IV. OUTREACH AND MARKETING

1. Overview

The success of children’s health insurance programs hinges on the program’s ability to enroll the eligible children. States’ experiences demonstrate that while some portion of the eligible population is generally easy to reach, there are others who are considered "hard to reach." In particular, the "hard to reach" populations present specific challenges for outreach and marketing efforts that may need to be specifically targeted, non-traditional, and often community-based in terms of enrollment strategies. These children and their families face many barriers in obtaining health insurance coverage including:

• confusing eligibility rules and complex application procedures;
• cultural and language problems;
• isolation of the target population from local and state health departments;
• transportation problems; and
• perception of welfare stigma often associated with state programs.

As states implement new programs under Title XXI, the issue of how best to reach uninsured children will be critical to the programs’ success. In particular, the 3.4 million children who are eligible for Medicaid but not enrolled may present major challenges to states in conducting effective outreach to uninsured children. States must explore these barriers and develop appropriate strategies to enroll eligibles. In order to reach the eligible population, successful outreach and marketing campaigns need to be continuous, widespread, multiform, have varied sources of information and be geared to a specific population [Williams, S., (December 8, 1997). Child Health Gains May Hinge on Aggressive Outreach. Medicine and Health Perspectives. 51(47), 1-4.]. For example, TennCare targets the African-American community in Shelby County by having local religious leaders educate their congregations about the program.

This section presents strategies that are currently being used by the nine study states to enroll eligible, uninsured children: successful strategies; outreach and marketing methods; preparation of marketing materials; coordination with other programs; and budgets. Samples of marketing/promotional materials are presented in Appendix C.

2. Successful Strategies

1. Understanding the Target Population

Outreach begins with understanding the target population, communicating the availability of health care coverage, and educating potential beneficiaries about the program eligibility requirements and how to sign up. States have implemented a variety of approaches and some states have used multidimensional outreach campaigns that combine printed materials, radio and television advertisements. Programs often distribute brochures at schools, churches, hospitals, clinics, businesses, government agencies, and other community sites.

School-based enrollment strategies have been implemented in Colorado, Florida, Massachusetts, and Tennessee (See Table 15).

• Colorado considers the "back to school enrollment program" their best outreach vehicle. The Child Health Plan operates under the philosophy that people may need to be exposed to the program three times before they react. Hence, the back to school program attempts to outreach to potential enrollees three times in close succession via television, radio, and written advertisements. In 1996, over 210,000 pamphlets were distributed to 848 Colorado schools in 42 counties.
• All Florida school children receive a uniform Healthy Kids brochure introducing them to the program, and Healthy Kids posters are displayed in schools.These materials stress the importance of scheduling regular preventive physician visits while enhancing recognition of the Healthy Kids program.
• In Massachusetts, informational letters are sent home with approximately 200,000 school children in 120 school districts. This effort has been successful in particularly for enrolling adolescents in the Children’s Medical Security Plan.
• In Tennessee, a consumer group assists the TennCare program with their outreach efforts. Fliers are distributed to every school and day care center in the state in order for children to take them home to their parents. This has proven to be an inexpensive and effective form of marketing for TennCare.

Table 15: Outreach and Marketing Methods

2. Use of Multilingual Materials

Many states have translated promotional materials into the languages of their target populations.

• Both Colorado and California offer outreach literature in English and Spanish.
• In Florida, special emphasis is placed on recruiting staff with multi-lingual talents. Staff are available who speak Spanish, Creole, Dutch, Danish, German, Arabic, Greek and English. Applications are printed in Spanish, Creole, and English.

Another approach to overcoming language and literacy barriers is staffing the hotlines with bilingual workers.

• Spanish speakers are available to assist Colorado residents in filling out applications for the Children’s Basic Health Plan through a toll-free phone line.

3. Word-of-Mouth

Studies in both Minnesota and New York found that most enrollees generally learned about the programs by word-of-mouth.

• In New York, most parents of enrolled children heard about Child Health Plus from a friend, school, or their doctor. Very few individuals have been reached as a direct result of a specific marketing activities such as TV, mailings, or community meetings. New York stresses that outreach and marketing continues to be a very important issue for their program. Even with the current marketing efforts of Child Health Plus, New York has only a 30% rate of penetration into their targeted population.

4. Impact of Geographic Differences on Marketing Efforts

Colorado’s Child Health Plan found that individuals from diverse geographic regions reacted differently to varied marketing strategies. When the Child Health Plan initially marketed the program within the Northeast region of the state, it was presented as a private insurance plan with a cost of $25 per year. The hope was that by making the state program comparable to private insurance, it would prevent individuals from linking the program with welfare. However, the effort was unsuccessful in enrolling children within this region of the state because residents were not trusting of the program. In the Western region of the state, however, county resource centers, public health departments, schools, and other community groups were supportive of the program. These Western counties created a system in which those individuals rejected from Medicaid would receive an application for the Colorado Child Health Plan. This coordinated strategy was very effective in Colorado.

