A study of California hospitals reveals successful practices for reducing the uninsured that could benefit many hospitals and their communities nationwide.

At a Glance

Hospitals should consider adopting eight strategies for helping individuals obtain health coverage:

  • Design enrollment procedures and practices that are transparent, consistent, and supported by effective tools.
  • Determine optimal levels of staffing and support for eligibility and enrollment functions.
  • Educate patients on health coverage options.
  • Position trained staff at critical access points.
  • Use innovative strategies to reach vulnerable populations.
  • Partner with key external stakeholders.
  • Partner with service vendors.
  • Assess the new environment.

With the enrollment period for the health insurance marketplaces (also known as exchanges) set to begin Oct. 1, rapid changes are taking place nationwide to expand health coverage and access to care for uninsured or underinsured individuals. 

Hospitals in all states could play a critical role in helping individuals enroll—and stay enrolled—in health coverage. Trusted in their communities and accustomed to providing patients with culturally and linguistically competent assistance, they are often the first place the uninsured come into contact with the healthcare system. 

California has been at the forefront nationally in implementing reforms set forth in the Affordable Care Act (ACA). The state has the largest number of uninsured residents of any U.S. state—7.1 million, comprising more than 21 percent of its population under age 65, according to the California HealthCare Foundation.

To support California hospitals’ efforts to help residents obtain health coverage, the California Hospital Association recently published a guidebook titled Helping Individuals Obtain Health Coverage Under the Affordable Care Act: Outreach and Enrollment Strategies for California Hospitals. The guidebook details eight successful hospital-based outreach and enrollment approaches currently used in hospitals for enrolling uninsured individuals into health coverage. The approaches emerged from interviews with specialists in patient registration, admissions services, patient access, financial counseling, and eligibility services. (See the sidebar below.)

The following strategies have been successfully used in California hospitals, but many of the approaches have relevance for any hospital helping individuals enroll into health coverage under the Affordable Care Act.

Design Effective Enrollment Procedures and Practices

A foundation for the successful enrollment of eligible individuals in health coverage is designing a process that is transparent, consistent, and supported by effective tools.

Hospitals must have thorough written procedures that address the various steps and processes used to enroll uninsured patients in appropriate programs. These written procedures serve as a guide for staff activities and create a framework for accountability that is transparent to all. Such procedures often prove most effective when jointly developed and maintained by patient registration, patient financial services, and other appropriate departments that interface with patients.

The most effective procedures reflect the hospital’s mission and describe in detail the operational aspects of using the process, including specifications about staffing roles and responsibilities required to implement and operate the process. They are updated regularly to improve practices and safeguard compliance with current law and regulation.

Having in place consistent processes and practices ensures that every patient who accesses the organization’s facilities is appropriately screened, interviewed, educated, and provided with coverage enrollment information at the appropriate time. Achieving and maintaining this consistency requires clearly defined responsibilities for all individuals—both employed and contracted—who complete the hospital’s eligibility screening and enrollment processes.

The hospitals contacted for this study by the California Hospital Association have worked to ensure that their enrollment processes are sensitive to each patient’s condition. They focus on whether a patient is ready—both physically and emotionally—to have the conversation required for eligibility screening. For example, in the emergency department (ED), the enrollment screening process takes place only after the patient receives a medical screening exam and is determined to be stable and conversation-ready. At this point, enrollment screening is designed to occur quickly and without disruption to the environment or patient care needs.

These hospitals also invest in effective electronic systems and software tools to capture information about potentially coverage-eligible individuals and sources of health coverage and to streamline the enrollment process. Numerous organizations have fully integrated their eligibility processes into their information systems. Among other benefits, this expands the organizations’ ability to communicate with potentially eligible patients to determine whether they may need assistance with completing the application and with discharged patients who are eligible for health coverage, but not yet enrolled.

The hospital specialists who were interviewed indicated that their systems and software support seamless sharing of eligibility and enrollment information both internally with the hospital’s staff, and externally with vendors, in accordance with existing business associate agreements and federal and state patient confidentiality laws. Their information systems also support eligibility and enrollment tracking over time, which provides hospitals with increased opportunities to help patients access health coverage.

Determine Optimal Levels of Staffing and Support and Provide Appropriate Training

To establish effective eligibility and enrollment processes, hospitals determine the optimum level of staffing and support that should be maintained at key access points. The hospitals contacted for this study thoughtfully considered the number and qualifications of staff and level of ongoing support needed for an effective registration process. 

Identifying or hiring staff with background or experience in healthcare coverage programs as well as eligibility and enrollment processes also can yield significant benefits. More than one hospital had hired financial counselors who formerly worked as county eligibility personnel.

Training, ongoing education, and assessment practices varied by hospital, but all registration staff typically are trained by others in the organization. 

