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Engagement and Enrollment Best and Promising Practices and Resources

December 2016

ACE TA Center

The ACE TA Center has developed a self-assessment tool to help your organization evaluate where you are in the process of implementing and adopting these best and promising practices. Start now.

Prepare your organization to best meet the enrollment needs of clients

Staff should know the basics of the ACA law, health coverage options (including Medicaid and Marketplace plans), and enrollment assistance available in their state. Offer training to all staff, including case managers, benefits counselors, peer advocates, clinical providers, social workers, receptionists, and other support staff to ensure all staff know the basics. Offer this training to all new staff, and conduct training every year before open enrollment.

Training should cover:

  • The benefits of comprehensive health coverage for RWHAP clients
  • The variety of pathways to health coverage for PLWH in your state
  • Your organization's general approach to engaging and enrolling clients
  • Staff roles and expectations for engaging and enrolling clients
  • Any updates or changes from previous years

Resources

  • Health Reform Frequently Asked Questions
    A list of frequently asked questions about the Affordable Care Act. Source: Kaiser Family Foundation.
  • HealthCare.gov: Get Answers
    A list of questions and answers related to health insurance coverage. Source: HealthCare.gov.
  • Get Covered Academy
    Training, consulting, and support services designed to expand efforts and help solidify and institutionalize a durable, sustainable culture of enrollment in communities nationwide. Source: Enroll America.

It is important to stay up-to-date on evolving state policies and federal guidance on ACA health coverage, eligibility, subsidies, and enrollment procedures as well as on changes related to Medicaid expansion and Part B/ADAP policies. In particular, keep up-to-date on the local impact of state and federal ACA policies on the communities you serve.

Ways to keep your organization informed of emerging issues:

  • Assign a staff person to be your organization's health reform expert
  • Stay aware of HAB policies by signing up for e-mail updates and attending HAB policy webinars, available at the HAB Ryan White and ACA webpage.
  • Know what your Part B recipient, including ADAP, or Part A recipient (if applicable) is pursuing with regard to coverage completion (see below) and other state-level policies on transitioning clients to health insurance. This includes knowing what financial help is available from the Part A and B recipients to help clients with premiums and out-of-pocket costs and if there are specific plans they can help with.
  • Learn about how the Medicaid program works in your state, eligibility criteria, and how it relates to the RWHAP in your state and/or EMA/TGA
  • Sign up for listservs of consumer advocacy groups, health policy forums, and HIV provider and advocacy groups (see below)
  • Attend coalition meetings with state consumer advocates and providers
  • Connect with local elected officials and state agencies that have been instrumental in advancing your state's ACA implementation (e.g., state department of insurance and state Medicaid agency)

'Coverage completion' refers to the process of examining the array of services covered by other payment sources (e.g., Marketplace, Medicaid) and coordinating the use of these resources with RWHAP funds to fill in gaps in affordability and address remaining barriers to care. These barriers may include geography and immigration status.

Resources

Provide cultural competency training to your staff so they understand the specific concerns of your client population, including the needs and concerns of people living with HIV. Cultural competency includes an awareness of and sensitivity to the client's concerns and prior experiences with health coverage, the health care system, discrimination, and stigma. While one or two trainings will not ensure staff cultural competency, the more your staff understands about your clients' unique culture, language, health literacy, and past experiences, the better they will be able to serve each client's unique needs. Whenever possible, hire bilingual and bicultural staff that reflect your client population.

Resources

  • National Center for Cultural Competence
    The National Center for Cultural Competence provides training and technical assistance, including in the form of online curriculum and training to support health and mental health care providers and systems promote and sustain cultural and linguistic competency. Source: Georgetown University.
  • AIDS Education and Training Center National Multicultural Center (AETC-NMC)
    The AIDS Education and Training Center National Multicultural Center provides training, education, and technical assistance to clinicians, providers and organizations in multicultural HIV/AIDS care. Source: Howard University College of Medicine.

Under the ACA, QHPs must contract with essential community providers (ECPs), which have experience caring for medically underserved populations. RWHAP medical providers are considered ECPs and should directly approach insurers about contracting to be a part of their provider networks. RWHAP providers that have FQHC status are also deemed ECPs and are therefore able to contract with QHPs and be eligible providers in state Medicaid programs. Ensuring that your organization is part of provider networks for QHPs and Medicaid will help your providers continue to serve clients who enroll in new coverage, ensure continuity of HIV medical care and support services, and facilitate retention of clients in care.

