November 1, 1999

How Schools Can Help Link Children to Free and Low-Cost 
Health Insurance Programs
by Donna Cohen Ross

Schools can be instrumental in helping families obtain free or low-cost health insurance for their children. States now are using funds available through the child health block grant — called the Children's Health Insurance Program (CHIP) — to expand their Medicaid programs, to create or expand separate child health insurance programs, or to take a combination of the two approaches. As a result, coverage is now available to more children than ever before. Yet, millions of eligible children still are not enrolled.

Conducting child health insurance outreach at school is a common-sense, high-impact strategy for a number of reasons. First, schools are where the children are! According to a March 1998 report by the U.S. General Accounting Office, 69 percent of uninsured, Medicaid-eligible children were either in school or had school-age siblings. In addition:

School districts and schools across the country are now helping students enroll in free or low-cost health insurance programs. Promising strategies include involving leaders at every level in the school community, creating links with school-based programs — such as the School Lunch Program and school-based health services — facilitating partnerships between schools and health-related organizations in the community, and providing direct application assistance to families with eligible children.


Enlist school administrators, staff, parent groups — and students.

School superintendents, principals, school nurses, social workers, guidance counselors, cafeteria workers, coaches, teachers, administrative staff — even school bus drivers — can provide child health insurance information and enrollment assistance. Some outreach campaigns have been able to provide resources for schools to hire new staff or to enable existing staff to devote time and effort to outreach activities. Others have found ways to assign Americorps members or other volunteers to schools for the purpose of conducting outreach. Students also can be involved in outreach efforts.

Massachusetts: Students take the lead in the "Coaches' Campaign" — Teens in Boston have stepped up to the plate to help get the word out about the availability of free and low-cost health insurance. Under the wing of Health Care for All, a health care advocacy group, the teens have helped organize the Coaches' Campaign. The goal is for coaches and school athletes to be a source of information and help for children needing health insurance. With creative assistance from a Boston advertising firm, posters and brochures have been designed that feature outreach messages aimed at school athletes, such as :

There are many opponents ... Health insurance shouldn't be one of them.

If you're an athlete, you belong in the game and nothing should get in your way ... especially health coverage.

Currently, Health Care for All and the Tufts Health Plan have partnered to provide outreach materials and to conduct presentations for as many as 200 coaches on the availability of children's health coverage. Tufts Health Plan arranged for the presentations to take place during the Red Cross CPR training for coaches and other school athletic staff. In addition, four teens and an AmeriCorps Promise Fellow based at Health Care for All are targeting specific school districts for more intense outreach efforts.


Distribute child health insurance outreach materials.

Informational flyers can be distributed at PTA meetings, in school newsletters, with report cards or school lunch menus, at kindergarten registration, or sign-ups for extra-curricular activities. Capitalize on the "ebb and flow" of the school year. Schools often set their schedules way in advance for mass mailings to families or family visits to schools. Coordinate your outreach efforts so they fit with the school calendar. For example, if you want to insert a notice about children's health insurance with school lunch applications that are mailed to families in September, you may need to have your notice prepared and approved before the end of the previous school year. Be aware that some schools now operate year-round, with students on staggered cycles. Mailings may be scheduled for certain points in each cycle.


Make health insurance outreach activities part of registration activities.

When children are registering for school — either as kindergartners or as new students — parents often are asked for various kinds of health-related information such as a child's immunization status or a person to call in case of a health emergency. This is a logical time to find out about children's health insurance status and to offer families assistance in applying.

Minnesota: "Welcome Center" helps children get health coverage at school registration time — Every year, more than 8,000 children register for school at the Welcome Centers operated by Minneapolis Public Schools in partnership with the Minneapolis Department of Health and Family Support's Family Stabilization and Health Access Program. At the Welcome Centers, new students can sign up for specific schools, arrange school bus transportation, and take English proficiency tests. In addition, Welcome Center staff, including public health nurses, a social worker, three bilingual advocates (Hmong, Spanish and Somali) and a health coordinator, are on hand to help families apply for health insurance for their children. They also follow-up with families to ensure that the application and enrollment process goes smoothly.


Connect children to health insurance through the School Lunch Program.

Since most children who are eligible for free or reduced-price school meals are likely to qualify for free or low-cost health insurance, making the link between these two programs is a promising strategy for reducing the number of uninsured children. At the beginning of the school year, send home information about the availability of free or low-cost health insurance with applications for school meals. Alternatively, notify families about their children's eligibility for health insurance at the "back end" of the school lunch application process — when they are informed that their children qualify for free or reduced-price school meals.

