Training the Trainer

• Uninsured children in US
• Uninsured children in Texas
• Racial/ethnic disparities in insurance coverage
• Barriers to being insured
• Impact of providing health insurance to uninsured children

Uninsured Children in United States

• Having no health insurance coverage profoundly negatively impacts children’s health, healthcare, and mortality
• But over 4.9 million US children uninsured
• Much less likely to have regular physician
• Experience greater access barriers to healthcare and have significantly higher unmet needs for medical care
• Have higher odds of avoidable hospitalizations
• During hospitalizations, uninsured children:
  • Have higher mortality
  • More likely to die after admission to pediatric intensive care unit
  • More likely to die when hospitalized for traumatic brain injury
• Uninsured children with special healthcare needs more likely to encounter financial barriers to care
  • For example, uninsured children have triple odds of unmet needs for mental healthcare

Uninsured in Texas

• Texas has highest number and fifth highest proportion of uninsured children of any state in our nation:
  • 7%, or 1 in 11 children
• Texas has been one of four minority-majority states in US since 2004
• Racial/ethnic minorities currently comprise 55% of Texans

Racial/Ethnic Disparities in Insurance Coverage

• Minority children experience substantial health-insurance disparities:
  • Only 5% of white children uninsured, compared with 8% of African-American and 12% of Latino children
  • Latino and African-American children account for 56% of all uninsured children in America, but only 42% of total population of US children
  • Latino and African-American children account for 70% of low-income children without health insurance

Barriers to Insuring Uninsured Children

• Focus groups of parents of uninsured children identified reasons why eligible children remain uninsured (Flores et al. Academic Pediatrics, 2016)
  • Lack of parental knowledge about Medicaid/CHIP
  • Failure to apply
  • Language barriers
  • Immigration status
  • Income
  • Income verification
  • Misinformation from insurance representatives
  • System problems
  • Hassles
  • Coverage decision still pending
  • Family mobility

Impact of Providing Insurance to Uninsured Children

• Studies indicate that providing health insurance to previously uninsured children can result in higher likelihood of:
  • Improved health
  • Reduced unmet needs for medical care and prescriptions
  • Having medical home
  • Fewer hospitalizations
  • Parents getting appointment same day or next day
  • Parent having < 30 minutes travel time to provider’s office

Summary

• Texas has highest number and among highest proportion of uninsured children of any state
• Latino and African-American children more likely to lack health insurance than white children
• Providing health insurance to children increases likelihood of having medical home, reduces unmet medical needs, and decreases hospitalizations
• Uninsured children more likely to not have a regular physician
• Language, hassles, and lack of knowledge about Medicaid/CHIP are barriers to health-insurance coverage

Parent Mentors share their experiences about being parent with child who applied for and received Medicaid or CHIP

Sharing Experiences

Moderator’s guide:

• Question 1: Why is it that minority children are less likely to have insurance?
• Question 2: How can Medicaid and CHIP do a better job of insuring uninsured children?
• Question 3: How can Parent Mentors be most helpful in helping the parents of uninsured minority children get their children insured?

• Kids’ HELP program
• Why Parent Mentors
• Other Parent Mentor programs in US
• Your job as Parent Mentor
• Confidentiality

Kids’ HELP

• Kids’ Health Insurance by Educating Lots of Parents
• Randomized controlled trial of effects of Parent Mentors on insuring minority children
• Primary Goal: to evaluate whether Parent Mentors more effective and cost effective than traditional Medicaid and Children’s Health Insurance Program (CHIP) outreach and enrollment methods in insuring eligible, uninsured Latino and African-American children

Secondary Goals

• To examine whether insuring previously uninsured children results in:
  • Improved health status
  • Better quality of life
  • Improved access to healthcare
  • Reduced unmet healthcare needs
  • Improved quality of pediatric care
  • Improved parental satisfaction with care
  • Reduced parental-reported financial burden
  • Fewer missed school days
  • Fewer missed parental work days
  • Lower medical costs and cost effective care

Why Parent Mentors?

Parent Mentors (PMs) specialized form of Community Health Workers (CHWs) in which parents of children with particular health condition or risk leverage relevant experience, with additional training, to assist and counsel other parents of children with same condition or risk

Your Job as PM

• Provide information on types of insurance programs available for children and application process
• Provide information and assistance on insurance program eligibility requirements
• Complete child’s insurance application together with parents and submit application with family
• Act as family advocate by liaison between family and Medicaid and CHIP
• Contact Medicaid/CHIP program representatives to correct situations in which child inappropriately deemed ineligible for insurance or had coverage inappropriately discontinued
• Assist with completion and submission of applications for renewal of child’s insurance coverage
• Address social determinants of health (poverty, food insufficiency, clothing, housing, etc.)

