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Engaging Hard-to-Enroll Clients and Tracking Your Efforts

November 2016

ACE TA Center

There are many reasons that your client may not yet be enrolled in health coverage. Clients may struggle with the process of enrolling because of life circumstances, such as complex physical and/or mental health conditions. Others may have fears or concerns about getting health insurance for the first time, while some clients may be ineligible.

This resource includes best practices and resources for engaging hard-to-enroll clients and tracking your efforts, using four steps.

Step 1. Determine if your client may be eligible for health coverage.

Explore health coverage options such as Marketplace plans, Medicaid, CHIP, Medicare, employer-sponsored health insurance coverage, or other private health insurance. Jump to Step 1 resources and strategies

Step 2. Engage hard-to-enroll eligible clients in conversations about coverage.

Consider aligning your engagement and enrollment activities with RWHAP eligibility determination and recertification activities. Jump to Step 2 resources and strategies

Step 3. Develop policies and procedures to document your efforts to enroll clients in coverage.

These policies and procedures can also help you to demonstrate “vigorous pursuit” of clients into health coverage. Document the steps you take toward enrolling eligible clients. Jump to Step 3 resources and strategies

Step 4. Document and monitor your efforts to enroll clients in coverage.

Implement your policies and procedures from Step 3, which may include collecting data on specific measures and/or having clients complete an attestation form. Jump to Step 4 resources and strategies


Step 1. Determine if your client may be eligible for health coverage.

Use the ACE TA Center Eligibility Decision Tree to determine your client’s eligibility.

  1. If the client is eligible for coverage, proceed to Step 2.
  2. If the client is not eligible, have them complete an attestation form to confirm that they will not be enrolling in health coverage. This example Health Insurance Enrollment Acknowledgement form includes documentation that the client will not be applying for health insurance. Source: New Orleans Health Department, Office of Policy and AIDS Funding.

Even if the client is ineligible now (e.g., clients that fall in the Medicaid gap), their eligibility may change. Changes in income, household size, employment, and immigration status may impact a client’s eligibility for coverage. Use these ACE TA Center resources to learn more.


Step 2. Engage hard-to-enroll eligible clients in conversations about coverage.

Clients may not immediately share their concerns about enrolling in health coverage. You may need to help the client identify their concerns and feel comfortable sharing them with you before deciding to enroll in coverage.

Common questions and concerns from clients about enrolling in health insurance:

  1. Why do I need health insurance? I already get my care through the Ryan White HIV/AIDS Program.

  2. Health insurance can be expensive. How do I pay for it?
  3. Will I still be able to see the doctor or nurse who provides my HIV care?
  4. What about my HIV medications? Will health insurance pay for them?
  5. Can I still get services and help from the Ryan White HIV/AIDS Program and ADAP?
  6. Will my family’s information be reported to immigration?
  7. I tried to enroll in health care before and was rejected. Why would this time be any different?
  8. What if I don’t enroll in health insurance?

Use these ACE TA Center resources to help you address common questions and concerns that clients may have about enrolling in health coverage.

Some clients may still not be ready to enroll, even after many conversations. See Step 3 below to document all engagement activities, whether they immediately result in enrollment or not. Continue trying to engage these clients, but let them know that the RWHAP is still available to provide HIV-related medical and support services to ensure they stay retained in HIV care. 


Step 3. Develop policies and procedures to document your efforts to enroll clients in coverage.

RWHAP recipients must demonstrate “vigorous pursuit” of enrolling clients in coverage. Your local Part A or Part B program may have additional or different guidance on how to document the process. This information can also be valuable for internal quality improvement.

Determine what enrollment data you will collect, including process and outcome measures.


Step 4. Document and monitor your efforts to enroll clients in coverage.

Document and monitor the process and outcome measures you identified in Step 3. Be sure to track all clients who are enrolled as well as those who decline to enroll or are ineligible. All clients who decline coverage or are ineligible should complete an attestation form explaining their rationale for declining health coverage.

If your organization does not already have an attestation form, consider adapting one of these examples:

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