Revised, December 1, 1999

How Early Childhood Programs Can Link Children
to Free and Low-Cost Health Insurance Programs

by Donna Cohen Ross

A child's early years are the time to nurture optimum growth and development, and to be on the lookout for any problems that require medical attention to prevent them from becoming major health concerns. Staff of early childhood programs — such as Head Start, child care centers, family child care homes, child care resource and referral agencies and others — have an important role to play in assuring the health of children in their care. Parents often rely on early childhood professionals whom they know and trust for advice and help in finding health care for their children. But, obtaining medical services, especially preventive care, can be difficult — or next to impossible — without insurance.

One of the most important first steps any early childhood program can take is to help families obtain health insurance for their children. Since the child health block grant — called the Child Health Insurance Program (CHIP) — was enacted by Congress in 1997, states have used new funds to expand their existing Medicaid programs, to expand or create new separate child health programs, or to take a combination of these approaches. These changes have made more children eligible for publicly funded health insurance than ever before. Working parents who earn low wages — and who are not likely to have health insurance through their jobs — need to know that their young children may be eligible for free or low-cost health insurance available through Medicaid or other child health programs. While approximately 11 million children in the U.S. are uninsured, more than four million qualify for free health coverage under Medicaid.1 An additional three million children in families with income below 200 percent of the federal poverty line are likely to be eligible for free or low-cost health coverage under a CHIP-funded program.2 Most uninsured children who are eligible for these programs — 85.4 percent — are in families with earnings.3 In addition, according to a recent GAO report, 54 percent of the uninsured children who are eligible for the Medicaid program are under age six.4 Thus, many of these youngsters are likely to participate in some kind of early childhood program.

Many families with eligible children don't realize their children qualify for health coverage. They may mistakenly believe that their family has to be receiving welfare for their children to be eligible or they may think that if they have a job their children cannot qualify. Others may know about the programs, but do not know how to apply. For some, a complicated application process or the requirement for a face-to-face interview at a social service office during business hours may present significant barriers. Early childhood programs around the country are now informing families about the availability of health insurance and also are helping them get their children enrolled. Some states have taken advantage of Medicaid administrative funds to contract with early childhood programs for these services. Some of the CHIP money states receive also can be used to help cover the cost of outreach activities.


Here are ten ways your early childhood program can help:

1. Inform families about the availability of free and low-cost health insurance — Display posters and distribute flyers or other materials any place where families and children gather. Post information on classroom bulletin boards and distribute at parent meetings. Send flyers home with children's artwork, lunch menus, and notices about upcoming activities. Don't forget children who are on the waiting list for child care or child care subsidies. Even though these children must wait for child care, chances are, they can get health insurance right away. If your state has a short, mail-in children's health insurance application, keep a supply on hand to give to families. Always provide a checklist of documents that must be submitted with the form. It is very important to let families know they may be eligible for Medicaid — or other coverage programs — regardless of whether they qualify for or receive cash assistance. Families also need to know that if they no longer are receiving cash assistance after finding a job or for some other reason, their children still are likely to be eligible for Medicaid. Parents may remain eligible for a period of time, as well.


2. Make income eligibility screening for free and low-cost health insurance programs part of the routine Income eligibility for early childhood programs can "flag" eligibility for Medicaid or separate CHIP-funded programs. For example, to qualify for Head Start, children generally must have family income below 100 percent of the federal poverty line; therefore, they are likely to be eligible for Medicaid, which allows children under age six to qualify if their family income is at or below 133 percent of the federal poverty line.

In 1999, in 17 states, income eligibility guidelines for subsidized child care are the same or lower than the state's Medicaid income guidelines for children under age six. In addition, in 16 of the 26 states that are operating separate CHIP-funded programs, the income eligibility guidelines for subsidized child care are the same or lower than the income eligibility guidelines for children's health insurance. In 30 states, children eligible for subsidized child care are likely to be eligible for health coverage either through Medicaid or a separate CHIP-funded program.5 Once you identify a child likely to be eligible for free or low-cost health insurance, at a minimum, refer the family to a place where an application can be submitted. Better yet, assist the family in completing a health insurance application. This can be relatively easy if your state has a simple, mail-in application form.