5. Mass Marketing versus Local Marketing

Though most of the states rely on mass marketing techniques to educate the public about their programs, Colorado, Tennessee and Washington target individuals at the local level to promote the program.

• In Colorado, five CCHP staff members work very closely with communities and conduct local outreach training. The state staff also created a database of county public and social service agencies that work with low-income families with children. The database helps state outreach workers coordinate efforts with local groups.
• Tennessee state officials conducted outreach meetings in all ninety-five counties, where they presented a video on TennCare that explained the program’s purpose and eligibility qualifications. Applications were distributed after the presentation. TennCare also employs this approach to outreach in town meetings, churches, and other community events. TennCare also uses local health departments as enrollment sites to engender community support.

• The Washington Basic Health Plus program targets individuals at the local level by training staff at community organizations and clinics about the program and enrollment procedures.

3. Coordination With Other Programs for Outreach and Identification of Potential Enrollees

1. Coordination

Five of the nine state programs described extensive efforts to coordinate with other children's programs and agencies for outreach and the identification of potential enrollees. States detailed the advantages of being able to capitalize on other organizations' expertise in attracting enrollees to their program.

The existing networks of community health organizations and schools are logical areas for children's health insurance programs to market their programs.

• CaliforniaKids partners with community organizations to identify and enroll eligible children. The organization's partners include: school nurses, Head Start and Healthy Start programs, Child Care Councils, Child Health, Disability and Prevention Program (CHDP), Access for Infants and Mothers (AIM), Boys and Girls Club, and Big Brothers, Big Sisters.
• In Florida, county public health departments and providers distribute applications for Healthy Kids. In addition, child care programs also market Healthy Kids by distributing pamphlets and applications.
• In Florida, county public health departments and providers distribute applications for Healthy Kids. In addition, child care programs also market Healthy Kids by distributing pamphlets and applications.

In many instances, existing organizations and administrative systems can be utilized to target the most needy children.

• Florida uses the school lunch program as a mechanism for charging reduced premiums to families. All children are eligible for the program, so the school lunch program serves as an administratively simple way for Healthy Kids to determine family need and identify the most appropriate subsidy level. This process for verifying children requires schools to send Healthy Kids an electronic table of all enrolled students and their eligibility for free and reduced lunches.
• In Massachusetts, the Children's Medical Security Plan coordinates with schools to send informational letters home with children. This coordination has been successful, especially in enrolling adolescents. In addition, WIC, MCH, family planning and community health clinics distribute informational materials on CMSP at their sites. Infants and toddlers are often reached through nurses, MCH programs, and the area hospitals (e.g., when children enter the emergency rooms for care, parents are questioned regarding their insurance status, and when applicable, they are referred to CMSP). CMSP coordinates closely with Medicaid, WIC, primary care sites, and the school health programs. For example, CMSP conducts joint marketing and outreach activities with Healthy Start to target families eligible for both programs. As CMSP has expanded its focus to include adolescents, the program has also worked closely with family planning clinics, state immunization programs and substance abuse programs.

Children's health insurance programs can capitalize on existing administrative skills and marketing knowledge of state agencies.

• The Massachusetts Children's Medical Security Plan (CMSP) was moved from the Department of Insurance to the Department of Health to capitalize on the marketing and outreach experience of the Medicaid and Maternal and Child Health Departments. It was understood that the Department of Health would target all children not eligible for Mass Health (Medicaid) and undocumented children, and that the use of this outstanding relationship between MCH and Medicaid would assist with the success of CMSP. After the move of the program to the Department of Health, enrollment increased from 20,000 to 36,000 children due to outreach and coordination efforts with other programs.
• In Minnesota, there has been a mixed effort to coordinate with other agencies to enroll potential beneficiaries. When MinnesotaCare was operated as a separate program focused on children, many state agencies referred children to the program. However, as the program has expanded to include all uninsured, outreach needs have increased substantially. It has been more difficult to keep up with those needs without more resources. Minnesota has embarked on a major outreach effort including a $1.5 million legislative appropriation to 26 separate grantees throughout the state, to reach targeted populations. Because enrollees transition in and out of eligibility for MinnesotaCare, a significant amount of time is devoted to coordinating with other public agencies. Minnesota has identified training new program staff about Medicaid as well as training Medicaid staff about MinnesotaCare to be essential in their outreach efforts. Minnesota has also developed a combined application form in which a potential enrollee can indicate an interest in being considered for both Medicaid and MinnesotaCare. Although the application is a combined effort, the eligibility determination continues to take place in two separate offices until the year 2000, when county agencies will have the option to administer MinnesotaCare.

One area of concern in reaching eligible children is reaching those with special health care needs.

• Minnesota Children with Special Needs, Minnesota’s Title V program for children with special health care needs, has a long history of working closely with both Minnesota’s Medicaid and MinnesotaCare programs to assure that children with chronic illnesses or disabilities have access to a comprehensive array of services. To facilitate this process, MCSHN has a toll free number that is designed to answer a variety of questions from referral resources, providers, and families of children with special health care needs. Minnesota continues to struggle with the implementation of a one-stop-shopping model for children with special health care needs. However, progress has been made with a single application for families to access Medicaid, MinnesotaCare, or MCSHN services. Joint use of eligibility cards and payment systems has also reduced confusion for providers for families. Efforts continue to move to a more seamless system of eligibility and services for children with special health care needs and their families.

