Outreach and Enrollment: The Path to New Opportunities in Coverage

2013 Annual Conference & Clinical Summit, “Aiming for Excellence” - “Inreach, Outreach & Enrollment”

Presenters: Sophie Stern and Dayanne Leal

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SECTION 1

• Who we are• What we do• What is the enrollment opportunity

Enroll America

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Our MissionMaximize the number of uninsured Americans who enroll in health coverage made available by the Affordable Care Act

Two-fold Strategy

Promoting Enrollment Best Practices

National Enrollment Campaign Using Cutting Edge Engagement Strategies

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Sampling of Our Partners

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How the Campaign Fits In

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1. Educate and Engage 2. Mobilize to Enroll 3. Work with Partners to Ensure System works

Enroll America will execute a national education and enrollment campaign

Successful implementation of ACA requires all-out effort by government, not-for-profits, insurers, hospitals, community health centers, health providers, and others

Campaign Strategies and Tactics

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Strategic Partners

Community Engagement

Data & Results Driven

Earned Media

Digital & Social Media

Paid Media

Surrogates

The 2014 Enrollment Opportunity

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Series10

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Source: May 2013 CBO estimates

Mill

ions

Enroll at least 16 million people in new coverage options

} 7 million in Exchange (“Marketplace”) coverage

9 million in Medicaid or CHIP}Source: May 2013 CBO estimates

Pennsylvania's Enrollment Opportunity

• <138% FPL in Medicaid or CHIP

• 138%-400% FPL in Exchange (“Marketplace”) coverage

Source: Centers for Medicare and Medicaid Services (CMS) analysis of the 2011 American Community Survey (ACS)

Non-elderly unins...0.0

500,000.0

1,000,000.0 400% FPL and up

Between 138-400% FPL

<138% FPL

1.24 million PA residents

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SECTION 2

• Public Awareness of New Coverage• Research and Messaging• Eligibility, Benefits and Timeline

Public Awareness of the New Coverage?

What percentage of uninsured people do you think know about

the new coverage options coming this fall?

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Increasing Awareness…

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…but many of the uninsured still don’t know

Source: Enroll America *Source: Kaiser Family Foundation

November 2012 June 2013* August 2013*0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22%45% 57%

Perc

ent o

f uni

nsur

eD A

war

e

Past Experiences Seeking Coverage

have shopped for insurance outside their job

44%have been uninsured for 2 years or more

67%

Source: Enroll America, November 2012

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Key Findings Across Segments

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Almost all (91%) believe health insurance is necessary or very important.

Cost and affordability are the biggest barriers.

Financial & health security are the biggest motivators.

Deep skepticism & confusion among consumers.

Sample Premiums Seem Unaffordable…

14Source: Enroll America, November 2012

16%

12%

…but focusing on yearly savings can help.

51%Percentage who found the same premium affordable when expressed in terms of annual savings compared to current premiums.

Reaction to a sample premium for a family of four, 250% FPL

All insurance plans will have to cover doctor visits,

hospitalizations, mental health and substance use

disorder services and prescriptions.

You might be able to get financial help to pay for a

health insurance plan.

If you have a pre-existing condition, insurance plans cannot deny you coverage.

All insurance plans will have to show the costs and what is covered in simple

language with no fine print.

4 Key Facts Reach Most Uninsured

One of these = top message

for 89% of population

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New Coverage Options in 2014

M’place w/out

Tax Credits

States that Don’t Expand Medicaid

Medicaid0-138% of poverty

Marketplace with Tax Credits139-400% of poverty

Marketplace with Tax Credits100-400% of poverty

Marketplace without Tax

Credits>400% of poverty

Medicaid*

Marketplace without Tax

Credits>400% of poverty

138% of poverty

400% of poverty

100% of poverty

400% of poverty

Medicaid cutoff

*Medicaid eligibility levels vary by state and population. Marketplace coverage without tax credits is available for individuals ineligible for Medicaid with income <100% of poverty.

