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 eight strategies highlighted here should not be construed as legal advice, they are likely applicable in many hospitals in most, if not all, states. 

Strategy No. 1: Design effective enrollment procedures and practices.

  • Transparent procedures: Ensure that written policies reflect the mission, provide staff with proper guidance and are regularly updated to improve practices and comply with current law and regulation.
  • Consistent processes and practices: Define role and responsibilities. Ensure enrollment processes are sensitive to each individual patient’s condition.
  • Effective tools: Integrate the eligibility process with the organization’s information systems, as feasible, and with exchange portals in the future. Ensure easy transfer of information internally and with vendors, and eligibility/enrollment tracking over time.

Strategy No. 2: Optimize staffing and support for maximum effectiveness.

  • Staffing: Ensure that your facility has access to multilingual staff or services. Consider staff roles, backgrounds, and staffing hours.
  • Training, ongoing education, and assessment: Provide staff education related to eligibility and enrollment policies and practices, including programs available to uninsured and underinsured. Assess staff effectiveness on ongoing basis.
  • Focus staff-patient communication: Educate staff in patient communication, with a focus on asking the right questions. Use scripting practices and tool.

Strategy No. 3: In partnership, educate patients on health coverage options

  • Values-based approach: Establish organization-wide values and care philosophies that will underscore how all patients are approached. Communicate with care: Develop clear patient communication guidelines for staff members, with a focus on establishing trust. Provide an appropriate setting for patient eligibility and enrollment screenings, including sufficient privacy.
  • Patient advocate approach: Provide patients written education materials in relevant languages. Hire multilingual staff and/or use translation services. Educate patients in a respectful manner and highlight the benefits and importance of having health coverage.
  • Uninsured vs. uninformed: Consider using exchange portals and other eligibility tools to educate uninformed patients about potential health coverage options.

Strategy No. 4: Position trained staff at critical access points.

  • Access points: Strategically position highly-trained staff at critical access points.
  • Staff responsibilities: Train and/or hire staff members with specialized knowledge in specific health coverage programs. Gather eligibility information in a timely manner, especially in the emergency department.
  • Centralized support centers: Consider centralizing coverage verification and/or other key functions with staff who support financial counselors (e.g., centralized call centers).
  • Clinician education: Conduct “internal outreach,” educating clinicians about enrollment-assistance capabilities and financial assistance programs.

Strategy No. 5: Use innovative strategies to reach vulnerable populations.

  • Individuals who are homeless: Conduct outreach to local homeless shelters and programs for these individuals; Use eligibility vendors for “boots on the ground” strategies (e.g., provide transportation; assist with enrollment in other government programs).
  • Individuals with mental illness and substance-use disorders: Educate staff on behavioral health and substance use disorder needs (e.g., recognizing when/how to obtain eligibility information from behavioral health facilities). Use eligibility vendors for face-to-face contact to obtain essential documentation.
  • Individuals who are undocumented: Train staff to recognize and address the initial barriers (i.e., develop and implement a nonthreatening, personalized approach). Hire multilingual staff and/or obtain translation services to facilitate communication and trust.

Strategy No. 6: Partner with key external stakeholders. 

  • Providers: Inform community physicians about hospital’s existing eligibility and enrollment services, and financial assistance programs.’
  • Other provider organizations: Coordinate/integrate eligibility and enrollment application process with community partners and other affiliated providers.
  • Community: Use community outreach personnel familiar with needs of target communities to provide health coverage information.
  • County and state personnel: Develop trusted relationships with county and state personnel, e.g., county public health personnel, Medicaid eligibility personnel, etc.

Strategy No. 7: Partner with service vendors.

  • Assessment of capabilities: Determine when and how to use vendors strategically to complement internal eligibility and enrollment capabilities.
  • Effective collaboration: Partner with vendors who have employees with significant experience working in the hospital’s local market and who share a common goal in helping the greatest possible number of patients; Strategically place vendors at critical access points in the hospital

Strategy No. 8: Assess the new environment.

  • Assessing the impact of the newly eligible population: Understand the potential impact of the newly eligible population in the local market. Conduct outreach and education regarding the state’s implementation of the Affordable Care Act. Consider/develop strategies to partner with brokers and insurers for enrollment in qualified health plans. Allocate physical space, technology, and other resources to assist enrollment staff in conducting eligibility and enrollment screenings. Develop staffing and training contingency plans for potential patient volume increase during enrollment and expansion periods.

Source: California Hospital Association, Sacramento, CA. Used with permission.


For more information, see Anne McLeod, Amber Kemp, Jody Hill-Mischel and Andrew Cohen's "Helping Individuals Obtain Health Coverage Under the ACA", hfm, October, 2013

Publication Date: Tuesday, October 01, 2013

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