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What Worked and What's Next? Strategies in Four States Leading ACA Enrollment Efforts

Current and Future Priorities

To build on their successes and lessons learned from the past open enrollment period, the study states were looking ahead to make continued improvements and focus on new priorities related to helping newly covered people understand how to use their health insurance and access needed care.

Enrollment and renewal

Educating consumers about continued Medicaid enrollment and Special Enrollment Periods for Marketplace coverage. Stakeholders indicated that now that open enrollment has ended, they are focused on making sure that consumers know they can still enroll in Medicaid and may qualify for a Marketplace special enrollment period. Assisters are playing a key role in spreading this message and some of the states are conducting outreach with this information (Figure 7). Medicaid and Marketplace staff also noted plans to continue outreach to groups such as graduating students and new mothers who may be Medicaid eligible or able to enroll through a special enrollment period.

Figure 7: Messaging on the Special Enrollment Period in Washington

Figure 7: Messaging on the Special Enrollment Period in Washington

Reaching remaining eligible but uninsured. Although all four study states successfully enrolled a large number of people in coverage, stakeholders recognized that there remain eligible individuals that they were not able to reach and enroll and are focused on identifying strategies to reach these consumers. In all states, Medicaid and Marketplace staff indicated that they are in the process of collecting more detailed information on who enrolled, including data on race, ethnicity, and language. Some also are conducting surveys to learn about consumers’ experiences enrolling. Staff indicated that they plan to analyze data to gain a better sense of who the remaining eligible but uninsured are in their state and determine the best strategies to reach them. Stakeholders highlighted several hard-to-reach groups whom they plan to target through specific outreach efforts during the next open enrollment periods, such as veterans, the LGBTQ community, individuals with limited English proficiency, young adults, and justice-involved populations. Marketplace staff in all states are also focused on increasing enrollment of small businesses in their Small Business Health Options Program (SHOP).

“Once we get a firm sense for sort of who we just enrolled, that leads to the next question which is, well, who’s still left?  And we’d like to go back out to the Marketplace and then try to assess what the uninsured rate currently looks like and then who those people are.” –Connecticut Marketplace Official

Supporting continuity of coverage. Stakeholders are also focused on ensuring that individuals who enrolled in coverage maintain it. Connecticut, Kentucky, and Washington are already conducting Medicaid renewals through their new integrated enrollment systems.  Based on early data that suggested that the renewal rates in Washington after this change were lower than expected, the state implemented a multi-pronged renewal reminder system, which helped raise renewal rates to pre-ACA implementation levels (See Box 3). Medicaid staff in Colorado indicated that they are still in the process of determining how they will conduct Medicaid renewals and are seeking to make the process as automated as possible. State officials in Colorado noted that they provided enrollees a pre-populated renewal form prior to ACA implementation and would continue to renew based on existing information unless a consumer reported a change in circumstances. The states are also exploring options to remind consumers about maintaining coverage. Connecticut began doing robo-calls to individuals not paying premiums, and Washington is considering sending text and email renewal reminders for Medicaid beneficiaries.

Box 3: Facilitating Retention in Washington through a Multi-Pronged Reminder System

In late 2013, the Washington Health Care Authority implemented a multi-pronged renewal reminder system to promote retention among Medicaid and CHIP enrollees and facilitate the transfer of their electronic accounts into the new Washington Healthplanfinder eligibility system. In 2014, all Medicaid and CHIP enrollees in Washington must complete their annual renewals by submitting a new simplified application to the Healthplanfinder online, through the mail, or in person. The Washington Health Care Authority, concerned that enrollees may not be familiar with this new process, began sending reminder letters 60, 40, and 20 days prior to enrollees’ scheduled renewal date with information about how to renew and how to obtain help from community-based organizations. Enrollees also receive a reminder call. Individuals who do not successfully renew by their renewal date receive a letter explaining that to continue receiving coverage, they may mail in a tear-off stub at the bottom of the letter using a self-addressed postage pain envelope (included with the letter), send an email, or call a designated toll-free hotline.

As of March 2014, nearly 417,000 renewals had been successfully completed in the new Washington Healthplanfinder portal and renewal rates have not reached a level consistent with what they were pre-ACA implementation. State officials credit the multi-pronged approach with increasing public awareness of the need to renew coverage and are looking forward to 2015, when most renewals occur through electronic matches with existing data sources and without the need for consumers to take any action.