States that Expand Medicaid

Requirements for ALL States

A Single, Streamlined Application

• One application for all health coverage programs• Available in online, phone, and paper

Use Modified Adjusted Gross Income/No Income Disregards

Eliminate Asset Tests

Eliminate In-Person Interview Requirements

Use Electronic Verification to the Greatest Extent Possible

Regardless of exchange type

or Medicaid expansion!

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Marketplace Eligibility

1. Eligible for the Marketplace?

2. Eligible for Tax Credits?

3. Eligible for Cost Sharing Subsidies?

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Eligibility for the Marketplace

US Citizen or legal immigrant

• Undocumented immigrants are not eligible to buy a plan through the marketplace

Not incarcerated

• Incarcerated individuals are not eligible to buy a plan through the marketplace

Eligibility for Tax Credits

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Eligible for the Marketplace

• Consumers with affordable, adequate offers of job-based coverage cannot get tax credits

No affordable, adequate offer of job-based coverage

• Medicaid expansion state: tax credits between 138-400% FPL• Non-Medicaid expansion state: tax credits between 100-400% FPL• 400% of poverty = $44,680 for a single adult, $92,200 for a family of four

Not eligible for Medicaid, CHIP, Medicare, etc.

Income <400% of poverty

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Eligible for Cost Sharing Subsidies?

Eligible for Marketplace

• About $28,000/year for a single adult• About $58,000/year for a family of four

Income <250% of poverty

Must purchase “silver” level plan from marketplace

Essential Health Benefits

1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services, including

behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic disease

management10. Pediatric services, including oral and vision care

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What is the timeline for getting health coverage?

• Open enrollment starts October 1, 2013, coverage starts January 1, 2014

• Regardless of your income… there will be a plan for you!

• Financial assistance available depending on income

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Marketplace Open Oct 1 to Mar 31

Sign up and select coverage

Coverage starts Jan 1*

*Must enroll by December 15th for coverage to start January 1st.

SECTION 3

• Enrollment process • Public Perception• Who will provide help

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Enrollment isn’t a snap

Program Percent of Eligible People Enrolled

Children’s Medicaid/CHIP, national average, 2009 84.8%

Medicare low-income subsidy, 2009* 40%

Unemployment benefits 72-83%

Earned income tax credit 80-86%

SNAP (food stamps) 54-71%

* Does not include populations automatically enrolled in the low-income subsidy.

Take-up in optional public benefit programs

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Single, Streamlined Application

Consumers can connect to whichever program they are eligible for, no matter where they start.

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Complete single application Determine eligibility

Enrolled in correct program!

Medicaid

CHIPIn-Person Assistance

Exchange

Single Application

Public Perceptions

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Three out of four of the newly eligible want in-person assistance to learn about and enroll in coverage.

Confused

Overwhelmed

Worried

Helpless

Secure

Confident

Reassured

Help gets them from here… …to here.

Source: Enroll America, November 2012

Value of In Person Assistance

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• What is and isn’t covered• Out of pocket costsKnowledge

• In-person beats online/self-service experienceSecurity

• Have provided all necessary paperwork• Have completed application correctlyConfidence• Know when their insurance will start• Know what to do if they need health services

before they get their cardReassurance

Source: Enroll America, Forthcoming

Who Will Provide Help?

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Certified Application Counselors

Navigators

*In-Person Assistance Programs not available in federally facilitated exchange states.

Consumer Assistance Programs

Medicaid eligibility workers

Insurance Agents, Brokers

Community Based

Groups

Community Health Centers

Where do you fit in this mix?

Help, I Need Somebody!

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What Kind?

From Whom?

How?

Where?

35%

36%

37%

45%

Health insurance…

Doctor or nurse

Family member

State employee…

Source: Enroll America, November 2012

Navigator Duties: Make Things EASIER

E Expertise (Medicaid, CHIP, QHPs)

A Accessibility (cultural, linguistic, people w/disabilities)

S Selecting a plan (facilitating)

I Impartiality

E Education

R Referrals

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Certified Application Counselors

• Integral part of ensuring adequate assistance, especially in states with fewer federal resourceso Important role for CBOs, providers, hospital staff, health centers, etc.

