Meeting #1: 25 July 2001 Present: Andrew Aoki, Lynn Fallin, Aileen Hiramatsu, Virginia Pressler, Sandy Willke (Annie Casey Foundation), Beth Giesting, and Barbara Luksch. 1. Welcome, Introductions and Timelines Beth Giesting welcomed the group and explained the opportunity the Hawaii Primary Care Association has to apply for a new four-year RWJF grant to continue its Hawaii Covering Kids efforts. 2. Review Grant #1 Objectives The statewide objectives are: a. Identify and enroll 100% of all of the eligible children who are not insured, b. Simplify the documentation and verification part of the application process, c. Link QUEST with CHIP, Immigrant Children's Program, and HMSA Children's Program, d. Coordinate and conduct major training programs for state and private outreach workers, e. Implement a statewide outreach and public information campaign, and f. Establish and maintain a hotline through Ask Aloha United Way. In addition to statewide efforts, there are two pilot projects. Kalihi-Palama Pilot Project's initial efforts were to pilot presumptive eligibility, but Med-QUEST (MQD) and Hawaii Covering Kids decided it was more feasible to focus on process simplification. Therefore this pilot project is looking at special efforts to enroll immigrant children. The Big Island Pilot Project has an exciting role in testing the electronic application system and establishing a system for school-based enrollment. We've made good progress with the cooperation of MQD in simplifying the application process. A major marketing campaign coupled with media outreach events for Kids Health Insurance Week in August should get the word out and increase enrollment. 3. What Has Worked So Far a. A good partnership with MQD. b. Spreading the word among Hawai'i's community groups about our project and mission. Piilani Pang from The Hawaii Uninsured Project recently noted that whenever she presents information, people ask "How are you working with the Hawaii Covering Kids?" and she also sees our posters everywhere. c. The Ask Aloha United Way hotline service has been superb. It is imperative to have a statewide number to handle calls. The limitation is language because it's only in English, so we must look at multilingual alternatives. A big advantage is if a person inquires about anything even remotely related to kids health insurance (e.g. local food pantry, children's immunizations) the information and referral specialist will ask, "Does your child have health insurance?" d.School Lunch Referral Form. Having an extra page during the 2000-2001 school year for parents to inquire about health insurance resulted in more follow-up activity at our office as well as the pilots. 4. Who Is Hawaii Covering Kids Currently Not Reaching? a. Adolescents ages 14 to 18 years; research at what point they become uninsured; use schools to identify low-income kids through various avenues (e.g. school lunch, counselors, field trip forms); attempt to make contact through sports, clubs, peer groups, peer counselors/mentoring, peer education, and college assistance type programs; tie into the school health curriculum and standards; work with hospital emergency rooms b. Parents of kids who are uninsured; parents who are uninsured are less likely to take their kids to the doctor even though the kids are covered, than parents who have some type of insurance themselves. c. Immigrant children--those with language and cultural barriers d. Hospitals e. Health Care Professionals (e.g. nursing students, physicians in private practice) f. Small Businesses g. Target Groups in Specific Geographic Areas h. Faith-Based Groups School emergency cards data shows the largest number of uninsured kids are adolescents. We work closely with WIC, Head Start, preschools, day care centers, and schools, but do not specifically target 14 to 18 year olds. There must be systems established to automatically identify uninsured kids and get them enrolled. 5. Covering Kids & Families Initiative a. Coordinate Existing Health Insurance Programs. This is not a major issue in Hawai'i because we are an expansion state with only one application. b. Conduct and Coordinate Outreach Programs. This is where the gap groups need to be analyzed. c. Simplify Enrollment and Renewal Processes. Previously it was the application and now we're also working on the renewal process. d. Families. We are one of the states that can include adults in our grant. e. Access. This will come later and is not included in the current grant proposal. 6. Supplemental Funds The maximum we can ask from RWJF is $1 million over four years and we must have 50% supplemental funds. Therefore, the total HCK budget would be $1.5 million. We cannot count federal or inkind funds. Sources could include philanthropic, private, state, and local government money and they must start by the third year of the grant. Suggestions: CHIP money from the Healthy Hawaii Initiative, outreach which incorporates health insurance into the health curriculum standards, philanthropic community, and family planning. We could also look for funders interested in specific programs such as the hotline service, electronic application, or a particular pilot project. Grants are often available only to local communities, therefore the pilot projects can help raise their own supplemental funds. 7. Local Project RFP Andrew offered to help write it and we will include details required by RWJF. There must be at least two local projects to model creative, innovative strategies to accomplish Hawaii Covering Kids goals. 