Resources

RWHAP will continue to be a safety net for people who are ineligible for health coverage, including those with ineligible immigration statuses and people who fall into the coverage gap in states that have not expanded Medicaid. For some of these clients, RWHAP may purchase coverage outright. Others may continue to receive services as before.

Be sure staff understand what will happen with these clients, in line with organizational and state policies. Provide this information in new staff training and integrate it into an annual training to prepare for open enrollment. Provide guidance on how to answer questions and address the concerns of clients who are ineligible for health insurance under the ACA. Contact your city, county or state Ryan White program to find out about Part A and B resources available to your clients.

Resources

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

Planning and implementation

Organizations should establish and maintain comprehensive policies and procedures that clearly describe their goals for engaging and enrolling clients in health coverage and helping them use their coverage and stay enrolled. The procedures should outline each step of the process, from identifying, engaging, and educating clients to tracking and documenting enrollment and renewal efforts. A comprehensive plan for client engagement should:

  • Include detailed procedures to educate, enroll, and track clients, and help them stay enrolled
  • Describe how you will reach clients and the information and materials you will provide
  • Include multiple strategies and communication channels for educating clients about affordable health coverage options
  • Use client-level data and feedback from your target population about preferred messaging
  • Be tailored to any specific client groups that you serve in order to address why they have not enrolled yet and what their concerns are.
  • Build client engagement, education, and eligibility screening into all aspects of operations (client services, educational programs, translation, transportation, etc.)
  • Specify roles for all staff members
  • Include strategies for measuring engagement and enrollment goals
  • Establish a schedule to re-screen clients who may have been ineligible before

Resources

Provide tailored trainings to staff with direct client contact in how to determine client eligibility, enroll clients, and help clients use and maintain their coverage. All staff with client contact should be prepared to provide basic information about coverage options and direct clients to others on staff who can provide more extensive information and direct enrollment assistance.

Even if your organization does not directly enroll clients, it is important for staff with client contact to understand the full scope of the enrollment process in order to help clients make enrollment decisions, use their coverage, and stay enrolled.

Given the still-changing state-specific contexts of ACA implementation, as well as evolving RWHAP policies, provide staff with regular updates and refresher trainings as well as specific job aids and tools.

Job aids and tools could include:

  • Benefit plan summaries - a list of health services covered by payor and benefit plans in your state
  • FAQs on eligibility screening, benefits counseling, and tax credits
  • FAQs to help medical providers discuss enrollment benefits with clients
  • Phone scripts for administrative staff to use when contacting clients
  • Consumer materials to help clients understand how to use their coverage and stay enrolled

Enrollment staff and case manager should be prepared to communicate the key messages about the following to clients at different points throughout the enrollment process.

  • Enrollment staff should know all enrollment deadlines for the current open enrollment period and provide clients with detailed information about financial help and the potential tax penalties for not enrolling.
  • Preparing for the enrollment process by providing clients with a list of documents (such as income, residency and immigration/citizenship verification) they may need.
  • Active plan selection is important during open enrollment, so encourage clients that were previously enrolled in a Qualified Health Plan to review their existing plan to see if it still meets their needs.
  • Choosing a primary care provider to ensure clients see a provider with HIV expertise or a primary care system providing coordinated, client-centered care.
  • Clearly communicate to clients what they will need to pay for based on the plan they selected, including premiums, co-pays, deductibles, and coinsurance. Use examples to demonstrate each of these key health insurance terms.
  • Explain to clients how they may be eligible for premium tax credits and cost sharing reductions (CSRs) to help make Marketplace plans more affordable.
  • At the time of enrollment, discuss the concept of qualifying events with clients and the need to report them to avoid adverse consequences such as financial penalties.

