Health insurance enrollment outreach & support

Evidence Rating  
Some Evidence
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  

Health insurance enrollment outreach and support programs assist individuals whose employers do not offer affordable coverage, who are self-employed, or unemployed with health insurance needs; individuals may be uninsured or need assistance renewing coverage. Such programs can be offered by a variety of organizations, including the federal and state health insurance marketplaces, government agencies, schools, community-based or non-profit organizations, health care organizations, and religious congregations. Outreach activities vary greatly and can include community health worker (CHW) efforts, other person-to-person outreach, mass media and social media campaigns, school-based efforts, case management, or efforts in health care settings. Outreach can occur at local events, via hotlines, online, or at fixed locations (e.g., community centers, non-profit offices, barbershops, etc.) and are often supported through grants from federal agencies or private foundations.

Expected Beneficial Outcomes (Rated)

  • Increased health insurance coverage

Other Potential Beneficial Outcomes

  • Increased awareness of health insurance availability

Evidence of Effectiveness

There is some evidence enrollment outreach and support activities increase enrollment in health insurance programs1, especially among children2, 3. However, additional evidence is needed to confirm effects.

Health insurance application support and information by community-based case managers may increase enrollment of uninsured children and reduce the time it takes for them to be enrolled2. Providing insurance applications to families seeking care in emergency departments may also increase child enrollment2. Multi-component approaches may also increase new enrollments of children3.

Based on the experience of programs working to enroll children in public insurance programs, school-based programs and campaigns appear to be successful strategies to reach those who are uninsured4, 5. An evaluation of Covering Kids and Families, a broad effort to reach uninsured children and their families, indicates that the program increases awareness of the availability of public health insurance programs for families with low and moderate incomes, and may increase enrollment4.

Partnering with other organizations4, 6 and using a mix of targeted messages and approaches is often recommended for successful outreach and enrollment activities6. Including technology-based systems (e.g., online benefit applications) in enrollment efforts may maximize enrollment overall3, while more traditional methods (e.g., community health worker (CHW) outreach) may increase enrollment among harder to reach populations3, 7. Pre-existing local support networks, including health exchange staff, local public health agencies, and advocacy organizations, may work together to offer on-site assistance with health insurance enrollment in places of trust (e.g., barbershops, spas and beauty shops, etc.)8.

Federal or state-sponsored television ads about health insurance marketplaces may feature messages specific to certain geographic areas, which may increase overall health insurance enrollment9. Television ads tailored to Hispanic populations are generally in Spanish and highlight telephone or in-person assistance rather than online enrollment10; such outreach efforts, that consider cultural and linguistic norms, appear to increase insurance enrollment among Hispanic populations11, 12. Hispanic individuals may be more likely to seek enrollment assistance than white individuals due to language barriers or immigration concerns13.

Patients may receive enrollment assistance and guidance on using insurance benefits at federally qualified health centers (FQHCs)14, 15, 16 and other safety net providers17. However, lack of staff time and knowledge, funding, and space constraints are often barriers to providing additional support17.

Early studies suggest that outreach programs such as Enroll America appear to increase Affordable Care Act (ACA) enrollment1, 18.

Impact on Disparities

Likely to decrease disparities

Implementation Examples

The health insurance marketplaces established by the Affordable Care Act (ACA) offer health plan shopping, outreach, and education, as well as enrollment support from Assister Programs, including certified application counselors and navigators, staff at federally qualified health centers (FQHCs), and agents and brokers (i.e., state-licensed professionals that sell private health insurance to individuals and/or businesses)16, 19. Larger Assister Programs are often better equipped to address enrollees’ more complex needs, including language translation, immigration-related problems, and challenges with reporting income16. Enrollment support is available locally and at a distance20. In 2019, an estimated 7 million individuals were supported by a mixture of paid and volunteer workers in navigating the ACA health exchanges, with many seeking help from the same assister as in previous years13. As part of the COVID-19 public health emergency, there is a new Special Enrollment Period to enroll in or change marketplace health insurance plans through August 15, 202121.

