Following are some ideas from states on how to communicate about retention. This list of ideas is not meant to be comprehensive -- it only represents the efforts of a few states encountered in the literature search and in interviews with experts.
- One state mails postcards in advance announcing that the renewal packet is coming soon, and that families need to complete the packet to stay enrolled in the program. Some states also send reminder postcards two weeks after the renewal packet has been sent to urge families to complete the packet.
- One state has redesigned its renewal notice so that it is now a checklist of items that families need to complete to successfully renew. The prior format was a paragraph of information about the renewal steps. The hope is that the checklist will be clearer to families and make it easier for them to comply.
- Some states have developed two-sided renewal forms -- one side in English and the other side in Spanish -- to ease language barriers.
- Some states use self-addressed, postage-paid envelopes for the return of renewal forms.
- One state printed its renewal forms on blue paper to distinguish it from the other materials sent by the program to families, and reminds families that it is time to renew by using the tagline, "If it's blue, it is time to renew."
- One state has a semi-annual SCHIP newsletter informing families of changes in the program. The newsletter also enables the program to repeat messages about retention and the importance of renewing. The newsletter has the added advantage of keeping addresses current by reminding families to contact SCHIP if they are planning to move.
- One state uses bright yellow stickers that say "Important Insurance Information" and attaches them to renewal packet envelopes to make sure families understand this material is important and not just a regular mailing from the program.
- One state has developed refrigerator magnets reminding parents to renew in SCHIP. The magnets provide the toll-free SCHIP phone number, as well as space for parents to write their SCHIP renewal date and their doctor's and dentist's phone numbers.
- One state mails renewal packets in envelopes with the SCHIP logo and address instead of the Department of Health and Human Services (DHHS) return address. The reason for this is to reduce any stigma that families may feel in receiving mail from DHHS, which also administers cash assistance programs.
- One state includes information about how to use insurance and contact information for the SCHIP office in the renewal packet.
- One state gives families stickers with their renewal deadline date on it.
- One state has developed training videos for outreach workers that include tips about renewal and how to keep eligible families enrolled in Medicaid and SCHIP.
- One state uses premium payment coupons (similar to car payments) and prints reminders and useful information on them. For example, they include a message about the families' ability to adjust their premium amount if their income goes down and reminders about renewal.
In our review of research and interviews with experts we could find little evidence that states are developing statewide media campaigns specifically designed to promote retention as they did with enrollment. There seems to be a number of reasons for this. Perhaps the most significant reason, according to experts, is that the budget shortfalls in many states mean that states are less interested in promoting enrollment, or retention, in Medicaid and SCHIP. There are also some experts who believe that a media campaign on the scale of the initial SCHIP awareness campaign is not as useful with retention. Rather, they suggest that grassroots communications efforts and focusing on renewal notices and other program materials are perhaps the best ways to increase retention. These and other issues are explored below.
An interview with one expert gives insight into how many other states are struggling with depleted state budgets for Medicaid and SCHIP. This expert said, "Right now, retention is not that big of an issue for the state." He goes on to report that his state recently cut almost all of the money given to the local public health departments for outreach and has even eliminated the "bounty" or the $25 application assistance fee that the health departments received for each successful enrollment. He said, "Media campaigns for [Medicaid and SCHIP] have been cut significantly…I haven't seen one in months. It appears as though the state is not trying to get the word out on these programs." In addition, he asserts that promoting Medicaid specifically has always been a low priority. He said, "There has notoriously been little money for outreach and retention for the Medicaid program."
Those media campaigns that still continue, in spite of budget concerns, tend to use original messages about the need to sign up children for Medicaid and SCHIP and do not explicitly address retention, according to some experts. One expert we interviewed described her state's media campaign as having been "extensive in terms of outreach and enrollment and minimal in terms of retention." However, a few experts disagree and say that these ads not only work for enrollment but can also help with retention. They point to messages about "lowcost or free health coverage" for "working families" that covers important medical services like "doctor visits and prescription medicine" and that provides parents with "peace of mind" knowing that their children are covered. They say these kinds of messages can work to remind parents why having health coverage is important and, therefore, help with retention.
Despite some overlap in enrollment and retention messages, there are still some aspects of retention that may be distinct. Experts say that, overall, there is less known about the kinds of messages that work to keep families enrolled in Medicaid and SCHIP other than those developed for enrollment. While states do seem to be learning about the best ways to communicate about renewal through changes to their renewal notices and other materials, there is much less known bout the underlying causes of why some families "forget to make premium payments or return renewal packets." The NASHP (2002) study found that many families admit they just did not get around to completing the forms or sending in the premium payments. These kinds of reasons for loss of coverage suggest some families may lack the motivation needed to comply with the renewal and premium-payment rules of Medicaid and SCHIP, and may not be sufficiently concerned about what the lack of health coverage could mean for their children and themselves. If confirmed, these attitudinal reasons for loss of coverage would suggest that new kinds of messages and communications ideas would be needed to keep these families enrolled. Little is known about what kinds of messages would address these types of barriers to interaction.
One expert we interviewed explained that the emphasis of states in regard to retention has been focused on community-based and local efforts to keep families enrolled. In fact, he questioned if a statewide media campaign is really the most effective way to increase retention. He recommended that we look instead to community-based efforts where local organizations, providers and others conduct outreach at the ground level, convincing families to sign up for and stay enrolled in programs. He believes this is the most promising strategy.
Part of this strategy involves "community-based applications assistors," who once assisted only with enrollment but are slowly moving to assist with renewal efforts as well. His feeling is that states are moving in the direction of finding ways to assist families on the grassroots level to keep their coverage and that some are looking to community-based organizations, schools, providers and others who were so effective with enrollment to convey assistance and messages about retention.