Resources

  • Eligibility Decision Tree
    This tool helps program staff assess whether a client may be eligible for Marketplace or Medicaid health coverage, depending on the client's current coverage, income and citizenship status. It also describes the continuing role of RWHAP services. Source: ACE TA Center.
  • Health Care Plan Selection Worksheet
    RWHAP program staff can use this worksheet as they help clients select the best health care plan for their situation. The worksheet helps users do a side-by-side comparison of different health insurance plans, including key elements that are essential for PLWH of color. Source: ACE TA Center.
  • Health Insurance Enrollment Tracking Worksheet and Checklist
    A worksheet to help your Ryan White HIV/AIDS Program clients enroll in health insurance, use their benefits, and stay enrolled. Complimentary enrollment and renewal checklists can help you to quickly see the high-level steps of the enrollment or renewal process. Source: ACE TA Center.
  • Marketplace Plan Renewal Flowchart
    This guide, designed for RWHAP providers and enrollment staff, provides a basic timeline for enrollment and renewals for 2015 coverage. It also walks through five important questions related to the enrollment and renewal process, and provides tips to help clients. Source: ACE TA Center.
  • Health Insurance Renewal Tracking Checklist
    The renewal checklist is a quick and easy way to check-off the steps taken to help clients through the renewal process, whether the client's financial assistance and plan selection remain the same or change. Source: ACE TA Center.
  • Special Enrollment Periods Fact Sheet
    This fact sheet is for enrollment assistors to help RWHAP clients know that there are certain "life events" or "special circumstances" that allow people to enroll in, or change private health insurance outside the open enrollment periods. Source: ACE TA Center.
  • Network Adequacy Checklist
    This checklist is to support consumer advocates in their work advocating for robust network adequacy standards at the state level. Source: Community Catalyst.
  • ACE On the Go - Podcasts for HIV Clinicians
    This podcast series provides 5-minute conversations with experts on how you can help your patients enroll, renew, and maintain health coverage; access financial support to cover medication costs, premiums and co-pays; and avoid gaps in care due to coverage changes. Source: ACE TA Center.
  • Quick Reference Guide: Access to Health Coverage for Immigrants Living with HIV
    Reference guide with information about working with immigrants living with HIV who need health coverage. Source: ACE TA Center.
  • Taxes and Health Coverage: What You Need to Know
    Consumer resource to help RWHAP clients answer key questions about health coverage and tax filing. Source: ACE TA Center.

Clients are most likely to successfully enroll in new coverage when the transition between engagement activities and enrollment support is seamless. Structure your work flow so that engagement and enrollment activities are closely related. Integrate the following into your workflow.

  • Engage clients in enrollment and make it easy for clients to get help with enrollment, whether it's on-site assistance or connecting them to a trusted partner agency.
  • Establish a process to verify income, qualifying life events, or other special circumstances that may change clients' eligibility for health coverage, premium tax credits and cost sharing reductions every six months.
  • Send clients reminders about upcoming renewal dates using a variety of communication channels, including phone calls, letters, and text messages.

Resources

RWHAP recipients must demonstrate vigorous pursuit of enrolling clients in coverage. Therefore, organizations should develop a procedure to document and monitor clients that choose not to enroll or refuse to be screened for eligibility. This process should include the number of contacts with a client where information about the benefits of enrollment was provided as well as documentation of their refusal. Have patients sign an affidavit or client acknowledge form that they have declined to enroll in coverage.

Resources

RWHAP providers are well aware that each client brings a unique cultural identity and life experience to his/her care visit. At the same time, the process of learning about health insurance can be confusing, and it is important to help clients get clear, accurate information to help them make decisions about their care.

Many RWHAP clients, particularly clients of color, may have concerns about enrolling in insurance (Medicaid or Marketplace plans) due to health inequities they have encountered that resulted in negative experiences with the health care system. Clients may fear that new providers will not accept their culture, life experience, sexual orientation, or gender identity. Clients may also have concerns about possible coverage changes; negative perceptions about the value and affordability of insurance; and fears about their medical status, a family member's immigration status, or other sensitive information being shared.

Given these challenges, trusted RWHAP staff should provide clients with information about new coverage options. Communicate responses to client questions completely and accurately using clear, plain language. In educating clients about new coverage options, use general messaging that has been demonstrated to be effective with uninsured people. However, you know your clients best! Develop tailored messaging that addresses specific concerns of PLWH and other subgroups within your client population.

Resources

Messaging for RWHAP clients
LGBT
American Indian and Alaska Native
Black/African American
Latino/Latina
Mixed Immigration Status Families

Newly insured clients may not understand everything about how health insurance works, what benefits they have, how to use new benefits, or the various out-of-pocket (OOP) costs for which they are responsible. It is essential to build clients' health insurance literacy so that they will be able to navigate the health care system to obtain health services and so that they do not lose coverage.

Staff Training

Train case managers and staff with direct client contact to help clients use their health insurance to get medical care, including HIV care and services. Such training should cover:

  • How to clearly explain how enrollment and health insurance works
  • How to help clients connect with covered services, including behavioral health services
  • The kinds of health insurance service denials that can be appealed, including procedures and timelines for appeals
  • How to help clients understand that they need to file taxes if they receive financial assistance

Consumer Tools

Develop consumer tools or identify existing tools that explain frequently asked questions and discuss the more complex topics with clients, such as:

Getting Care
  • Using your insurance card
  • What benefits are covered or not covered
  • In-network and out-of network providers
  • A patient's right to appeal service denials
  • Pre-approval rules
Costs and Affordability of Coverage
  • Premium payment deadlines
  • Deductibles, co-pays, coinsurance, and OOP limits
  • Tax information such as premium tax credits and cost sharing reductions (CSRs)

As time passes, clients will gain more experience with insurance. Continue to support them in using and managing their coverage, as needed.

