As of February 2016, a total of 31 states and the District of Columbia are moving forward with the ACA Medicaid expansion to adults. While millions of individuals have gained Medicaid coverage since initial implementation of the ACA coverage provisions in 2014, an estimated 8.8 million individuals who are eligible for coverage through Medicaid or the Children’s Health Insurance Program (CHIP) remained uninsured as of 2015.1 These include adults made newly eligible by the expansion as well as children and adults who were already eligible under pre-ACA rules but not enrolled. Reaching and enrolling these individuals into coverage will be one important component of achieving continued coverage gains moving forward. Moreover, as additional states may take up the expansion in the future, outreach and enrollment efforts will be key for achieving successful enrollment as the expansion is implemented. Keeping eligible individuals enrolled over time through successful renewals of coverage also will be important for maintaining coverage gains achieved to date.
This brief identifies a range of successful strategies to reach and enroll Medicaid- and CHIP-eligible individuals as well as options to facilitate renewals. It draws on a collection of previous work examining state enrollment experiences after implementation of the ACA (listed in Appendix A). In sum, it shows that states that have achieved enrollment success have embraced an array of strategies and approaches that include promoting the expansion through strong leadership and collaboration, implementing broad marketing and outreach campaigns, establishing a coordinated and diverse network of assisters, developing effective eligibility and enrollment systems that coordinate with the Marketplace, and planning ahead to translate coverage gains into improved access to care.
Outreach and Enrollment Strategies
Leadership and Collaboration
Promoting coverage efforts through strong leadership and collaboration with key stakeholders. States have cited strong leadership as a factor that contributes to successful coverage efforts. For example, in Kentucky, the previous governor made successful implementation of the expansion a priority, and stakeholders indicated that this leadership carried down through top state officials who were highly engaged in on-the-ground enrollment efforts and personally committed to achieving success. The former governor and other leading state officials were often present at local level enrollment events to demonstrate their leadership and support for the coverage expansion. Similarly, other leading states noted that ACA implementation built on earlier state-initiated reform efforts that streamlined Medicaid enrollment policies and established a culture of coverage in the state. In addition to strong leadership, close collaboration between stakeholders has been identified as a contributor to success. This includes collaboration across state agencies as well as with the community, advocates, and providers (including clinics and other health care providers). This collaboration is supported through early engagement of stakeholders, regular meetings, and ongoing information sharing. Leading states have also pointed to the importance of keeping state legislators updated on coverage progress and the value of having data available to show progress achieved at the district level.
Marketing and Outreach
Providing a combination of broad mass marketing campaigns and localized grassroots efforts. Mass marketing campaigns through print, television, radio and billboards help raise awareness of coverage options. States found that utilizing high profile figures such as the governor to deliver messages in these campaigns can demonstrate strong leadership for the expansion and the governor’s personal commitment and engagement in the effort. Some states also utilized other public figures such as sports stars in mass marketing efforts. In combination with these mass media efforts, local level outreach and enrollment efforts play a pivotal role in educating consumers and encouraging them to enroll in coverage. Stakeholders point to the importance of conducting an array of outreach and enrollment initiatives through numerous local avenues including churches, college campuses, beauty and barber shops, local grocery or community stores, libraries, and extension centers. Recognizing that many in the newly eligible population may be in working families, small businesses and job placement sites have also been identified as effective outreach sites. Outreach avenues historically used to reach families, such as schools and sports leagues, also remain important for reaching eligible children and parents. Offering outreach and enrollment assistance at large community events, such as fairs and sporting events, provides opportunities to efficiently reach large numbers of people. States and assisters also found it effective to create their own local enrollment events. Other approaches that have been particularly successful include establishing walk-in enrollment storefronts or temporary enrollment sites and providing mobile enrollment vans that can travel across the state and into rural areas.
Maintaining outreach efforts outside of open enrollment. Outside of open enrollment periods, when media coverage and public awareness falls off, targeting outreach to correspond with life events (such as graduation, job loss, marriage, divorce, birth) associated with health coverage loss and/or a change in eligibility is key. Developing partnerships with entities that serve people in these situations provides an avenue to reach individuals during these transition periods. Moreover, providing continued outreach to communicate that Medicaid enrollment remains open year-round is particularly important outside of open enrollment periods.
Targeting outreach and enrollment efforts to harder to reach communities (e.g., Hispanics, African Americans, immigrants, the LGBT community, young adults, and veterans). Partnering with churches and other community organizations that serve particular populations, including food banks, homeless shelters, and immigrant support organizations, is helpful for connecting with hard-to-reach communities. These organizations are trusted by community members and, particularly for immigrants, speak their languages. In addition, developing customized outreach materials and resources can help in connecting with targeted populations. For example, in an area of Connecticut with a large Portuguese-speaking population, fact sheets were created in Portuguese. Similarly, assisters in Colorado serving the African American community developed informational materials that focus on the importance of obtaining health coverage to address some of the specific health problems faced by African Americans. Moreover, advertising on Spanish-language radio and in Spanish-language newspapers were found to be cost-effective strategies for reaching the Hispanic community in several states.