How Am I Paired with Families?

• Study targets five areas of Dallas with highest proportion of uninsured Latino and African-American children.
  • Latinos:
    1. West Dallas: 67% Latino, 69% with family income < 200% of federal poverty threshold
    2. Northwest Oak Cliff: 43% Latino, 35% with family income < 200% of federal poverty threshold
    3. East Dallas: 41% Latino, 39% with family income < 200% of federal poverty threshold
  • African-Americans:
    1. South Dallas: 77% African-American, 71% with family income < 200% of federal poverty threshold
    2. South Oak Cliff: 60% African-American, 48% with family income < 200% of federal poverty threshold
    3. West Dallas: 30% African-American, 69% with family income < 200% of poverty threshold

Parent Mentor Assignment

• For participants assigned to PMs
  • Research staff pairs participants with PM based on race/ethnicity and zip code
  • PM called by research staff and given family contact information
  • PM and participant choose mutually convenient time to set up first visit (within 3-5 days of recruitment)

Map of Target Kids’ HELP Communities

• Areas targeted in this project

How Program Works

Parent Mentor Stipend

• Amount of money depends on number of families whom you mentor
• You probably will average two hours per month per family, but child’s and family’s needs will determine how much time you must spend with them

Confidentiality

• PMs must maintain strict confidentiality concerning health, financial, and any other personal matters for all people involved in Kids’ HELP program

Summary

• Main goal of Kids’ HELP study: to evaluate whether PMs more effective and more cost effective than traditional Medicaid and CHIP outreach and enrollment in insuring eligible, uninsured Latino and African-American children
• Secondary goals:
  • Better quality of life
  • Improved access to healthcare for child
  • Fewer missed school days for child
  • High parent satisfaction with child’s care
• PMs already have experience with completing Medicaid and CHIP applications and obtaining coverage for their own children
• PMs must maintain strict confidentiality about health, finances, and personal matters of families they work with
• PMs help families renew Medicaid and CHIP coverage

• General PM skills
• Helpful tips on being good PM

General Parent Mentor Skills

• Being excellent support system
• Providing helpful tips
• Problem solving

Being Excellent Support System

• Complete, submit, and renew Medicaid/CHIP application, together with parents
• Help compile all supporting documentation
• Communicate regularly with appropriate insurance agency
• Help parents select healthcare plan for child
• Help parents schedule healthcare provider appointments for child
• Help parents establish medical home for child
• Address social determinants of health, including food insufficiency, housing, benefits, and poverty
• Be supportive

Helpful Tips for PMs

• Be understanding
• Let speaker finish
• Ask questions
• Give families positive feedback
• Provide suggestions

Problem Solving

• Identify problem
• Identify ideas to eliminate problem or make it better
• Choose idea that’s best way to solve problem
• Identify ways to accomplish family’s goal
• Remember, Program Coordinator always available to address questions or concerns

Summary

• PMs expedite coverage by early and frequent contact with Medicaid and CHIP
• PMs help families select healthcare plan, choose healthcare providers, and establish medical and dental homes
• Tips:
  • Be understanding
  • Let speaker finish, ask questions
  • Give positive feedback and suggestions
• Problem solve

• Family home visit
  • When to meet with family
  • What to do at first meeting
• Monthly phone contact
  • How and when to contact families
  • What to do when calling families

Visit

• Family visit made within 3-5 days after enrollment
• PM provides support to family and educates family about Medicaid and CHIP programs

Follow-Up Home Visits

• Schedule follow-up home visits as needed
  • Complete or revise insurance application
    • Available on-line, by phone, or paper
  • Review and answer family’s questions
  • Assist family with identifying healthcare providers
  • Discuss communicating with child’s healthcare providers
  • Assist in scheduling healthcare visits
  • Complete renewal application

Phone Calls by PMs

• PMs call each family at least monthly
  • Review progress on child’s insurance application
  • Discuss next steps
    • Health plans available
    • Healthcare providers (medical, dental, and specialty [if needed])
    • Types of appointments
    • Scheduling appointments
    • Medical and dental homes
    • Reviewing insurance for child and getting together needed documents