8. Next Steps 25 July 2001: Planning Committee Meeting #1; get ideas from those who could not attend 15 August 2001: Announce Hawaii Covering Kids Phase II at State Coalition meeting 5 September 2001: Post Local Project RFP on web site 31 October 2001: Local Project proposals due to HPCA 9 November 2001: Planning Committee Meeting #2; Final brainstorming session and review of Local Project Proposals 9. More Ideas a. Hardy Spoehr (Papa Ola Lokahi) One goal in Hawaii should be to get 100% of Native Hawaiian children enrolled in health insurance through marketing and outreach efforts. b. John Casken (UH School of Nursing) Educate nursing students in their fourth year and include information in courses related to health professional administration, complex care, and community health. Also get information to dental hygienists. c. Peter Kay (CyberCom, Inc.) * Expand the current electronic application to a step-by-step walk through process that could be accessed at public libraries, offices, etc. * Find a way that computer information can interact with adolescents to pique their interest and help get their parents to act. * Explore viral marketing--similar to hotmail.com--to spread information. * Research voice activated response forms ********** Meeting #2: 9 November 2001 Present: Andrew Aoki, Virginia Pressler, Dee Helber, Peter Kay, Beth Giesting, Barbara Luksch, and John Casken. MQD Represntatives: Nan Tome (Hilo), Gail Omura (Maui), Vickie Napuelua (Kapolei), Wayne Nishi (Kauai), and Alan Takahashi (Honolulu). 1. Welcome and Introductions Beth welcomed the group. She thanked everyone for coming to the meeting and for their support of our Hawaii Covering Kids project. 2. Legislative Initiatives Beth briefly explained bills that may be introduced during the 2002 legislative session: a. Increase the FPL for children and youth to 300%. The federal match is 69.44% which makes it a cost effective proposal. This will help cover a currently uninsured gap group, appeal to business organizations, and shore up health care providers. b. Permanently end the enrollment cap that was temporarily lifted due to unemployment problems associated with September 11. Eliminating this barrier will cover more adults at 100% FPL. c. Finder's fees to enroll more kids. Senator Matsuura would like to establish a program that reimburses schools or community organizations a set fee for each child on a successful application. d. Draw down Med-TANF delinking funds that are currently available with a 90% match from the federal government. It could fund upgrades to Med-QUEST's HAWI computer system and additional community outreach eligibility workers. 3. Improving and Expanding the Electronic Application (E-App) The most significant technology improvement since our November 1999 vision is with Adobe Acrobat that allows easier document creation and the ability to read data from a completed form. Peter suggested our progress during the next few years will include: a. Refine field testing of the current electronic application. Kameo (CyberCom programmer), Barbara, and Amy Rosenberg (Maui Pilot Project outreach worker) are working closely on debugging. Nan said hospitals are an ideal setting to implement the e-app. The e-app helps accomplish MQD's goal of a more complete application by eliminating obvious errors before it is sent and speeding up the process. It was suggested we include a link for help if the person needs technical assistance or has an application question. Note on other states: Barbara mentioned California's demo site because their e-app is similar to Hawaii's internet-based system. Washington has a Trial Eligibility Calculator that gives the user information on programs he/she may be eligible for. Colorado links their Children's Health Insurance Program application with a computer system using the state's eligibility determination programming. b. Interface the E-App with Med-QUEST's HAWI computer system. Barbara and Peter will meet with James Lum (DHS computer systems manager) to develop ways of increasing the eligibility office's efficiency through technology to integrate the e-app directly into HAWI. It will serve as a model for state government. c. Use technology to promote enrollment. Viral marketing promotes innovative ways to spread a message via technology. Peter used the example of hotmail.com that has a link at the bottom of the user's email message for the receiver to sign up, too. He suggested tying finder's fees to our goal of targeting adolescents. 4. Med-QUEST Ideas for the New Grant Alan, Nan, Gail, Vickie, and Wayne were invited to share their ideas based on their offices' experiences. a. Outreach workers need to have people skills and take the initiative to visit families. It is important to be at the grassroots level to integrate the program and be committed to helping families. b. More work should be accomplished with schools including assertive follow-up with parents. c. MQD's new Public Information Officer must work closely with the DOE to link with school lunch recipients. d. When the emergency cards are scannable, MQD can link with DOH school health aides to identify and enroll uninsured students. e. The new grant should include: preschools, systematic links with health-related school requirements, evaluation component to discover why kids are uninsured, training for application assistants, and giveaway incentives. 