“I think we all knew to a degree, that this conversion was a big lift…The renewal process of the future is going to be a much simpler, more passive process for the enrollee, with the auto data match capacity of the Exchange.” –Washington Medicaid Official

Continuing enrollment system upgrades. All four study states continually improved the functionality of their enrollment systems throughout the open enrollment period and plan continued improvements and enhancements moving forward. Colorado is planning to move to a single integrated system for Medicaid and Marketplace determinations and to add more features, including electronic uploads of documentation. Kentucky is moving all Medicaid determinations, including disability-based determinations, as well as those for other social service programs, to its new system. It also plans to enhance the plan browsing experience for consumers by incorporating estimated premium tax credit subsidies into the prices they view. Washington is building the ability for Medicaid enrollees to enroll in a managed care plan through the Marketplace portal instead through the separate Medicaid system. Connecticut is continuing work to upgrade its Medicaid system to allow for greater coordination with the Marketplace. The Connecticut Marketplace also recently launched an enrollment app for smartphones and tablets, based on data collected indicating that large shares of individuals enrolled on smartphones and tablets. Colorado launched its mobile app in 2013 and is working to enhance its functions for the next open enrollment period.

Consumer Assistance

Enhancing training and support for assisters. Stakeholders in all four study states generally indicated that it will be important to enhance and improve training for assisters for the next enrollment period to address gaps in knowledge and improve their ability to handle complex cases. For example, some assisters emphasized a need for more hands-on training with the eligibility portal. Given that a large number of assisters in Connecticut had prior experience in Medicaid, some suggested they would benefit from increased training on private coverage and strategies to convey information about premiums and cost sharing to enrollees. Conversely, brokers and other assisters indicated a desire for more training on Medicaid, and, in Colorado, both Medicaid and Marketplace officials indicated that they plan to incorporate more information on Medicaid into the training sessions. Some stakeholders also suggested that combined training sessions with assisters and brokers would beneficial and allow them to share tips and other information. Finally, a few assisters noted that, because many consumers are continuing to rely on them for other types of assistance beyond enrollment, it would be helpful to incorporate additional professional development training into curricula, including modules on effective documentation, conflict resolution, cultural competency, and how to access other social services. Beyond enhanced training, stakeholders also indicated that it will be important to continue to develop the technical assistance and support made available to assisters to make sure they have readily available access to help that can answer questions, assist with complex cases, and help resolve any technological related enrollment problems.

Ensuring adequate consumer assistance. Stakeholders also agreed that one-on-one in-person assistance will remain essential for the next open enrollment period, especially for targeting hard-to-reach populations. However, there are uncertainties about future funding for existing assisters, and contracts in some states have ended or are scheduled to end in early 2015. Several of the assister groups stressed that it would be important to recertify and continue to fund organizations that played a central role in assistance during the first open enrollment period given that they have already developed trusted relationships with individuals in the community and learned many lessons that they could employ in the future. Because assisters are also providing significant post-enrollment assistance to consumers, advocates noted that continued funding, training, and support for these individuals will be important to ensure that newly enrolled individuals are able to access care and renew coverage. While decisions about funding for assisters are not yet final, Marketplace staff in Connecticut indicated that they are trying to collect best practices from the most successful assisters to disseminate more broadly. Both state officials and advocates also noted that brokers will also likely continue to play an important role in helping individuals enroll into coverage. Looking ahead to the next open enrollment period, states are also planning for larger call center capacity and developing strategies that will allow them to adjust capacity to accommodate surges in enrollment.

Access and Utilization of Care

Increasing health insurance and health care literacy. Stakeholders in all four study states heavily stressed that one of the biggest priorities they are facing is helping newly covered individuals gain a better understanding of how health insurance works and how to access needed care. In Colorado, Medicaid and Marketplace officials are developing messaging and videos for consumers to educate them on how to use benefits as well as seasonal messaging related to health and wellness. Medicaid staff in Washington developed a First Timers Guide to Washington Apple Health, which instructs new enrollees on how to use their benefit cards and how a health plan works, and includes answers to some frequently asked questions, including how to find a primary care provider or make an appointment. In Connecticut, Marketplace officials are working with local foundations to develop some materials relating to health insurance literacy and launch a campaign encouraging people to “own their own health.” Assisters and brokers also have developed their own materials, including pamphlets and flyers in languages appropriate for the specific populations they serve and indicated that they continue to help consumers understand their plans, benefits, and notices they receive from Medicaid and the Marketplace.