Messaging that directs individuals to assistance resources, includes personal testimonials, and emphasizes availability of financial help and benefits of coverage. One key role of messaging is to raise awareness of available coverage options. States also found that providing personal testimonials from individuals who have benefited from gaining coverage; emphasizing the affordability of coverage, for example by indicating that it may be free or low-cost; and identifying the benefits of having coverage are effective messages to encourage enrollment. In addition, states have pointed to the importance of messaging that emphasizes that Medicaid enrollment remains open year-round and directs individuals to local enrollment assistance resources.
Personalized, one-on-one assistance provided through trusted individuals in the community. Successful states established extensive consumer assistance networks that drew on existing assistance resources. These networks include assisters of varied backgrounds who are able to provide assistance that is personalized to the community being served. Experience also suggests that providing additional state funding beyond that available through federal sources can help increase the capacity of assisters.
Coordination among assisters. Facilitating coordination among assisters makes scheduling, outreach, and other tasks more efficient and supports sharing of scarce resources, such as multi-lingual staff and expertise on complex cases. Using shared appointment schedulers and jointly planning outreach and enrollment events maximizes limited resources, enabling assisters to reach more people. Especially when targeting immigrant populations, coordinating enrollment events can ensure bilingual staff or interpreters are available to meet with clients. Some states used regionally-based structures to organize and coordinate assister activities. In addition, facilitating strong relationships between assisters and brokers supports referrals and information sharing that enables individuals to connect to the specific assistance they need. Some states have also tied enrollment assistance into broader assistance tools, such as the United Way 211 resource call-in line or local 311 call-in service lines.
Providing sufficient assister training and support. States can support assisters by providing dedicated resources for assisters who have questions or need assistance while helping a client. For example, providing dedicated telephone lines for assisters helps reduce long waits when they need support with complex cases, website problems, or other issues, leading to quicker resolution of those problems. States can also dedicate Medicaid agency staff to support assisters. For example, in California, the Medicaid agency, Medi-Cal, assigned staff to work with each assister organization. This not only allows assisters to get fast and reliable feedback on their questions but also fosters strong relationships between the agency and assisters. Although many assisters have experience helping consumers enroll in Medicaid, they may need additional training on the new eligibility rules, how to answer consumer questions related to their transition from Marketplace to Medicaid coverage, and how to navigate the Medicaid online portal. Moreover, although the process of transferring files between the federal Marketplace and state Medicaid agencies is improving, state agencies can work closely with assister organizations to help facilitate such transfers.
Expanding call center capacity to meet increased need. During the initial year of enrollment under the ACA, some states did not adequately expand call center capacity, which contributed to long wait times and dropped calls. To meet increased demand, states trained and hired more staff, contracted with additional vendors, extended call center hours, and created tiered levels of assistance so calls could be directed based on what type of assistance a caller was seeking.
Engaging the provider community in outreach and enrollment efforts. Providers can play an effective role in educating their patients about coverage options and encouraging enrollment. In particular, safety-net hospitals and community health centers play an important role in enrollment because they have existing relationships with their patients and their staff is experienced in communicating with their patients and enrolling people into Medicaid coverage. Beyond conducting “in-reach” to uninsured patients they already serve, they also can conduct outreach to uninsured patients in the communities they serve.
Building systems to support smooth coordination with the Marketplace. Smooth coordination with the Marketplace system is key to ensuring that cases move between the Marketplace and Medicaid. States that use a State-based Marketplace for Marketplace coverage eligibility determinations have established a single integrated Marketplace/Medicaid eligibility determination system, eliminating the need to transfer accounts between programs to make an eligibility determination. However, in states relying on the Federally-facilitated Marketplace (FFM), Healthcare.gov, electronic accounts must be transferred between the FFM and state Medicaid eligibility determination systems to provide a coordinated, seamless enrollment experience for individuals as envisioned under the ACA. Moreover, when new states take up the Medicaid expansion, communication and coordination will be necessary to transition individuals with incomes between 100-138% FPL from Marketplace coverage to Medicaid. States relying on the FFM can facilitate coordinated enrollment by authorizing the federal system to make final Medicaid eligibility determinations rather than assessments of Medicaid eligibility.
Offering consumer friendly features. Certain features of state systems have proven to be particularly effective for facilitating enrollment. These include allowing individuals to quickly pre-screen their eligibility for coverage after answering a few questions, enabling individuals to electronically upload documentation when it is required, and allowing people to search for local assistance resources. Moreover, offering mobile-based options or apps expands options for consumers who rely on mobile-based technology to connect to the system.