5. Local Project "Call for Proposals" Update Beth explained that due to recent national and local events, the postmark deadline was extended to 26 November 2001. An external review committee will meet on 10 December 2001 to discuss the submitted proposals and recommend pilot projects to HPCA for the new grant. 6. Outreach Methods and Supplemental Funding Andrew suggested we research what causes parents/guardians to wait before submitting an application and sites for immediate sign-ups. (Note: MQD's experience is that they wait until there is an emergency before completing the form). We brainstormed ideas for the attached matrix with suggested outreach and enrollment activities and possible supplemental funding. 7. Next Steps a. Barbara will request letters from statewide coalition members next month. These are crucial components of the grant proposal because the Covering Kids philosophy is that the coalition implements the project. b. A team will go to Phoenix, Arizona in March to present our proposal to the Covering Kids National Advisory Committee and The Robert Wood Johnson Foundation. ********** Meeting #3: 11 February 2003 Present: Vickie Gates, Gwen Ouye-Nakama, Jacque Smith, Joan White, Beth Giesting, Dee Helber, Barbara Luksch, Mary Rydell, Carol Murry, and Pat McManaman. 1. Welcome and Introductions Beth welcomed everyone, especially The Hawaii Uninsured Project representatives and Vickie who is visiting from the Academy for Health Services Research and Health Policy in Washington, D.C. The committee's DOH representative will be the new deputy director and Lillian Koller (DHS Director) will be the new Med-QUEST representative. 2. The Hawaii Uninsured Project Joan White, Executive Director, explained their two grants to reach the goal that all Hawaii residents have access to health insurance. The HRSA grant is $1.1 million for one year to conduct qualitative and quantitative research and it ends June 30, 2003. A second grant was recently awarded for $1.3 million from The Robert Wood Johnson Foundation for three years. The Hawaii Uninsured Project has six workgroups with for these target areas: uncovered worker pool, complete enrollment, expanding coverage for children and youth, expansion and enhancement of the safety net, Compacts of Free Association, and Hawai'i Prepaid Health Care Act. It was noted that the children and youth focus is policy related and does not overlap with Hawaii Covering Kids' activities. More information is available at The Hawaii Uninsured Project. 3. Hawaii Covering Kids Updates a. Matching Funds Our four-year goal is $800,000 and to date we have received $321,281 from seven local foundations and a federal grant. Three proposals are pending. b. Local Projects The projects in Kahuku and on Kaua'i are doing extremely well. In addition to directly enrolling children and youth in QUEST and Medicaid, they are working on sustainable systems for rural hospitals and private health care providers. c. Major Media Outreach Campaigns There were two major initiatives: Immigrant Media Campaign in June and Get Teens Covered by Health Insurance in August. We combined media advertising (e.g. radio, television, and print) with outreach activities. More details are on the web site at http://www.coveringkids.com/news/Section_155.asp d. MQD Enrollment Data for 0 Through 18 Year Olds As of 30 November 2002, there were 72,299 in regular QUEST, 1,844 in regular Medicaid Fee-for-Service, 8,859 in the CHIP expansion, and 1,883 in the Immigrant Children's expansion. We discussed the extremely difficult task of obtaining timely data from Med-QUEST, including useful breakdowns (e.g. enrollment by census tract and age, cases closed by reason, QUEST/Medicaid birth by islands, etc.). Requests were made but there has been no response. e. Data Project Bill Wood's Year 2 quantitative report (School Year 2000-2001) was recently published and copies were distributed. Year 3 (School Year 2001-2002) is pending. There have been two focus group studies conducted by Market Trends Pacific, Inc. (April 2002 for parents and guardians and November 2002 for pregnant women). The first report, "A Focus Group Study of Uninsured Children in Hawaii" is available and the second "A Focus Group Study of Pregnant Women Concerning Health Insurance" is pending. f. Simplification: Application and Renewal Processes There is a new MQD application effective October 2002 which has been extremely well received by outstationed eligibility workers, outreach workers, eligibility workers and most importantly the customers. We discussed that it is currently only available in English and since 15% of Hawai'i's population are immigrants, Med-QUEST must develop multilingual forms. Also, most questions do not pertain to families applying for children or pregnant women only. Approximately 800 children are dropped from QUEST and Medicaid monthly due to "failure to provide information" during the renewal process. This means the form and/or extensive verification was not submitted to Med-QUEST. Ideally, Hawai'i will adopt a passive renewal system to better retain eligible customers, however in the meantime a new reapplication form has been developed. 