“There’s a responsibility we have to get people to understand what insurance is; what it does; what it means. Stop the average person on the street, they don’t know what a co-pay is; they don’t know what a deductible is…So we’re going to be doing a lot of messaging around that because what we realize is we’re creating a whole new group of consumers who maybe don’t have a true understanding of what they’ve gotten or how to use it.” –Connecticut Marketplace Official
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“The education around using your coverage, accessing care, getting assigned a primary care provider, how to work with your plan when it’s appropriate and how to work with us when it’s appropriate. That will continue…It is going to be an ongoing, continual process.” – Washington Medicaid Official

Supporting access to care for the newly insured. Stakeholders in the study states also noted that they are focused on ensuring that the gains in coverage lead to improvements in access to care. In Kentucky, early insights show that newly insured individuals have increased access to specialist care, prescription drugs, and behavioral health and substance abuse services. Kentucky also broadened Medicaid coverage for behavioral health and substance use disorder services, which stakeholders noted will be key services for many newly covered individuals. Medicaid officials in Colorado noted that they currently are heavily focused on provider recruitment for increase access for its growing base of enrollees. Moreover, some providers in the study states indicated that they are engaged in efforts to help get newly enrolled individuals connected to primary care services. For example, one community health center in Washington established a tracking system that allows have health center staff to schedule a primary care appointment for individuals as soon as they enroll. Using funding from internal reserves, the health center is also modifying assisters’ roles to allow them to call and conduct follow-up and home visits with enrollees about missed appointments to determine if there are other barriers such as lack of transportation that prevent them from obtaining preventive care. Similarly, an assister in Washington that serves at-risk youth recently received grant funding for a pilot project to help homeless youth enroll in coverage and select a health plan, and then provide staff to accompany individuals to their first doctor’s visit to help with care coordination. Further, the primary hospital system in Waterbury, Connecticut, which served as one of the largest assisters in the region, has implemented a system to coordinate care for newly enrolled beneficiaries (Box 4, next page).

Box 4: Coordinating Enrollment and Care Among Providers in Waterbury, Connecticut

The Waterbury hospital system serves the greater Waterbury area, which includes 19 towns in the eastern region of Connecticut and has among the highest uninsured rates in the state. During open enrollment, the hospital system built upon its previous experience serving the uninsured by enrolling uninsured patients in new health insurance coverage options and connecting them to care. In 2004, the hospital received grant funding to hire case managers to coordinate care for the uninsured, develop a shared database, and enroll eligible individuals into Medicaid and CHIP. Under the ACA, the hospital trained additional staff in two emergency rooms, a federally-qualified health center, and two hospital outpatient clinics to identify uninsured patients as they seek care and provide one-on-one enrollment assistance. Assisters also conducted outreach in homeless shelters and churches in the region.

During open enrollment, assisters within the Waterbury hospital system enrolled more than 1,000 people into coverage, and as patients enrolled in coverage, case managers provided education about using services and helped connect them to primary care. Now that open enrollment has ended, assisters continue to help uninsured patients enroll into Medicaid and CHIP and are collecting information on those who missed the Marketplace open enrollment period but may be eligible to purchase private coverage to do targeted outreach to them during the next open enrollment period

“It wasn’t just signing up people for insurance …we really say when we engage someone is; we want you to be able to get healthcare and get it in the right way.” –Assister in Waterbury Hospital, Connecticut

Maintaining safety net provider capacity. Safety net providers are facing significant changes as the ACA coverage expansions are implemented. As a result of the coverage expansion many of the patients they serve may gain coverage, which will increase their ability to obtain reimbursement for services. However, as patients gain coverage and access to a broader array of providers, safety net providers also indicated the need to adopt strategies to remain competitive and maintain their patient base, such as upgrading facilities and rebranding themselves. Moreover, with the increases in coverage, they face new demands to enhance their administrative capacity to bill to multiple insurers. Some stakeholders also noted concerns about potential decreases in grants and other sources of funding for safety net providers, since funders may believe there is a decreased need for these funding sources because of increased reimbursements stemming from coverage gains.

Lessons Learned Conclusion

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