Resources

Health Insurance Literacy
Getting Care: Not HIV-specific
  • From Coverage to Care
    Resources to help people with new health care coverage understand their benefits and connect to primary care and the preventive services that are right for them. Source: Centers for Medicare & Medicaid Services.
Getting Care: HIV-specific
Costs and Affordability of Coverage

Staffing and partnerships

While every RWHAP recipient and subrecipient has a role to play in helping their clients get enrolled, partnerships can play a vital role in improving organizations' capacity to help their clients get covered and use their new health insurance. Some clients may not come in for RWHAP services very often, and connecting with them may require partnering with organizations with local community ties. Think broadly about where to engage with clients who may not visit your agency often.

  • Consider partnering with trusted venues such as faith-based and cultural organizations, other CBOs providing services to people of color, schools, adult literacy programs, grocery stores, barber shops, and hair salons.
  • To reach people with behavioral health challenges, such as substance abuse, consider collaborating with treatment centers, homeless shelters, needle exchange programs, and recovery events.

Because one-on-one enrollment assistance is associated with increased enrollment rates particular with communities of color, the ACA provides standards, training, and funding for navigators in all states to provide one-on-one assistance with enrollment. Many states have similar programs in place to help underserved populations enroll in Medicaid and CHIP, and some states are now providing funding and training to expand their pool of enrollment assisters to enroll people into expanded coverage options under the ACA.

Enrollment assisters walk people through the complicated application and enrollment process and help to determine and document eligibility for coverage and subsidies, compare and select health plans, and complete and submit the application. One-on-one assistance may be more important for clients who have never had health insurance, may be distrustful of the health care system, or may not feel they need to enroll because they already receive RWHAP services. Enrollment staff who provide one-on-one assistance should understand the needs of PLWH, including the importance of avoiding gaps in medication coverage and ensuring that medications and HIV care services are affordable.

Resources

If possible, train at least one person to be an enrollment assister. In addition to facilitating enrollment, enrollment assisters (such as certified application counselors, in-person assisters, or navigators) can help clients with renewals and coverage transitions due to qualifying life events. These are all key reasons for having an on-site enrollment assister that can provide dedicated enrollment services year-round. Having one or more enrollment assister on staff provides great benefits:

  • Clients will be able to receive enrollment assistance from an organization they already know and trust.
  • Having on-site enrollment assistance at a place clients already visit for services reduces enrollment barriers.
  • RWHAP staff trained as enrollment assisters may be more aware of and sensitive to the particular needs of RWHAP clients and will know the coverage completion options and support services available to clients through RWHAP.
  • In-person assistance is still the most effective way to enroll people into new insurance options.

Take advantage of navigator, in-person assister, and certified application counselor (CAC) training and grant funding that may be available in your state to certify staff. If more than one staff member is certified, some may be able to specialize in Medicaid enrollment and others in Marketplace plan enrollment.

If you do not have an enrollment assister on staff, partner with other organizations that provide assistance (see Best Practice: Partner with organizations that provide enrollment assistance).

Resources

While having on-site enrollment assisters is preferable, there are many reasons such as funding and staffing constraints at your organization may not allow it. In this case, identify potential partner organizations that serve your target population and are funded to enroll clients in health coverage. Ask community members about agencies where they have had good experience with enrollment assistance.

  • Provide consultation and training to enrollment specialists in partner organizations on the health care, confidentiality, and other needs of PLWH, as well as guidance on which health plans best meet the needs of your clients
  • Choose culturally competent partner organizations and establish referral relationships with them to enroll your clients. Cultural competency includes an awareness of and sensitivity to the client's concerns and prior experiences with insurance and the health care system, as well as past experiences of discrimination and stigma.
  • Establish procedures for referring clients to partner organizations, including asking case managers to provide an in-person introduction to the enrollment assister if at all possible.
  • Make it as easy as possible for clients to engage with these partners. If possible, provide space within your own organization for outside enrollment assisters to meet with you clients.

Resources

Train staff to help clients file appeals for eligibility and service denials. If organizations do not have capacity in-house, establish connections and referral relationships with legal aid and consumer assistance programs, health care consumer advocacy groups, and others that offer assistance with eligibility and service denials in your state. Once these connections are established, provide referral information to staff so that clients can be connected to specialists who can advocate for them and expedite and resolve their appeals.