Organizations such as Enroll America provide outreach and education to maximize coverage uptake18. Some organizations tailor support to specific populations: for example, Young Invincibles offers local enrollment and re-enrollment assistance to young adults22. The Public Library Association provides resources on health insurance outreach and enrollment support methods that libraries can use to develop and distribute printed materials, host workshops or informational sessions, and advertise on TV, radio, and social media using customizable materials from their Outreach Hub23. Tools such as health insurance enrollment tracking add-ins to electronic health records (EHRs) may be used by community health centers to identify patients without insurance, support enrollment, and track acceptance rates14.

The Minnesota Department of Health’s MNsure Navigators are often based in community organizations, providing services in numerous languages, including basic health insurance education and enrollment assistance for public and private health insurance plans, and offer enrollment resources in 22 languages24. West Virginia’s health insurance help line, WV Navigator, offers assistance via phone and virtual chats25. The Insure Duluth Coalition, a 15-organization partnership of health and social service organizations in Duluth, MN, offers enrollment assistance in-person and by phone, hosts local outreach events, and has supported the integration of outreach and enrollment navigation into the workflow of direct service providers (e.g., homeless outreach organizations, utility assistance program), to connect with hard to reach populations7, 26.

Insurance outreach and support efforts played a large role in the 1997 launch and subsequent expansion of the State Children’s Health Insurance Program (SCHIP). States’ outreach efforts evolved as their programs matured; general outreach and awareness strategies such as mass media campaigns were often replaced with targeted outreach via community organizations for hard to reach populations27.

Implementation Resources

Healthcare.gov-Get help - Healthcare.gov. Get help applying and more: Find local help or get contacted.

CMS InsureKidsNow - Centers for Medicare and Medicaid Services (CMS). InsureKidsNow: Connecting kids to coverage national campaign.

PLA-ACA - Public Library Association (PLA). Libraries connecting you to coverage: Affordable Care Act. American Library Association, Community Catalyst, and Robert Wood Johnson Foundation.

Kreuter 2014* - Kreuter MW, McBride TD, Caburnay CA, et al. What can health communication science offer for ACA implementation: Five evidence-informed strategies for expanding Medicaid enrollment. Milbank Quarterly. 2014;92(1):40-62.

Urban-Monitoring and tracking state ACA implementation - Urban Institute. Monitoring and tracking implementation efforts of states and the Affordable Care Act.

Footnotes

* Journal subscription may be required for access.

1 Mathematica-Hoag 2014 - Hoag S, Orzol S, Orfield C. Evaluation of enroll America: An implementation assessment and recommendations for future outreach efforts. Princeton: Mathematica Policy Research (MPR); 2014.

2 Cochrane-Jia 2014* - Jia LY, Yuan BB, Paul G. Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database of Systematic Reviews. 2014;(11):CD008194.

3 Cousineau 2011 - Cousineau MR, Stevens GD, Farias A. Measuring the impact of outreach and enrollment strategies for public health insurance in California. Health Services Research. 2011;46(1):319-335.

4 Urban-Courtot 2010 - Courtot B, Klein A, Howell E,  Benatar S. Covering kids & families evaluation. Performing outreach with limited resources: CKF grantees' successes and challenges over three years. Washington, DC: Urban Institute; 2010.

5 Mathematica-Irvin 2006 - Irvin C, Trenholm C, Rosenbach M. Detecting enrollment outbreaks in three states: The link between program enrollment and outreach. Princeton: Mathematica Policy Research (MPR); 2006.

6 Urban/SHADAC-Courtot 2012 - Courtot B, Coughlin TA. Best practices in SHAP outreach, eligibility, and enrollment activities. Issue Brief #30. Minneapolis, MN: University of Minnesota State Health Access Data Assistance Center (SHADAC), Washington, DC: Urban Institute; 2012.

7 Dauner 2015 - Dauner KN. Assessing a coalition for outreach and enrollment in Minnesota’s health insurance exchange. Qualitative Report. 2015;20(3):251-267.

