Best and Promising Practices for Engaging, Enrolling, and Retaining People with HIV in Health Coverage

The ACE TA Center conducts an ongoing process of identifying best and promising practices. The development of this collection began with a systematic assessment of best practices in 2013 on outreach and enrollment. The assessment included a comprehensive literature search and website review as well as key informant interviews with Ryan White HIV/AIDS Program (RWHAP) grantees.

Through these efforts, the ACE TA Center has identified the following best and promising practices for engaging, enrolling, and retaining people with HIV in health coverage. Though the current list is most relevant to enrollment in Marketplace health insurance, many of the best practices can also apply to Medicare and Medicaid enrollment work. Regardless of the type of enrollment being conducted, each best practice should be tailored to the specific needs of your HIV program, community, and client population. 

To help your organization implement these best practices, relevant ACE TA Center resources and tools, including Medicare-specific resources, are provided throughout the document.

1. Prepare your organization to best meet the enrollment needs of clients.

1.1 Train staff on the basics of health insurance. 

All staff that interact with clients, including case managers, benefits counselors, peer  advocates, clinical providers, social workers, and front desk staff, should know the basics of health insurance, including health coverage options available to eligible clients and the enrollment processes in their state. The basics of health insurance should include information that a person can’t be discriminated against because of their health status, and that they can’t be denied coverage due to a pre-existing condition. 

1.2 Stay informed of state and federal health care policies. 

It is important to stay up-to-date on evolving policies and federal guidance related to health insurance eligibility, financial assistance, and enrollment processes. This includes keeping track of changes related to Medicare, Medicaid, and RWHAP Part B/ADAP policies in your state. You can do this by staying in touch with the health insurance Marketplace ( or your state Marketplace), and your state’s Department of Insurance. The ACE TA Center monitors federal policy related to health care access and disseminates key updates. Sign up for the ACE mailing list to stay informed!

1.3 Train all staff on the importance of using inclusive language and practicing cultural humility. 

Inclusive language is communication that is free of prejudiced, stereotyped, or discriminatory views of groups of people, based on personal characteristics such as gender, gender expression, race, ethnicity, socioeconomic status, ability/disability status, religion, sexual orientation, etc. Humility is the most important quality providing equitable services. Staff should understand that addressing privilege is always a work in progress and requires being open to learning and utilizing intentional, innovative language and design tailored to the communities one works with. Encourage the engagement of staff and clients that reflect the local community in organizational policy development, administration, and service delivery. The more that staff understand about their clients’ unique culture, language, health literacy, and past experiences, the better they will be able to serve each client’s unique needs. 

1.4 Train staff on how your organization and the RWHAP, including ADAP, may provide services for clients who are not eligible for health coverage. 

The RWHAP will continue to be a safety net for people who are not eligible for health coverage. For some of these clients, the RWHAP may purchase health coverage outright. Others may continue to receive RWHAP and other safety net services as before, including medication access. Staff should understand how the RWHAP will serve clients that are ineligible for coverage, including what RWHAP Part A and B recipients, including ADAP, are doing in their state for these clients and what other federal, state, and local resources may be available.

2. Engage clients to enroll in health coverage, use their coverage, and stay enrolled. 

Planning and implementation 

2.1 Develop a comprehensive plan to engage and enroll clients in health coverage and help them stay enrolled. 

Organizations should establish and maintain comprehensive policies and procedures that clearly describe their plan for engaging and enrolling clients in health coverage and helping them use their coverage and stay enrolled. 

2.2 Train staff with direct client contact to determine eligibility, enroll clients, and help clients maintain coverage. 

All staff with direct client contact should be prepared to provide basic information about health coverage options and connect clients to staff or external partners who can provide direct enrollment assistance. HIV programs should provide tailored training to staff on how to determine client eligibility, enroll clients, and help clients use and maintain their coverage. Staff should be prepared to explain Marketplace financial assistance options (e.g., premium tax credits and cost sharing reductions) to clients, as well as information about the potential state-specific tax penalties for not enrolling. Staff should also communicate to clients how the RWHAP may be able to help with insurance and medication costs. 

2.3 Assess your work flow to routinely screen clients for eligibility and plan renewals. 

Clients are most likely to successfully enroll in new coverage when the transition between engagement activities and enrollment support is seamless. Structure clinic workflow to screen clients for changes in eligibility both during routine clinic visits throughout the year and during Marketplace Open Enrollment. This will help ensure clients who are newly eligible for Marketplace coverage or eligible to re-enroll get enrolled promptly, and receive appropriate enrollment assistance. Staff should also routinely screen for RWHAP Part B/ADAP eligibility. 

2.4 Develop procedures for eligible clients that do not enroll. 

RWHAP recipients must demonstrate vigorous pursuit of enrolling clients in health coverage. Organizations should document their efforts. Clients that are eligible but choose not to enroll should be asked to sign an affidavit saying that they have declined to enroll in coverage. Your local RWHAP Part A or Part B program may have additional or different guidance on how to document "vigorous pursuit."

2.5 Tailor messaging and communication appropriately for your client population. 

RWHAP clients may have concerns about enrolling in health coverage for many reasons, including fear of sharing their personal information, concerns about stigma and discrimination, and previous negative experiences with the health care system. Given these challenges, trusted RWHAP staff should provide clients with comprehensive information about coverage options using clear, plain language and allow time to listen to and discuss people’s specific concerns. 

2.6 Train staff on health insurance literacy to communicate with clients about how to enroll in health coverage, use their health coverage, and stay covered. 

Clients may not understand everything about how health insurance works. Staff with strong health insurance literacy skills who are knowledgeable about key health insurance terms, forms, processes, and instructions will be able to work with clients more effectively and help them to enroll in health coverage, use their health coverage, and stay covered. Staff will also be more prepared to help clients address health insurance-related challenges as they arise, minimize gaps in coverage, and manage potential health and financial challenges.

Staffing and partnerships 

2.7 Provide one-on-one enrollment assistance for clients, especially those who haven't had health insurance before. 

Enrollment assisters walk people through the application and enrollment process, help to determine and document eligibility for coverage and financial assistance, compare and select health plans, and complete and submit the application. One-on-one enrollment assistance is associated with increased enrollment rates and is particularly important for clients who have never had health coverage, may be distrustful of the health care system, or may not feel they need to enroll because they already receive RWHAP services. 

2.8 Have at least one staff person trained as an enrollment assister. 

RWHAP staff trained as enrollment assisters (such as certified application counselors, in-person assisters, navigators, or Medicare SHIP counselors) will be able to provide enrollment assistance in the context of the RWHAP and the specific health care needs of people with HIV. Clients may also feel more comfortable receiving assistance from an organization they already know and trust, which can reduce enrollment barriers. 

2.9 Partner with organizations that provide enrollment assistance if you do not have an on-site enrollment specialist or need additional enrollment help. 

If you do not have an on-site enrollment assister at your organization, identify potential partner organizations that serve your key populations and are trained to enroll people in health coverage. These partnerships can expand your organization’s capacity during Open Enrollment and also support plan renewals, or enrollment needs during a Special Enrollment period. 

Provide consultation and training to these partner organizations on the health care, confidentiality, and other needs of people with HIV, as well as guidance on which health plans best meet the needs of your clients and whether RWHAP, including ADAP, provides financial support for particular plans.