Alabama: The Child Care Resource Center in Opelika, Alabama is one of 12 management agencies under contract with the state Department of Human Resources to determine eligibility for subsidized child care. Since Alabama's income eligibility guidelines for subsidized child care are lower than the state's Medicaid eligibility guidelines for children under age six — and the income eligibility guidelines for the separate CHIP-funded program, ALLKids — it is easy for child care counselors to identify children likely to qualify for free or low-cost health insurance. If the child is not enrolled in Medicaid or ALLKids already, the counselor helps the parent complete a children's health insurance application at the same time the application for subsidized child care is completed. (A single application can be used to enroll in children's health insurance, whether the child is found eligible for Medicaid or ALLKids.) The counselors ensure that the completed applications are mailed in — families are not required to have a face- to-face interview. If a parent reports that the child already is enrolled in Medicaid, the counselor takes the time to discuss the importance of EPSDT benefits and how families can utilize them.


3. Make sure training programs include information about the availability of free or low-cost health insurance for children. Many early childhood programs conduct training of one sort or another. Whether it's health and safety training for classroom staff, in-service training for providers or parenting classes for parents, there are many opportunities to incorporate information on how families can obtain health insurance.

Georgia: Georgia's Right From the Start Medicaid Program (RSM) employs nearly 200 outreach workers that work in local communities all over the state to find and enroll eligible pregnant women and children in Medicaid. Recently, RSM workers were invited to attend a training session for family child care providers in the Atlanta area. RSM workers discussed the benefits of the Medicaid program and demonstrated the easy application process. Family child care providers who are well-informed about the application process — or who have been through it themselves — are in the best position to share this information with families of children in their care. Medicaid brochures and a local number to call to get help from an RSM worker were provided for family child care providers to share with parents of children in their care. Providers were given an opportunity to get their own children enrolled after the training. (Since Georgia implemented it's CHIP-funded separate program, called Peachcare, RSM workers also can assist families in completing the Peachcare application.)


4. Provide application assistance. Early childhood staff can help families complete child health insurance application forms. In Ohio, child care providers are being trained to assist families with the Medicaid application and to provide needed follow-up to ensure children get enrolled. In Virginia, child care providers in the Richmond area are participating in a child health enrollment campaign. Local businesses are helping to provide books, toys, playground equipment and other needed supplies to early childhood programs involved in this special effort.

Work with your state or local Medicaid agency to become a Medicaid outstation, or arrange for Medicaid enrollment workers to visit your center on a regular basis. Keep in mind that these eligibility workers can rotate among several locations. Team up with other early childhood programs in your area to "round out" the worker's itinerary. Alternatively, staff of community-based organizations can be trained to assist families with Medicaid applications. In some states, Medicaid or CHIP administrative funds are being used to help cover the costs associated with these activities.

Louisiana: Louisiana's Department of Health and Hospitals contracts with community-based organizations to become children's health insurance application centers. The Regina Coeli Child Development Center in Covington, which operates 12 Head Start programs serving approximately 1400 children, has staff trained and certified by the state to provide this service. Throughout the year, Head Start staff use a variety of methods to tell families about children's health insurance, including flyers and monthly newsletters. Families can make an appointment to fill out an application when they drop off or pick up their children, or at another more convenient time. Regina Colei's costs for providing this valuable service are reimbursed by the state — $14 for each completed application. While Louisiana has had this system in place for a number of years to enable families to apply for Medicaid for their children, the enrollment sites are now being encouraged to use the LACHIP application, a joint form that can be used to apply for Medicaid or the state's CHIP-funded program. All verification documents must be attached to the form in order for the enrollment site to receive the $14 reimbursement.

Be sure your enrollment site addresses the needs of applicants in your community. For example, provide child care so parents can give their attention to completing the application. Offer interpreters for applicants who speak languages other than English. Schedule hours that are convenient for working families, such as early mornings, evenings or weekends.


5. Persuade your state to adopt the Presumptive Eligibility Option and use it to enroll children in Medicaid. Under the Balanced Budget Act of 1997, states have the option to allow Head Start centers, as well as agencies and organizations (such as child care resource and referral networks) that determine eligibility for subsidized child care, to make presumptive eligibility determinations for Medicaid. Based on a family's declaration of its income, if the child appears to be eligible for Medicaid, he or she can be enrolled on the spot for a temporary period, pending a formal Medicaid eligibility determination. In states that adopt this option, early childhood programs can play an extremely important role in directly enrolling children in Medicaid, providing a chance to apply for health insurance in a familiar, comfortable setting and enabling working families to apply without having to take time from the job to do so. Presumptive eligibility also can help get children into routine health care and medical treatment swiftly. The law requires that families complete the formal Medicaid application process within a set period of time and early childhood programs can be instrumental in helping families close this loop. Nine states, including Connecticut, Indiana, Massachusetts, Michigan, Nebraska, New Hampshire, New Jersey, New Mexico and New York, have adopted the presumptive eligibility option. Of these, four states have implemented procedures.