Information from a school lunch application generally may not be shared with or used by anyone not directly connected with the administration of the School Lunch Program, unless the parent has given permission for this to occur. Many schools now include a check-off box on the school lunch application that enables the parent to indicate he or she is interested in receiving more information about children's health insurance and to grant permission to the school lunch staff to forward the family's name and address to the appropriate agency. In some cases, by checking the box, families can give permission for information about their income or other specifics to be shared with the child health program. This can start the eligibility determination process.

Consider adopting this type of school lunch application in your school district. Prototype school lunch applications, featuring the check-off box, can be obtained by visiting the U.S. Department of Agriculture (USDA) website at For the "check-off box" system to work, procedures need to be in place to transfer the information from school lunch applications to the state or local child health agency and to process that information so that families receive appropriate application assistance. These activities will require school lunch staff and child health agency staff to receive training, and implementation may require additional resources.

Families Find Support for Getting Children Insured in Seattle Schools

Seattle schools are the focal point for Kids Health 2001, an all-out effort to get children enrolled in Medicaid — and a contingent of grassroots "family support workers" and school nurses are making it happen! The family support workers are available in 65 elementary schools to help families obtain a range of benefits and services. Along with school nurses, they now have been trained by the Washington Health Foundation’s Child Health Access Program (CHAP) to assist families with applications for Medicaid. To ensure adequate support for the outreach effort, the Washington Health Foundation also has provided the funding to increase the work hours for four family support workers and four school nurses who now can devote their full time to providing application assistance.

A series of school-based promotional activities have focused attention on the help parents can get from the family support workers. First, a letter from the school superintendent on the importance of health insurance for children was mailed to 36,000 families in nine different languages. The letter encouraged families to call their school’s family support worker or school nurse — or the CHAP telephone line — for application assistance. The letter generated a huge response. Each school now displays posters which emphasize that ongoing help in applying for children’s health insurance is available from the family support worker or school nurse. In addition, City Year Youth Corps workers are helping with outreach and application assistance at special events. Soon they will have pagers so they will be able to receive messages and get back to families within 24 hours.

The next step is to make application assistance a systematic part of the school routine. At kindergarten registration and school sports registration families will be able to apply for health insurance for their children. Seattle schools have already been experimenting with linking Medicaid application assistance to the School Lunch Program. By checking a box on the school lunch application, families can now give permission for their name and address to be shared with the Medicaid agency so that a Medicaid application can be mailed to them. Next year the school district is planning to pilot a new idea that takes the school lunch connection a step further. The school lunch application will be printed on a self-duplicating NCR form. By checking the box on the form, families will give permission for a copy of the form, which includes family income information, to be mailed to the Medicaid agency for the purpose of determining income eligibility for coverage. The Medicaid agency will contact families to get any additional information they may need — such as the child’s immigration status — to make a full eligibility determination.


Persuade your state to adopt the Medicaid "presumptive eligibility" option.

Under the Balanced Budget Act of 1997, states have the option to allow staff of school-based programs that receive Medicaid reimbursements to make presumptive eligibility determinations for children, that is, they can enroll children provisionally if they appear eligible based on their family's declaration of its income. (States also have the flexibility to allow presumptive eligibility determinations in their CHIP-funded separate programs.) Nine states have adopted the Medicaid presumptive eligibility option — CT, IN, MA, MI, NE, NH, NJ, NM, and NY — and of those states, four currently are implementing presumptive eligibility procedures. At least one state — New Mexico — allows schools that are Medicaid providers to presumptively enroll children in Medicaid. Presumptive eligibility provides families the chance to obtain health coverage for their children on the spot in a familiar setting and can link children with routine health care and medical treatment without delay. Families then have a set amount of time to complete the formal application process, school staff can help them meet this obligation.