• Training provided by the exchange • Funding

o No federal funding for CACs, but Medicaid administrative match available for Medicaid CACs (23 states fund now, but Nevada does not)

o Flexibility for private funding

• Must disclose conflicts, but fewer prohibitions than navigators, IPAso Agree to “act in best interest of the applicant”

• Must make info accessible to people with disabilities• No obligation to do outreach

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New CAC Option for Organizations

• Organizations may certify staff/volunteers to become CACs

• Eligible organizations must:o (1) have processes in place to screen

staff/vols to ensure that they protect personally identifiable information

o (2) engage in services that position them to help those they serve with health coverage issues, and

o (3) have experience providing social services to the community.

• Orgs must enter into agreement with exchange and are responsible for their CACs following federal rules

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Differences Between Assister Types

Navigators/In-Person Assisters CACs

Conduct outreach X

Culturally/linguistically accessible services XServices for people with disabilities X XSubject to state training/certification rules (where they exist) X X

Funded through government dollars XMust be free from conflicts of interest XPermitted to have conflicts of interest, as long as disclose these to the exchange and to the consumer, and agree to act in best interest of applicant

X

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SECTION 4

• Who is the uninsured• What role do you play• Inreach, Outreach and Enrollment Best

Practices

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Five Clusters of Targets

Uninsured, Unnecessary & Uninterested

Reluctant but Reachable

Desperate and Believing

Connected, Low-income Women

Insured but At-Risk

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Uninsured, Unnecessary & Uninterested

• 71% uninsured, most >2 years• Only 22% consider health insurance necessary• Skeptical that they could find affordable coverage

in 2014• Good news: this group is moveable

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Best messengers• Family• Friends• Doctor

Top motivators • Financial security• Finding a plan to fit budget• Individual mandate$$$

Reluctant but Reachable

• 64% uninsured, most have tried to find coverage

• Young, low-income, least educated, many have young children in Medicaid/CHIP

• Majority (71%) consider health coverage necessary

• “Soft” believers, can be moved when told more about new options

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Best messengers• Doctor• Someone like

them who has tried it

• Someone from health agency

Top motivators • Reliable coverage• Financial security• Finding a plan to fit budget

Desperate & Believing

• Poorest, sickest, least educated• 1/3 receive SNAP benefits• Strongest interest, least skepticism in new

coverage options• Not aware of new options, but instantly

interested when told

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Best messengers• Medicaid office• Federal/state

government official

• Doctor

Top motivators• Financial security• Finding a plan that fits their

budget• Mandate

Connected, Low-Income Women

• Well-connected to Medicaid (themselves or their children)

• Nearly half (48%) receive SNAP benefits

• Many in fair/poor health, have chronic health conditions

• Interested in new coverage options, but skeptical about costs

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Best messengers• Someone like

them who has tried it

• Medicaid office• Federal/state

government agency

Top motivators • Plan will be there for them when they

need it• Financial security• Find a plan that fits their budget

Insured, but At Risk

• Young, low-income (<250% FPL)• 63% covered now, but risk losing coverage: aging off parent’s

plan, losing Medicaid, low-wage worker getting coverage through job

• Weak interest in new options, very skeptical

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Best messengers• Family member

(mom, spouse)• Doctor• Someone like them

who has tried it

Top motivators • Financial security• Plan will be there

for them when they need it

• Find a plan that fits their budget

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Relationships with the uninsured

Insured patients = better long term health outcomes

Medicaid Primary Care Rates IncreasePart

of C

ore

Mis

sion

People trust

providers

Enroll the Whole Family

Why Health Centers, Rural Health Clinics and other like-mission providers?

Outreach and Enrollment Opportunities

• What role will your organization play?

• What is your organization currently doing?

• What tools exist?• What tools does your

organization need?