6. Conduct children's health insurance outreach at special events. Health fairs, Head Start recruitment day, kindergarten registration, community festivals, or story hour at the library offer opportunities to talk to families about health insurance for their children. Be there — any place, any time families and children are likely to gather.

New Mexico: In New Mexico, the Laguna Pueblo, Division of Early Childhood, conducts an annual event called "Child Find" in seven villages. During "Child Find" activities, children under age five receive comprehensive screening for developmental, nutritional, medical, vision, dental and hearing problems. Children with special needs are identified and appropriate referrals are made. Flyers and posters promoting the "Child Find" are distributed by members of the Laguna Interagency Coordinating Council for Young Children, as well as through schools, post offices and local merchants. Upon entering the "Child Find", each parent is asked whether the child has private health insurance or is enrolled in Medicaid. If not, a social worker from the Indian Health Services hospital facility is on hand to assist parents in filling out New Mexico's three-page Medicaid application. In two to three weeks the social worker checks in with the family to ensure that the process has gone smoothly and to find out if the child's Medicaid eligibility has been approved. She can provide assistance if there are any procedural problems.


7. During home visits, share health insurance information and assist families in applying. Home visits present a special opportunity to discuss family health issues. Families may be more relaxed and willing to take the time to learn about the benefits of coverage and complete application forms. A variety of early childhood programs have a home visiting component: Some Head Start programs visit families at home. The Home Instruction Program for Preschool Youngsters (HIPPY) helps parents learn to read to their children at home. The Child and Adult Care Food Program visits family child care providers to help plan nutritious meals and learn proper kitchen sanitation procedures.

Oklahoma: "Family Partnership Managers" who are employed by the Cookson Hills Head Start Program in Cherokee County, Oklahoma, take the time during home visits with Head Start families to help them fill out a Medicaid application. Family Partnership Managers are able to complete most of Oklahoma's short Medicaid application for the family before the home visit, since Head Start collects much of the same information for its own purposes. All families need to do is answer a few additional questions and sign the form. In Oklahoma, no documentation of income is required, so the completed form just needs to be mailed in to the local Department of Human Services.


8. Use a telephone resource line to encourage families to seek information about free or low-cost health insurance and get children enrolled. Child care resource and referral agencies (CCRRs), which help parents find appropriate, affordable child care, do much of their work over the telephone. During their conversations with parents they often share information about services other than child care that families and children need. They can provide information about how to obtain health insurance and help families complete simple applications over the telephone. Follow-up calls can be made in a few weeks to ensure that the process has gone smoothly or to give additional help. The child care resource and referral networks in Washington State and Michigan are conducting these types of activities.


9. Use your clout with local employers Many early childhood programs have strong links with the business community. Child care resource and referral agencies may have contracts with local businesses to help their employees locate child care. Child care centers may be in-house providers for private companies or may care for the children of workers employed in nearby businesses. Capitalize on these relationships by encouraging businesses to alert their employees to the availability of Medicaid and other health insurance programs. Business owners may realize that children's health insurance is important to families, but the cost of providing dependent coverage may be more than many employers — especially small employers — can handle. Remember that children who have private health insurance cannot participate in a state's CHIP-funded health insurance program. However, children with private coverage can participate in the traditional Medicaid program as long as they meet the income guidelines. Medicaid can fill gaps in private plan coverage, or may help families with premiums, deductibles or co-payments required by employer health plans.


10. Don't forget about your own staff — Many workers in early childhood programs have children who are eligible for free or low-cost health insurance. Average salaries for these workers tend to be quite low — around $14,600 per year — which means their children are likely to qualify in most states.6 Post information about child health insurance on staff bulletin boards or insert information into employee paychecks.

End notes

1. Thomas M. Selden, Jessica S. Banthin and Joel W. Cohen, "Medicaid's Problem Children: Eligible But Not Enrolled," Health Affairs 17 (May/June 1998), p.196.

2. Center on Budget and Policy Priorities calculation based on March 1998 Current Population Survey data from the U.S. Census Bureau.

3. Center on Budget and Policy Priorities calculation based on March 1998 Current Population Survey data from the U.S. Census Bureau.

4. U.S. General Accounting Office, Medicaid: Demographics of Nonenrolled Children Suggest State Outreach Efforts, (Washington, DC: Government Printing Office, March 1998), p. 11.

5. Center on Budget and Policy Priorities analysis, October 1999.

6. Bureau of Labor Statistics, 1997 National Occupational Employment and Wage Estimates.