Eligibility and enrollment staff at these hospitals receive education and training on specific programs available to the uninsured. Numerous hospitals cited the benefits of training staff to assist patients specifically with Medicaid applications. Having well-trained staff enables hospitals to more effectively reach patients who might qualify for Medicaid and mitigates the effects of county staffing limitations. 

To this end, hospitals should provide enrollment and financial counseling staff with ongoing training and assessment to ensure their continued effectiveness. For example, one hospital developed a patient navigator “orientation pathway” that includes key knowledge objectives, teaching strategies, and an outcome evaluation.

All of the hospitals studied were focused on staff-patient communication during eligibility and enrollment processing. Numerous organizations have scripting tools for their staff to use with patients. The scripts include such items as how to explain to patients what their health coverage options are and how to respond to specific questions.

In Partnership, Educate Patients on Health Coverage Options

To enhance patient access to health coverage, hospital eligibility and enrollment staff work to develop a partnership-like relationship with the patient. The goal is to create trust and engage the patient in a conversation about their health coverage options. 

Many of the interviewed organizations say organization-wide values influence how they approach each patient. For example, one element of staff training is to try to make patients more comfortable discussing what can be sensitive information, such as income or employment status. 

Each of the hospitals studied incorporates an advocacy or financial caregiver approach during each patient eligibility/enrollment encounter. Such an approach creates a dignified experience, which engages the patient in a discussion of health coverage in a nonthreatening way. The focus is on education—on providing prompt and reliable information at the point of care. 

Although patients are provided with written educational materials in appropriate languages, as feasible, many patients prefer to learn about programs through conversations instead. If language is a barrier, staff may refer the patient to someone else in the hospital who speaks the same language as the patient or may use a translation service to support such dialogue. 

Effectively reaching noncompliant patients is a particular challenge. Hospitals sometimes counsel patients multiple times about health coverage options available to them and how to apply, but for whatever reason, the patients choose not to do so or fail to supply the needed documents or information. Staff continue to treat patients with respect and dignity while ensuring that the message is expressed and there are no gaps in communication.

It is especially important to consider the unique educational needs of patients who are newly eligible for health coverage. “Having extra hands on deck to educate this different audience of patients will be important,” says one specialist who was interviewed. “We will need to spend more time discussing options and health coverage terminology that these individuals may not find familiar.” 

Position Trained Staff at Critical Access Points

Hospital access points for the uninsured are numerous, including inpatient admitting areas, EDs, obstetrics departments, pharmacies, laboratories, and outpatient facilities. All of the hospitals contacted for this study are purposeful about positioning highly trained enrollment staff who are equipped with the necessary tools in these access points so that they may build strong relationships with patients.

For example, trained financial counselors are positioned in the ED of one hospital. Equipped with laptops on wheeled carts, these counselors can more easily gather eligibility information once a patient is stabilized and conduct interviews with patients at the bedside, in various rooms, and in the lobby. In some hospitals, coverage verification and/or other key functions are centralized in departments or call centers with staff who support financial counselors.

Many of the interviewed hospital staff members stressed the importance of educating clinicians practicing in their facilities about the organization’s enrollment assistance capabilities and financial assistance programs. This “internal outreach” helps to ensure that clinicians know about the organization’s assistance processes and are familiar with how and when to refer patients to financial counselors and other enrollment staff.

Use Innovative Strategies to Reach Vulnerable Populations

Helping the uninsured enroll in health coverage is particularly challenging when individuals are homeless, have a mental illness and/or substance-use disorder, or are undocumented. The California hospitals that were studied have developed innovative strategies to enroll these vulnerable populations. 

Individuals who are homeless may be eligible for Medicaid or may qualify for charity or discounted care. Many of the study hospitals have developed innovative outreach programs with city-operated homeless programs. For example, one organization leases seven beds at the local homeless shelter for patients whom physicians don’t feel comfortable treating and releasing back to the streets. This strategy gives the individuals up to a three-day stay to help improve their health status. 

Many of the hospitals use eligibility and enrollment services vendors to assist with enrolling this hard-to-reach population. Vendor employees are able to visit shelters and other local gathering spots to locate specific individuals and obtain the information necessary to enroll them in health coverage.

Individuals with behavioral health issues often require similar strategies, because their use of hospital EDs is high, and success in obtaining the information necessary to enroll them in health coverage is often low. Hospitals might consider using financial counselors who are specifically trained to assist patients with behavioral health needs, including those who have issues with alcohol and other substance abuse.

Convincing individuals who are undocumented to seek enrollment in any health coverage program is challenging for a multitude of reasons, not least of which is their fear of deportation. It is important for hospitals to train eligibility and enrollment staff to recognize and address the high level of anxiety they may encounter from patients who are undocumented. Approaching these patients in a nonthreatening, nonauthoritarian manner and having multilingual staff and/or translation services on hand to ensure effective communication are critical to help build patient trust.

Partner with Key External Stakeholders

Getting Californians enrolled in health coverage requires a multifaceted approach by hospitals, focused both on internal enrollment efforts and on bridge-building with external stakeholders. 