4. Policy Issues Affecting Children and Youth a. Native Hawaiians Papa Ola Lokahi is requesting the federal government pay 100% for Medicaid and Medicare benefits for Native Hawaiians who access health care through a community health center or NHHCS. The proposal is modeled after similar American Indian and Alaskan Native legislation and millions of dollars could be used to improve health care for the community such as increasing the FPL limits and enhancing MQD's benefit package. Papa Ola Lokahi wants to make sure the money that is saved doesn't simply go back to the state's general fund. b. Compacts of Free Association Rich Meiers, President and CEO of the Healthcare Association of Hawai'i, is tracking potential federal reimbursement from the Department of the Interior to health care providers. Uncompensated health care costs for citizens from the Freely Associated States are approximately $9 million per year in Hawai'i. c. Expanding FPL to 300% for Children and Youth Beth met with Susan Jackson, DOH Tobacco Settlement Office, to calculate using unspent CHIP allocations to increase the QUEST and Medicaid income limits. Combining the reserves and future payments, there is enough money to cover children and youth up to approximately 300%. A bill has been introduced in the legislature yearly since 2001 to enact this measure. d. Deeming of Immigrants Immigrants who entered the United States after 22 August 1996 cannot receive QUEST or Medicaid benefits until they have been in qualified status for five years. Effective 19 December 1997 people sponsoring a relative must sign an "enforceable" affidavit of support that has the binding effect of a contract and allows states to deem sponsors income. This means a sponsor's income may be counted as available to the immigrant when she/he applies for QUEST or Medicaid. The applicant's household size remains the same, however the sponsor's income is considered in determining household income. The exceptions are emergency Medicaid, immunizations or testing and treatment of communicable disease outside Medicaid, domestic violence by sponsor or sponsor's family members, and hungry or homeless for a twelve-month period. CMS has not issued its guidance on deeming, therefore Hawaii's rules are not in effect. One complication is that when deeming starts, only children who qualify for programs that get federal match will be deemed (e.g. have been in the country more than five years and have the new affidavit of support). e. V Visas A child (or spouse) can come to the U.S. if petitioned by parent while waiting for a residency-type visa. INS issues a V visa, the child can attend school, and apply for a Social Security number by first obtaining an employment authorization card (cost = $88 per person). However, immigrants entering the country with a V visa are considered non-immigrants who don't intend to reside in the U.S. permanently and therefore cannot qualify for QUEST or Medicaid. f. Grandparents, Guardians, and Single Parents Applying Only for Their Children If there is an absent parent in the household, Med-QUEST's HAWI computer system makes automatic referrals to the Child Support Enforcement Agency. Therefore, due to fear of physical and/or emotional retribution, most guardians and single parents will not apply for QUEST or Medicaid for their children. When the state adopts a separate children and pregnant women's application, the absent parent question will be eliminated and we can conduct outreach activities targeting these families. 5. Next Meeting Two Covering Kids & Families representatives, Ann Marchetti and Marisa de la Garza, will visit Hawaii to monitor our project. Their first meeting will be with the Planning Committee on May 13. ********** Meeting #4: 13 May 2003 Present: Ann Marchetti, Marisa de la Luera, Joan White, Peter Kay, Dee Helber, Kris Foster, Lillian Koller, Clarysse Kami Nunokawa, Ruth Ota, John Casken, Kristell Corpuz, Barbara Luksch, and Beth Giesting. 1. Welcome, Introductions, and Updates Following introductions, Barbara updated the group: a. Matching Funds: we have almost $600,000 from twelve organizations committed during the four-year grant. b. The report on our successful media outreach campaign, "Get Teens Covered by Health Insurance," was printed and distributed. This year's Back-to-School initiative will focus on Vietnamese, Micronesian, and Korean immigrants with Hawaii Community Foundation funding. c. Electronic application trainings were held for local project outreach workers and Med-QUEST staff in Kahuku and on Kauai. We are funded for Phase 2, however we must wait for Med-QUEST's official approval of the new children and pregnant women application before completing programming. d. Lillian Koller wants Med-QUEST's process to reflect the barest minimum rules required by the federal government so all people eligible for their programs are enrolled and retained. She is working closely with our Process Simplification Task Force to eliminate barriers and improve customer service. e. Major upcoming activities include Malama i na Keiki 4 and training workshops for statewide outreach workers. f. The task forces and workgroups designed our Year 2 work plan (1 June 2003 to 31 May 2004) based on our approved grant proposal and matching funds. 2. Covering Kids & Families National Program Office (Ann and Marisa) We discussed the political and economic environments affecting Hawaii Covering Kids and possibilities for simplification and coordination opportunities. The group remarked on the tremendous value Covering Kids and Covering Kids & Families have brought to Hawaii since 1999. Their leadership in implementing a national vision to help children and youth through public health insurance initiatives has positively impacted our families. ********** Meeting #5: 27 September 2005 Present: Dee Helber, Noe Foster, John Casken, Barbara Luksch, Beth Giesting, Laurel Johnston, Hardy Spoehr, Linda Rosen, and Chris Pablo. 