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An Action Plan for Health Centers

1. Develop a plan

2. Invest in staff

3. Make your data work for you

4. Utilize technology

5. Hold on to what you’ve got

6. Recognize everyone’s role in outreach

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Outreach Planning…

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Outreach Best Practices

I. Identify your strengths

II. Identify and understand your target

III. Build an outreach plan

IV. Identify essential skills

for staff

V. Utilize consumer

tested messages

VI. Follow up, monitor, evaluate

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I. Identify Your Strengths

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Who does your organization currently reach?

• Recognize your stakeholders such as staff, patients, community members and partners

What programs and resources currently exist?

• Build strong relationships and trust with community leaders. They can refer patients to you

I. Identify Your Strengths (cont.)

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How can services be coordinated and integrated?

• Map patient entry points• Institutionalize process at each point to educate and potentially assist

eligible patients• Focus on consistency across the organization

What is the outreach program’s goal?

• Reach specific ethnicity?• Geographic region? • Age?• Demographic?

II. Who is Your Target Audience?

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53%47%

Race/Ethnicity Percent of Uninsured

Uninsured Rate

White (non-Hispanic) 45% 13%

Black (non-Hispanic) 15% 21%

Hispanic 32% 32%

Asian/Pacific Islander 5% 18%

American Indian/Alaska Native 1% 27%

Two or More Races 2% 15%

62%Live in Families

with at least One Full Time Worker Under

100%100-138%

139-250%

251-399%

400%+

38%

13%

25%

13%10%

Federal Poverty Level

Source: Kaiser Commission on Medicaid and the Uninsured, October 2012

Tips for Targeting

External

Utilize peer to peer outreach

Promote word of mouth

Develop referral networks with partners

Use data to identify uninsured

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III. How to Create an Outreach Plan

Choose your target

Set a goal (metrics)

Identify who your support will be (who’s

your champion?)

Create your message to target

your audience

Create timeline of events + activities

+ outcomes

Evaluate your work

Follow up, follow up, follow up

IV. Essential Skills for Staff

Flexibility Sense of humor

Understanding of target

population

Readiness to try new tactics

Outgoing personality

Willing to work nights and weekends

Understands importance of

follow-up

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V. Consumer-tested materials

• Know your audience• Use plain language• Find the right translator• Monitor the translation• Get an independent review• Use a clear and consistent

design• Always conduct consumer

testing

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VI. Follow up, monitor, evaluate

Plan

Do

Check

Act

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Incorporating Best Practices in Your Work

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Before the appointment

During the appointment

Post appointment

Incorporating Best Practices in Your Work

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Before the appointment

During the appointment

Post appointment

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Before the appointment

• Develop a referral network with organizations who provide application assistance • Help consumer make an appointment • Give them a reminder (text or call) the day before• Make sure they have transportation to the appointment

During the appointment

Post appointment

Incorporating Best Practices in Your Work

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Before the appointment

During the appointment

• Build trust• Answer questions• Go slowly• Provide the consumer with a next steps document for after the appointment

Post appointment

Incorporating Best Practices in Your Work

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Before the appointment

During the appointment

Post appointment

• Follow up to make sure they’ve paid their premium • Help them set up a primary care physician• Follow up occasionally to:

• Confirm/update contact information• Seeing if they’ve seen their primary care provider• Reminding them about the upcoming open enrollment period

Incorporating Best Practices in Your Work

In-reach and Outreach ideas and tools

In-Reach

Text (and/or voice) messaging

Newsletter

Website

Social media

Direct mail

Appointment cards

On-site promotion

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Ways Providers Can Help

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Train staff on four key messages

• Clinicians and outreach, administrative staff

Consider getting staff trained as Certified Application Counselors

• Partner with a local organization and develop referral relationships• Offer space in your office for assisters to meet with patients

Identify Navigators and other assisters who can help

• Include information about healthcare.gov and the hotline on your voicemail, on-hold message, and website• Hang posters in waiting room

Spread the word!

Thank You!

Visit Us For More Information On:• Best practices in outreach & enrollment• Messaging research• Mapping tools• Outreach toolkits• News and events• …and more!

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Questions?

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Dayanne Leal National Outreach Specialist

dleal@enrollamerica.org

Sophie SternSenior Policy Analyst

sstern@enrollamerica.org