Summary

• PM responsibilities include:
  • Completing insurance applications with parent
  • Helping parent obtain medical and dental homes for child
• PMs need to meet with the families within 3 to 5 days of recruitment
• Medicaid/CHIP application completed on-line, by phone, or on paper

• Medicaid
  • History of Medicaid
  • Cost of Medicaid
  • Renewal
• Children’s Health Insurance Program (CHIP)
  • History of CHIP
  • Cost of CHIP
  • Renewal
• Eligibility for these children’s health-insurance programs

Texas Medicaid

• Children’s Medicaid paid for by state and federal government combined
• In 1967, Medicaid began as “entitlement” program
  • Neither federal government nor state of Texas can limit number of eligible people who can enroll
  • Every eligible child gets same service
• “Optional” groups covered in Texas include pregnant women and infants, and “medically needy” children
• In 2007, 71% of Medicaid recipients in Texas <21 years old

Modified Adjusted Gross Income

• Figure used to determine income eligibility for children’s Medicaid and CHIP
  • Adjusted gross income plus any tax-exempt Social Security, interest, or foreign income received
• Must be below 203% of federal poverty threshold (FPT) for children less than one year old
• Must be below 149% of FPT for children one to five years old
• Must be below 138% of FPT for children six to 18 years old

Texas Health Steps (THSteps)

• Early and periodic screening, diagnosis, and treatment (EPSDT) services include
  • Medical check-ups
  • Diagnosis and treatment of conditions found during screening
  • Coordination with other programs
  • Transportation assistance

What is Not Needed for Medicaid

• Families don’t have to receive:
  • Temporary Assistance for Needy Families (TANF)
  • Social Security Income (SSI)
  • Women’s Infants and Children (WIC) Program assistance

Costs of Medicaid

• No cost to family of child covered by Medicaid

Renewal

• Medicaid generally requires renewal once yearly, but income testing can be required every six months
  • Health and Human Services Commission mails notifications (not copies of renewal application)
  • Renewals can be completed on-line or by mail
  • For renewal, parents must respond to all requests in notification letter

CHIP

• Children’s Health Insurance Program (CHIP)
  • Offers health insurance for low-income children from birth to 18 years old whose family earns too much for Medicaid, up to a threshold
  • 2007 updates extended coverage to 12 months, allowed child-care deduction, increased asset limit, and eliminated 90-day waiting for most families
  • Families must report net income every six months
  • Family gross income can be up to 206% of FPT

90-Day Rule

• Children enrolled in CHIP for first time after being covered by private health insurance have 90-day waiting period before CHIP coverage begins
• Exceptions:
  • Parents laid off
  • COBRA
  • Changes in parental marriage status
  • Loss of Medicaid
  • Cost of purchasing insurance for child is greater than 10% of parent’s salary

CHIP Out-of-Pocket Costs for Family

Co-payment may be required for doctor visits and prescription drugs, ranging from $3 to $10

CHIP Renewal

• Renewal application required once per year
  • Notification sent in ninth month
  • Renewal can be completed on-line or by mail

Eligibility Criteria for Medicaid and CHIP

• Family size
• Monthly income
• Assets

Family Size

• Determined by counting parents, step-parents, or adoptive parents of applicant child
• Also includes all children of parents living in same household with applicant child

Monthly Income

• Medicaid and CHIP provide charts to determine income eligibility
  • Maximum monthly income for Medicaid listed by family size and child age
  • Maximum monthly income for CHIP listed by family size

What services are covered by Medicaid and CHIP?

• 23 services, including:
  • Well-child visits
  • Surgical services
  • Skilled nursing facilities
  • Outpatient hospital and ambulatory healthcare
  • Laboratory and radiological services
  • Nursing-care services
  • Inpatient/outpatient mental-health services
  • Emergency services
  • Dental and vision services
  • Tobacco cessation

Summary

• To qualify for Medicaid or CHIP:
  • Families do not need to receive financial assistance
  • Family income must be at or below certain levels
  • Family assets must be under certain level
• Family not charged for Medicaid
• Medicaid’s THSteps provides diagnosis, treatment, transportation, scheduling, and periodic and regularly scheduled medical check-ups
• CHIP renewal occurs yearly, with income report by family at six months

Kids’ HELP

• Pre-test review
• Questions and answers

• Step-by-step instructions for completing application
• Four ways to submit application:
  • On-line
  • Mail
  • Fax
  • Call 211

Application: Step 1 and 2 (pages 2-6)

• Step 1: Tell us about yourself (1 page)
  • Information about parent or guardian completing form
• Step 2: Completed for each family member (2 pages)
  • Two copies provided, make copies for additional family members
  • Do not need immigration status or Social Security number for family members not applying for Medicaid/CHIP