1. Go Forth and Sustain Yourself! This was the meeting’s theme as our committee discussed Hawaii Covering Kids Phase 3. Robert Wood Johnson Foundation funding will end 31 May 2006 and it was decided to explore local funding for the statewide initiative three additional years (1 June 2006 through 31 May 2009). 2. Hawaii Covering Kids Highlights (June 1999 to Present) Barbara mentioned these selected highlights: Simplification * Med-QUEST forms in typable PDF format on coveringkids.com web site * Simplified “Womb to Tomb” Med-QUEST application * Children and pregnant women application * Helped eliminate unnecessary documentation and verification requirements * Passive renewals for cases with children * Wrote and continuously updated question and answer handout on Med-QUEST rules and procedures * Contract with 211 hotline to answer questions, mail applications, and connect callers with community outreach workers Outreach * Informational web site (www.coveringkids.com) * Coordinated with natural points of contact (schools, WIC, Head Start, Good Beginnings Alliance, community health centers, Native Hawaiian Health Care Centers, public health nursing, DOH immunization campaign, etc.) * Pharmacy Campaign: half-page flyers distributed at 151 locations statewide * Multilingual flyers (currently 17 languages) * Annual back-to-school campaigns * Immigrant media campaigns (Chinese, Filipino, Korean, Marshallese, Samoan, and Vietnamese) * Participated in community events with game and giveaways * Began athlete’s campaign * Extensive media coverage (radio, newspaper, television, and internet) Coordination * Annual Malama i na Keiki conference for outreach workers and Med-QUEST eligibility workers statewide * Community Training Workshops: 32 sessions for 377 participants from 86 organizations * Established a statewide network of outstationed eligibility workers regularly that communicates with Med-QUEST’s Eligibility Branch Most Importantly * Hawaii has someone who can be contacted regarding children’s health insurance information and issues. * 11,500 additional children and youth have been enrolled in QUEST and Medicaid the past eighteen months. * Through health insurance enrollment, more children are connected to medical homes and getting preventive services which improves Hawaii’s overall health status. 3. Possible Kids Initiatives in New QUEST Waiver (starting July 2006) Beth noted that children and youth may be eligible up to 225% FPL and there might be a possible premium-share option for those in households from 225% to 300% FPL. 4. Financial Resources to Sustain Statewide Initiative We estimate Hawaii Covering Kids funding for the statewide project--personnel, office space rent, monthly parking, Oahu mileage, cellular telephone, interisland travel, and indirect costs--is $125,000 annually. We brainstormed funding opportunities including Hawaii State Department of Human Services (currently contributing $33,000 annually towards personnel and indirect costs), Hawaii State Department of Health uninsured fund (prevention saves the state money), community health centers (more insured children and youth increase their financial revenues), Tobacco Settlement Funds, Kapiolani Foundation, Queen Emma Foundation, Hawaii Community Foundation, Healthcare Association of Hawaii and Hawaii Health Systems Corporation (fewer uninsured children and youth using emergency room services help hospitals financially), QUEST plans (simplification and coordination decrease their administrative costs), Hawaii Hotel and Lodging Association, and Chamber of Commerce of Hawaii Public Health Fund. Hardy explained that Congress is considering legislation to have the federal government provide 100% matching funds to Med-QUEST for Hawaiians who access health services in hospitals and community health centers. This would make more money available to the state for Med-QUEST benefits and increased public health insurance outreach activities. 5. Priorities for Continued Outreach, Enrollment, and Coordination We discussed that uninsured kids would always be a moving target. Barbara presented a “to do” list: Simplification * Help Med-QUEST improve customer service * Expand electronic application * Simplify other Med-QUEST Forms * Simplify letters Med-QUEST sends to customers * Continue updating and distributing question and answer handout on Med-QUEST rules and procedures Outreach * Continue outreach through natural points of contact * Continue athlete’s campaign * Increase outreach to grandparents raising grandchildren * Businesses * Labor unions and associations * Young Adults (18 to 19 years old) * Public housing * Immigrant media campaigns for other ethnic groups * Print flyers in additional languages (Chamorro, Fijian, Kosraen, Thai, Yapese, etc.) Coordination * Continue annual outreach workers conference * Continue community training workshops * Continue outstationed eligibility workers network and communication with Med-QUEST The committee highlighted engaging the business community, especially through labor unions and associations. 6. Next Steps Barbara will first prepare three-year proposals for the QUEST plans with an explanation of activities and deliverables. After receiving their feedback, she will meet with other potential funders to continue the Hawaii Covering Kids statewide project.