Nebraska: Presumptive eligibility streamlines enrollment for children — Nebraska has adopted the presumptive eligibility option in children's Medicaid. And, while schools have not yet been given the "go ahead" to make presumptive eligibility determinations, staff of community health centers and local health departments who have been authorized to do so are getting their foot in the schoolhouse door. For example, a staff member of Panhandle Community Services health center, attended a parent information night at a local elementary school in Scotts Bluff. She was able to directly enroll children in Medicaid by assisting parents with a simple two-page form that takes only a few minutes to complete. In the presumptive eligibility process, if the child appears to qualify, the health center gives the parent a copy of the form which serves as a temporary "enrollment card" and will be accepted by health care providers as proof of coverage if the child needs medical care before the final Medicaid eligibility determination is made. Another copy of the form is submitted by the health center staff to the local Medicaid office within five days. The family has several weeks to follow through by providing income verification. Health center staff are available to help families complete this last step. While the presumptive eligibility process is very new for children, state officials report it is working well and they anticipate a "final approval" rate of over 80 percent.


Arrange for eligibility workers to be assigned to schools.

States must provide the opportunity for families to apply for Medicaid at sites other than the Medicaid office. To accomplish this, eligibility workers may be outstationed at certain hospitals or health clinics. States also can outstation eligibility workers at non-traditional sites such as schools and child care centers. Keep in mind that eligibility workers can rotate among several locations.

Utah: Families can apply for Medicaid at school — Every day, one of Salt Lake City's Medicaid eligibility workers comes to work at an unusual place — Edison Elementary School. The worker was placed at the school by the Utah Department of Health after the Department's Division of Maternal and Child Health participated in a health fair at the school and found that many of the students were suffering from untreated health conditions. The eligibility worker is available to Edison families five days a week to assist them in filling out Medicaid applications. In addition, he serves families in six other schools by conducting presentations at parent-teacher nights, communicating with school counselors and making home visits. He also has sent Medicaid information to families in four languages: English, Spanish, Bosnian and Tongan.


Create partnerships between schools and organizations 
involved in delivering health services.

While school officials may understand the value of assisting families in obtaining health insurance for their children, they may not feel equipped to do the job on their own. They may worry that school staff already are "spread too thin" with multiple responsibilities to take on new tasks, or they may be concerned that special expertise is needed to properly assist families. For these reasons, schools may wish to call on local health care providers to work with them on outreach and enrollment activities.

West Virginia: Partnership with federally qualified health centers helps children get insured through school — New River Health Association is a federally qualified health center that operates four school-based health clinics and also provides technical assistance to other school-based clinics in elementary, middle and junior high schools across West Virginia. Clinic staff let parents know that if their children qualify for free or reduced-price school meals they also are likely to qualify for children's health insurance. Staff at the in-school clinics provide the families of potentially-eligible children with an application form and material explaining program benefits. They follow up with a phone call to offer further assistance, if necessary. New River staff maintain a good working relationship with the local Medicaid office so they can troubleshoot if there are problems.

Idaho: Schools and hospitals work together — A partnership between hospitals and schools in Idaho is in full swing. The Hospital Consortium of North Idaho received a three-year, $600,000 Rural Health Demonstration grant from the federal government to enhance school nursing in 12 school districts in five northern Idaho counties. For example, the Coeur d'Alene school district contracts with the Kootenai Medical Center for a nurse who covers 14 schools. This busy nurse says she is inseparable from her cell phone. If she's called to help out when a child is injured on the playground, she can keep in constant touch with the school until she arrives at the scene. The phone also comes in handy for helping uninsured children get coverage through Medicaid. She's often on the line with local Medicaid workers, arranging application appointments or ensuring that papers are processed. The nurse has helped convince lots of families to submit applications even when they thought their children wouldn't qualify.


Work with state child health agencies to ensure resources 
are directed to school-based outreach activities.

In general, states can use Medicaid and CHIP administrative funds for activities related to identifying potential beneficiaries, informing them about the programs and helping them apply for benefits. Recent HCFA guidance indicates that states may claim federal matching funds through Medicaid and CHIP to help cover the cost of school-based outreach and other administrative activities. See HCFA letter, October 18, 1999, States can enter into an interagency agreement or contract with school districts or schools to perform such activities.


Find out more about getting involved in outreach activities.

A comprehensive outreach kit, Free and Low-Cost Health Insurance: Children You Know Are Missing Out, is available from the Center on Budget and Policy Priorities' Start Healthy, Stay Healthy Campaign. The kit contains posters and flyers in English and Spanish, an innovative screening tool that can tell whether children are likely to be eligible for free or low-cost health insurance in their state, and a complete Outreach Handbook filled with ideas on how to inform low-income working families about children's health insurance and how to get their children enrolled. For more information on outreach activities and how to order a kit, visit the Center's web site at