8 Hatch 2019 - Hatch M, Yurman R, Amirkhanyan AA, Johnston J. Barber shops, salons, and spas: The complexity – and simplicity – of implementing outreach and enrollment contracts under the Affordable Care Act. Journal of Public Management & Social Policy. 2019;26(2):19-47.

9 NBER-Aizawa 2020 - Aizawa N, Kim YS. Government advertising in market-based public programs: Evidence from the health insurance marketplace. National Bureau of Economic Research (NBER). 2020: Working Paper 27695.

10 Kemmick Pintor 2020 - Kemmick Pintor J, Alberto CK, Arnold KT, et al. Targeting of enrollment assistance resources in health insurance television advertising: A comparison of Spanish- vs. English-language ads. Journal of Health Communication. 2020;25(8):605-612.

11 AHRQ HCIE-Capitman - Capitman JA, Gonzalez A. Bilingual, culturally competent community health workers increase insurance enrollment, access to care, and self-efficacy among low-income Latinos. Rockville: AHRQ Health Care Innovations Exchange.

12 AHRQ HCIE-Chaves-Gnecco - Chaves-Gnecco D. Culturally competent outreach, services, and education improve access to insurance, primary care, and immunizations for Hispanic and Portuguese children. Rockville: AHRQ Health Care Innovations Exchange.

13 KFF-Pollitz 2020 - Pollitz K, Tolbert J, Hamel L, Kearney A. consumer assistance in health insurance: Evidence of impact and unmet need. Menlo Park: Henry J. Kaiser Family Foundation (KFF); 2020.

14 Hatch 2020 - Hatch B, Tillotson C, Huguet N, et al. Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial. BMC health services research. 2020;20(1):428.

15 Askelson 2021* - Askelson NM, Brady PJ, Wright B, et al. Communicating a complicated Medicaid waiver program to enrollees in Iowa: How Federally Qualified Health Centers support Medicaid members. Journal of Ambulatory Care Management. 2021;44(1):12-20.

16 KFF-Pollitz 2016a - Pollitz K, Tolbert J, Semanskee A. 2016 Survey of health insurance marketplace assister programs and brokers. Menlo Park: Henry J. Kaiser Family Foundation (KFF); 2016.

17 Yarger 2017* - Yarger J, Daniel S, Biggs MA, Malvin J, Brindis CD. The role of publicly funded family planning sites in health insurance enrollment. Perspectives on Sexual and Reproductive Health. 2017;49(2):103-109.

18 Mathematica-Orfield 2015 - Orfield C, Hoag S, Orzol S. Maximizing coverage through outreach: Second year experiences of Enroll America in North Carolina and Ohio. Ann Arbor, MI: Mathematica Policy Research (MPR); 2015.

19 CMS-Marketplace - Centers for Medicare & Medicaid Services (CMS). Health Insurance Marketplace: The official marketplace information source for assisters and outreach partners.

20 Healthcare.gov-Get help - Healthcare.gov. Get help applying and more: Find local help or get contacted.

21 Healthcare.gov-COVID-19 - Healthcare.gov. Marketplace coverage and coronavirus.

22 Young Invincibles - Young Invincibles. Get help for open enrollment. Washington, DC.

23 PLA-ACA - Public Library Association (PLA). Libraries connecting you to coverage: Affordable Care Act. American Library Association, Community Catalyst, and Robert Wood Johnson Foundation.

24 MDH-Health insurance - Minnesota Department of Health (MDH). COVID-19: Resources to find low cost healthcare or get health insurance.

25 WV Navigator - WV Navigator. West Virginia’s health insurance help line. First Choice Services.

26 Insure Duluth - Insure Duluth. A Duluth community resource for navigating MNsure, the state’s health insurance exchange. Duluth, MN.

27 Mathematica-Rosenbach 2007 - Rosenbach M, Irvin C, Merrill A, et al. National evaluation of the state children's health insurance program: A decade of expanding coverage and improving access. Princeton: Mathematica Policy Research (MPR); 2007.

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