Application: Step 3 and 4 (page 7)

• Step 3: American Indian or Alaska Native
  • Are you or is anyone in your family American Indian or Alaska Native?
    • If no, go to Step 4
    • If yes, complete Appendix B
  • Step 4: Your family’s health coverage
    • Indicate current coverage for each family member
    • Coverage employer-sponsored
      • If yes – Complete Appendix A
      • If no – go to Step 5
    • Facts about people applying for benefits
      • If Children with Special Health Care Needs
        • If yes, who?
      • Does applicant child travel with migrant farm worker
        • If yes, who?
      • Signing up to vote
        • May do so at same time, but not required to complete application

Application: Step 5 and 6 (page 8)

• Read and sign this application
  • Explanation of applicant parent’s responsibility and rights to obtain and maintain health insurance for child
  • Description of renewal coverage in future years
  • Signature must be present on completed application faxed or mailed; on-line application, use electronic signature
• Submission methods and instructions

Application: Appendix A and Coverage Tool (pages 9 -10)

• Health coverage from jobs
  • Completed only if someone in household eligible for employer-sponsored health coverage
    • Employee to provide coverage information: eligibility, term, and cost
  • Health coverage tool
    • Used to obtain employer-sponsored coverage information from employer

Application: Appendix B and C (pages 11-12)

• Appendix B – completed by American Indians and Alaska Native
  • Eligible for coverage from Indian Health Services
• Appendix C – Assistance with Completing this Application
  • Complete only if received assistance from certified staff of Marketplace or state partners

Summary

• Child’s Social Security card not used for citizenship documentation
• Need Section 2 completed for each family member
• Section 3 and Section 4 completed if applicable or answer “no”
• Mail or fax: Must sign before submitting
• Online: Must use electronic signature

• Contact information for Medicaid & CHIP
• Health plans available
• How to get healthcare provider for child
• Changes in personal information for parents or child

Health Plans Available

• After approval, families receive information packet about available managed-care options.

Changes in Personal Information

• Parent must report to state Medicaid/CHIP offices changes of: address, phone number, e-mail, or any other contact information; children moving from/to home; number of people living in home; expenses; and income within 10 days of change

Summary

• Medicaid and CHIP contact information available through state Health and Human Services
• Health-plan information available through state Health and Human Services
• On-line tools available for locating doctors and pharmacies
• Parents need to report to Medicaid/CHIP changes in addresses, names, phone numbers, expenses, income, and number of family members

• Medical and dental home definition
• Helping parents to communicate with healthcare providers
• Types of healthcare appointments
• How and when to schedule follow-up appointments

Medical Home

• Primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective for all children and youth, including those with special healthcare needs (American Academy of Pediatrics definition)
• Dental Home: dental care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective for all children and youth, including those with special healthcare needs

Helping Parents to Communicate with Healthcare Providers: “SPEAK”

• Stay honest
• Prepare and ask questions
• Educate yourself and your child
• Act and be assertive on behalf of child
• Keep positive attitude

Language Issues and Communicating with Your Healthcare Provider

• As Parent Mentor, you can help families with limited English proficiency by assisting with
  • Scheduling appointments
  • Finding interpreter services
  • Obtaining bilingual handouts
  • Finding English adult education classes

Types of Appointments

• Well-child visit: check-ups, shots, and routine preventive care
• Sick visit: when child sick contact healthcare provider to determine office visit or emergency department visit
• Follow-up appointment: after hospital, emergency-department, or sick visit; allows healthcare provider to check child’s status
• Specialist visit: when required, for specialty services

How and When to Schedule Follow-up Appointments

• Have parents make appointment
• Have parents record date and time of appointment
• PMs should call family to remind family of appointment

Summary

• Medical and Dental Homes – accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective primary care and dental care
• Insisting families schedule appointments does not help families with limited English proficiency
• Well-child appointments made for check-ups and shots

Kids’ HELP

• Review and Post Test
• Post Test review

• Activity log
• Home-visit checklist
• Phone-call checklist

• Testimonials:
  • Participants – English & Spanish
  • Parent Mentors
  • Recruitment site managers
    • SM Wright Foundation (South Dallas neighborhood food bank, used clothing and furniture provider) – Mr. Jackson
    • Brother Bill’s (West Dallas neighborhood food bank and health clinic) – Susan Presley Griffin
  • Research Staff