Resources

  • Affordable Care Act Marketplace Plan Appeal Flowchart
    Flowchart developed by Community Catalyst to help assisters and consumers determine how to best address a problem with eligibility or coverage. It covers when to file a Marketplace appeal versus an appeal with an insurer versus a complaint with a Department of Insurance. Source: Community Catalyst and National Health Law Program (NHeLP).
  • How to appeal a Marketplace decision
    This resource describes how consumers can appeal Health Insurance Marketplace decisions that they do not agree with. Source: HealthCare.gov.

Document and monitor your organization's engagement and enrollment efforts

Enrollment into health insurance and effective monitoring of coverage stability is important to increase client's retention in both coverage and care. You can also use these data to demonstrate that your organization is "vigorously pursuing enrollment" of eligible clients as required by HRSA. Once clients are enrolled, your program can continue to track qualifying events, renewals, churn (i.e., people whose income changes mid-year and they bounce between different health plans or experience gaps in care), and how long clients stay covered once they are enrolled.

In order to routinely track and evaluate your organization's enrollment efforts, you will need to first identify and define the data you need to collect. This could include keeping track of the number of new applications submitted or clients enrolled in new coverage.

Develop an inventory of your data to determine what data you are currently collecting and how and where you are documenting the information (e.g., electronically or paper-based). Use this inventory to identify gaps in the data you are collecting compared to your targets.

Resources

Once you have identified what data you need to track enrollment efforts, you can update your data systems and use this data to document "vigorous pursuit" and track each client's enrollment progress (e.g., screened for eligibility, application completed, application submitted, coverage obtained).

This information will help you assess the effectiveness of your organization's enrollment strategies. If something isn't working, make adjustments for the next enrollment period.

Use client level data in existing data systems to:

  1. Identify clients who may qualify for new ACA health coverage and assess their eligibility.
  2. Identify if there are sub-populations of clients that are largely uninsured to target engagement efforts

Develop an implementation plan describing who will be targeted for enrollment (your target population) and how they will be targeted (specific enrollment activities; setting; staffing). Set goals for future enrollment efforts so you can assess effectiveness.

Generate reports using your data systems to:

  1. Identify clients who may be eligible for health coverage, including their age, current insurance status, and income
  2. Target and prioritize engagement, education, enrollment, and plan renewal efforts
  3. Estimate staffing and resource needs for these efforts, especially for those hard to reach clients or those resistant to enrollment.
  4. Share data with relevant staff (e.g., case managers, enrollment assisters) to support their work with clients, point out shared accomplishments, and ask them to discuss their challenges and share ideas for improvement.
  5. Use the data you've gathered, including feedback from frontline staff to make ongoing improvements to the enrollment process.

Resources

Monitor and report your organization's enrollment activities, outcomes, and challenges. Consider ways to obtain regular feedback from enrollment assisters and case managers related to organizational enrollment challenges.

Monitor and report your clients' challenges enrolling and using new coverage. As your clients begin using their new coverage, many of them may encounter difficulties accessing care because of a lack of affordable services and medications in their plan. The RWHAP should track client access problems to advocate for improvements in health plans and coverage and to refine ways that RWHAP services can reduce coverage gaps. Problems may include:

  1. Accessing needed medications
  2. Service denial
  3. Affordability problems due to high out of pocket expenses
  4. Losing coverage due to non-payment of premiums
  5. Covered services that are geographically distant or otherwise hard to access
  6. Receiving below standard-of-care HIV services
  7. Suspected discriminatory practices

Review these data at regular intervals and report problems in using coverage and accessing services to the state ADAP, state Medicaid office, the state Marketplace, and consumer advocacy groups. For example, Part A and B recipients could incorporate this information into how they provide training and support, establish policy, and collaborate with and provide information to other entities.

Resources

  • SpeakUP! Project
    A project to help people living with HIV get the care they need through health care reform. This national project will monitor, catalog, and analyze the problems experienced by people with HIV in the new health care system. Source: HIV Health Reform.
  • Department of Insurance Templates
    These State Departments of Insurance (DOI) Templates, created by the Center for Health Law and Policy Innovation, are intended to support the development of grievance letters from advocates/providers to state's DOI regulators. Source: Center for Health Law and Policy Innovation.
  • In the Loop
    An online community where people who are engaged in helping individuals enroll in health insurance can interact with others doing similar work. Source: Community Catalyst.
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