The California hospitals that were studied commonly conduct extensive outreach and partnering initiatives with entities in surrounding communities. These entities include other healthcare organizations, physicians and other providers, state and county agencies, and other sites in the community, such as schools and places of worship.

For example, one organization sends bilingual community outreach workers who are familiar with the needs of target communities to county fairs, farmers markets, school registration nights, sporting events, churches, city halls, and county parole department programs. The outreach workers are equipped with bilingual materials that explain the different health coverage programs and options.

These hospitals also work toward building relationships with the staff of county social services agencies to support health program enrollment. One organization notes that onsite county eligibility personnel work side-by-side with hospital eligibility staff. Hospital staff members monitor every patient whose paperwork has been turned in to the state and meet periodically with county eligibility personnel to determine coverage progress and status.

Partner with Service Vendors

Use of eligibility and enrollment service companies is widespread among the hospitals studied, whose staff consider such vendors important to timely patient enrollment in federal and other health coverage programs. 

The California hospitals represented in the guidebook commonly assess organizational capabilities and compare them with vendor capabilities. The hospitals can then determine when and how to use vendors strategically to complement internal eligibility and enrollment processes. Some organizations refer only complex enrollment cases to vendors, where patients are hard to reach or noncompliant. Other hospitals refer enrollment cases for outside assistance when vendors’ local knowledge of county-specific programs would enhance the hospital’s efforts.

In selecting vendors, hospitals indicate that two criteria are most important for effective collaboration. The first is aligned goals between the hospital and vendor in helping the greatest-possible number of patients enroll in health coverage; vendors should not be too selective and accept only the least complex cases. The second is the availability of vendor employees who have significant experience working in the hospital’s local market (given that vendors with an “established presence” have knowledge of local programs, the individuals staffing those programs, and locations of shelters and other facilities).

The transfer of patient enrollment cases from hospital staff to the vendor’s staff optimally provides a “warm handoff,” wherein vendor staff receive as much information as possible, such as the program(s) for which the person may be eligible. 

Assess the New Environment

The number of individuals who will be seeking care at hospitals as uninsured, but eligible for new health coverage will be market-specific. The assessment of an organization’s patient populations and demographics is key to understanding the impact of a larger eligible population on hospital enrollment processes and staffing. 

California hospitals with staff interviewed for this study are considering how to appropriately staff to provide screening and eligibility determin-ation for the newly eligible population. Planning is critical. Numerous organizations indicate that they are not adding staff now, but can train and increase resources quickly during the enrollment period and early years of the expansion, if needed.

Some organizations are looking at increasing financial counseling staff and third-party companies because, as one hospital staff member notes, “At the end of the day, whichever programs are accessed, it takes lots of arms and legs on the ground to complete applications.” 

Enhancing Access to Ensure Future Coverage

California’s hospitals are committed to the goal of enhanced access to health coverage for all Californians. The hospital specialists interviewed by the California Hospital Association believe that these eight strategies for eligibility screening and enrollment will support hospitals’ efforts as healthcare reform advances. 

Hospitals will continue to be one door through which the uninsured pass. Early enrollment of the newly eligible population is particularly vital to ensure that individuals will have health coverage for their next episode of care. Although the approaches highlighted here should not be construed as legal advice, they are likely applicable in many hospitals in most, if not all, states. 

Anne McLeod is senior vice president for health policy, California Hospital Association, Sacramento, Calif., and a member of HFMA’s Northern California Chapter.

Amber Kemp is vice president for healthcare coverage, California Hospital Association, Sacramento, Calif..

Jody Hill-Mischel is a managing director, Kaufman, Hall & Associates, Inc., Los Angeles, and a member of HFMA’s Southern California Chapter.

Andrew Cohen is a vice president, Kaufman, Hall & Associates, Inc., New York, and a member of HFMA’s Metropolitan New York Chapter.


About the Outreach and Enrollment Strategies Guidebook 

Research for the guidebook published by the California Hospital Association, Helping Individuals Obtain Health Coverage Under the Affordable Care Act: Outreach and Enrollment Strategies for California Hospitals, was conducted through interviews throughout California with key hospital management and supervisory staff responsible for patient registration, admissions services, patient access, financial counseling, and eligibility services. 

These individuals identified what they considered to be proven strategies for determining eligibility and enrolling individuals into health coverage. 

The guidebook also includes a sample patient access walk-in script as a way of showing staff how to positively interact with patients seeking coverage information. According to the guidebook, staff must learn what questions to ask to better understand a patient’s circumstances and how to respond to potential questions. Sample questions surround whether patients have a medical record number, what county they live in, and whether they have existing health coverage.

As experience is gained with implementation of the Affordable Care Act, new strategies will likely emerge. 

The American Hospital Association provided funding for the guidebook and related webinars.

Publication Date: Tuesday, October 01, 2013

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