Harnessing data and technology to facilitate enrollment and renewal. Several options are available to states to utilize data available from other programs to facilitate enrollment and renewal, including Express Lane Eligibility and the new Supplemental Nutrition Assistance Program (SNAP) facilitated enrollment strategy. States that have utilized these options have enrolled large numbers of eligible individuals quickly and efficiently. The Centers for Medicare and Medicaid Services (CMS) also offered states an option under waiver authority to utilize child enrollment data to reach and enroll parents, which has proven effective in some states. CMS has outlined other strategies that utilize child enrollment data to facilitate parent enrollment that do not require special authorization. These include using child enrollment data to identify potentially eligible parents and then collecting additional information necessary to enroll the parents. CMS also indicates that children’s renewal dates can be extended to synchronize renewal dates for the whole family as parents are enrolled. With regard to renewal, automating renewals for as many groups as possible by relying on available data helps keep eligible individuals enrolled and reduces the workload on agencies to process renewals. Providing 12-month continuous eligibility also supports stable coverage and reduces agency workload associated with processing renewals. States have an option to adopt 12-month continuous eligibility for children and can obtain a waiver to provide it to adults.
Translating Coverage into Improved Access to Care
Increasing health literacy and ensuring adequate provider capacity. As states achieve coverage gains, they point to the importance of increasing health insurance and health care literacy among newly insured individuals, particularly since many of those gaining coverage may have been uninsured for long periods of time and be unfamiliar with how to access the health care system with insurance. Some states are developing their own education materials for consumers. For example, the Washington state Medicaid agency created a first-time user guide for new Medicaid enrollees, which includes basic information on what is covered, how to arrange a doctor’s visit, and who to call for assistance with different issues. In addition, stakeholders have noted that the “From Coverage to Care” materials developed by CMS have been helpful in supporting these health coverage literacy efforts. Some Medicaid managed care plans also are working directly with their members on education. Some states have also taken steps to enhance provider capacity and benefits to meet increased demands for care as a result of the Medicaid expansion. For example, Kentucky expanded access to behavioral health providers by allowing Medicaid to contract with additional provider types (such as licensed drug alcohol counselors) and added new substance abuse treatment services to Medicaid. Both Colorado and Washington added adult dental benefits to Medicaid subsequent to the expansion, but stakeholders noted that there is a limited supply of dentists to provide these services, particularly given the high demand for them. Continued efforts to expand capacity and access, particularly in rural areas and for specialties subject to overall shortages, will be important for supporting improved access as coverage gains are achieved.
Three years into implementation of the ACA, millions of individuals have gained coverage through Medicaid. However, 8.8 million individuals are eligible for Medicaid or CHIP but remain uninsured. Reaching and enrolling these individuals will be important for achieving continued coverage gains looking ahead. Moreover, outreach and enrollment strategies will be key for supporting successful enrollment as additional states may implement the Medicaid expansion in the future. State experiences to date point to an array of effective outreach and enrollment strategies that states and other stakeholders may look to as tools to support continued enrollment gains. These strategies include implementing broad marketing and outreach campaigns, promoting the expansion through strong leadership and collaboration, establishing a coordinated and diverse network of assisters, developing effective eligibility and enrollment systems that coordinate with Marketplace coverage, and planning ahead to translate coverage gains into improved access to care.
Related Resources from the Kaiser Family Foundation
“Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey,” January 2016, http://kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/
“Fast Track to Coverage: Facilitating Enrollment of Eligible People into the Medicaid Expansion,” November 2013, http://kff.org/medicaid/issue-brief/fast-track-to-coverage-facilitating-enrollment-of-eligible-people-into-the-medicaid-expansion/
“Year Two of the ACA Coverage Expansions: On-the-Ground Experiences from Five States,” June 2015, http://kff.org/health-reform/issue-brief/year-two-of-the-aca-coverage-expansions-on-the-ground-experiences-from-five-states/
“What Worked and What’s Next? Strategies in Four States Leading ACA Enrollment Efforts,” July 2014, http://kff.org/health-reform/issue-brief/what-worked-and-whats-next-strategies-in-four-states-leading-aca-enrollment-efforts/
“Key Lessons from Medicaid and CHIP for Outreach and Enrollment Under the Affordable Care Act,” June 2013, http://kff.org/medicaid/issue-brief/key-lessons-from-medicaid-and-chip-for-outreach-and-enrollment-under-the-affordable-care-act/
“2015 Survey of Health Insurance Marketplace Assister Programs and Brokers,” August 2015, http://kff.org/health-reform/report/2015-survey-of-health-insurance-marketplace-assister-programs-and-brokers/
“Connecting Consumers to Coverage: Lessons Learned from Assisters for Successful Outreach and Enrollment,” September 2014, http://kff.org/health-reform/issue-brief/connecting-consumers-to-coverage-lessons-learned-from-assisters-for-successful-outreach-and-enrollment/
“Survey of Health Insurance Marketplace Assister Programs,” July 2014, http://kff.org/health-reform/report/survey-of-health-insurance-marketplace-assister-programs/