring the best way to link the school lunch application with children’s health care.
While forms were moved around and used, in many instances, what was needed was something more — promotion of planning and coordination so a system and procedures could be in place to make use of the information from the application form, she says. "In those instances when something productive happened, it was because there had been some coordination at the state or local level between people working in nutrition and health care."
A major issue was what schools did with an application once it was returned by a family. "Is there a system in place to make use of the information to make a health care eligibility determination? In a lot of places, that just didn’t happen," Ms. Cohen-Ross says.
"Families may have checked the box on the form, but because there was no system in place, they didn’t hear back and thought they weren’t eligible, and so they passed up other outreach. There needs to be better collaboration and a plan in place."
She suggests that states could follow up on applications that are sent to school districts to offer assistance and could authorize sharing of income information and not just a family’s name and address.
Reportedly, a USDA interim rule will require a written agreement between state agencies so a system will have to be in place to make use of the information. Such a requirement, Ms. Cohen-Ross says, would be a great help in acknowledging what has to happen in both the school and the health care agency.
Rachelle Wagner, who has worked on the program in Cincinnati for Automated Health Systems, tells SHW that in the first pilot year, they used the modified application to obtain a parental release for information and an indication of interest in learning more about health insurance for their children.
Her company sent the application to about 20 school districts and met with the public and parochial schools that used it to set up a protocol for gathering the information.
The Cincinnati public schools arranged for telephone calls to families to try to encourage them to complete the application. Wagner estimates they reached 25% of the families. Problems with lists not having telephone numbers and other logistic difficulties cut the response. They received the names of 3,400 children in Hamilton County and sent out 1,500 applications.
The rest of the state, Ms. Wagner says, used a mail center to mail applications for health insurance in response to the information they received. Parent involvement coordinators from the schools also conducted outreach to encourage parents to apply.
Ms. Wagner says an initial lesson learned is not to do so much upfront telephoning and instead concentrate on coaching people in submitting an application. She also says it would help if schools shared telephone numbers and even Social Security numbers.
The Center on Budget and Policy Priorities says that technical challenges related to sharing information from school lunch applications with Medicaid and CHIP, such as waiver language, methods for matching records, and strategies for electronic information transfers, should be reviewed and stumbling blocks removed. "While using the school lunch application to identify children who are likely to qualify for health coverage is a crucial first step, greater emphasis should be placed on aggressively facilitating enrollment of those children in health coverage programs," the report says.
[Contact Ms. Cohen-Ross at (202) 408-1080 and Ms. Wagner at (513) 731-2345.]