4. Preparation of Materials

1. In-House Marketing Efforts

The majority of the states interviewed prepare outreach and marketing materials in-house. Florida and Washington have staff who are responsible for marketing and outreach in addition to other program responsibilities. Other programs have staffs who do not have outreach or marketing as part of their job title, yet are responsible for conducting these activities as part of their general responsibilities.

• Of the 13 people employed by Florida Healthy Kids, one employee is solely dedicated to outreach and marketing functions. Another individual is responsible for assisting with outreach, and is also responsible for the preparation of enrollment forms.
• Initially, Washington Basic Health Plus designated specific staff members to be "outreach workers." However, Washington no longer actively recruits individuals into their program and does not require staff to perform marketing, communication, and outreach duties in addition to their other responsibilities. In order to enroll, families must contact the Washington Health Care Authority.

2. Use of Contractors

In contrast to Florida and Washington, Massachusetts and New York have employed contractors to market their programs.

• The Massachusetts’ Children’s Medical Security Plan is redesigning promotional materials with John Hancock Insurance Company to include program eligibility changes. An informational flyer will be used to specifically target teens and their families.
• In New York, outreach and marketing materials are prepared by three different sources: Child Health Plus staff, contracted insurance plans, and marketing contractors. Specific state staff act as liaisons to the marketing departments of the contracted plans and marketing contractors. Two groups were contracted: one designated specifically for New York City; and the other the rest of the state. Both engaged in major activities including targeting schools and health centers, producing large volumes of mailings, and organizing meetings and presentations to over 16,000 individuals. Any materials developed outside of Child Health Plus must be submitted and approved by the state office. There are also specific clauses in contracts with plans and contractors to prohibit them from using fraudulent marketing and enrollment activities.
• In the Pennsylvania CHIP program, The State Department of Insurance is not involved in marketing. In contrast to other programs, contracted providers are required to produce and distribute their own outreach and marketing materials.
• TennCare’s managed care organizations conduct their own marketing. Marketing guidelines are provided to the contracted managed care organizations in addition to the marketing rules specified in their contracts with TennCare. TennCare reserves the right to approve all marketing materials before distribution.

Table 16: Coordination with Partners

*Because Colorado Children's Basic Health Plan has not yet been implemented, outreach and marketing information comes from the state-sponsored Colorado Child Health Plan's experience (CCHP). The current CCHP will roll into the new Children's Basic Health Plan.

5. Outreach and Marketing Budgets

Most programs rely upon public information campaigns via media and large population techniques rather than on community outreach workers who may interact directly with the targeted population. In the nine states, the percentages of program budgets allocated for outreach and marketing ranged from 1% to 16%.

• Washington allocates less than 1% of their administrative budget for marketing, comprising approximately 7.5% of the total premium budget. For all materials produced, funding is drawn exclusively from the printing and postage budget. At the onset of the program, approximately 2% to 5% of the administrative budget was spent on marketing. However, this amount has been reduced as they are no longer actively recruiting beneficiaries. Since most outreach and marketing is conducted through community stakeholders, the administrative allocation for marketing and outreach has never been substantial.
• In Florida, total administrative costs for marketing and outreach are 5.2% of the total budget. This includes administration and evaluation in addition to outreach and marketing. As marketing is primarily targeted within schools, costs include the production of the enrollment forms, flyers for children to take home, and posters to display in schools.
• New York provides approximately 1% to 2% of their total budget for outreach and marketing efforts.
• In Pennsylvania, the contracted insurance plans for the Pennsylvania CHIP program are required to spend 2.5% of their grant allocation on outreach and marketing. Most plans actually conduct substantial amounts of outreach and marketing based on in-kind contributions.
• Colorado and California also place a high emphasis on marketing and outreach and have allotted approximately 11.3% and 16% of their total program budgets for this purpose.

1. Use of Requests for Proposals (RFPs)

Minnesota took a novel approach by sending out a request for proposals to community groups focused on designing appropriate outreach strategies for the local level. Administrators of MinnesotaCare considered the response a success – 28 public and private proposals were submitted and 26 approved. The applications were evaluated based on the strategies proposed, the ability to raise matching funds, and the capability to contact and serve the targeted population. MinnesotaCare plans to provide $1.5 million in grants over the biennium to support the initiatives of the selected groups.

2. Coordinated Outreach Efforts

An approach common to all nine states was the coordination of outreach efforts with other programs. Relying on an "extended family" in the community serves two primary functions: (1) it is a cost-effective method for programs with small outreach budgets; and (2) it effectively reaches shared target populations. Partners include schools, child care centers, local and state public health departments, providers, medical associations, family planning clinics, state maternal and child health departments, Medicaid, WIC, Head Start, Healthy Start, among other programs and organizations (See Table 16).