Medicaid and Marketplace Outreach and Enrollment

Medicaid and Marketplace Outreach and Enrollment

Joshua Ewing 5/8/2014

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The first open enrollment period for private insurance plans offered through the state and federal marketplaces has come to an end. As you can see on the updated maps below, results have varied from state to state. State legislators and staff are using this opportunity to evaluate their own outreach and enrollment efforts, as well as, the efforts in other states, and prepare for the next open enrollment period which begins on Nov. 15, 2014.

Regardless of who runs the marketplace in a given state, it is important that legislators and legislative staff understand policy changes necessary to facilitate outreach and enrollment, as well as the resources currently available in their state.

There are a variety of reasons for this, including: In many states, Medicaid enrollments through the marketplace outpaced private plan enrollments as a result of the no-wrong-door/single-entry point policies. Because legislators have an oversight role for their state Medicaid programs, it’s important for legislators to remain informed about how these new enrollees are coming into the program. 

In addition, legislators frequently address concerns and questions from constituents in their districts; having accurate, up-to-date information will not only help them do their jobs, it can help to dissolve misconceptions in the general public.


States that chose to operate their own marketplaces received establishment grants to set up their marketplace. Navigator organizations were prohibited from receiving establishment grant funding, but states were allowed to set up optional in-person assister programs that could be funded by the establishment grants until the marketplaces were self-sustaining. 

For states that chose to partner with the federal government on their marketplace, and those states that opted to let the federal government fully manage the marketplace in the state, nonprofit community organizations, community health centers and licensed agents and brokers were among the groups that received separate federal funding to conduct outreach and enrollment activities.

Legislative Roles and Opportunities

  • Regulate navigators and assisters—Navigators and assisters are professionals who carry out non-partial educational activities about insurance options available through the marketplace, help consumers determine eligibility and enroll in coverage. One of the most common actions being taken by state legislatures is to regulate navigators and assisters, for example, by considering the adequacy of training, certification and patient privacy protections.
  • Data collection—State legislatures can can require and fund data collection, analysis and reporting on marketing and outreach costs and outcomes.
  • Monitor and track state investments—As is the case with any state program, legislatures monitor and track state investments to ensure that they support cost-effective and evidence-based outreach and enrollment strategies.
  • Foster and build relationships and strategic partnerships—Outreach and enrollment assistance involves partnerships with health plans, faith-based organizations, foundations and other community organizations. Legislators often know these groups and individuals and can help to facilitate community partnerships.
  • Community leaders—Legislators can play an important role in helping their constituentsunderstand their coverage options and the pathway to obtain coverage.

State Examples of Outreach and Enrollment

State outreach and enrollment activities vary considerably depending on a numbers of factors, including marketplace oversight (state-run vs. federally-run), the state’s decision regarding Medicaid expansion, political support and buy-in, and other factors. A few examples follow.

  • Media Campaigns—"Connect for Health Colorado" conducted a public awareness campaign in both English and Spanish that includes television, print, radio, and billboard advertisements. It also established a large presence on a variety of social media platforms, including Twitter, Facebook, LinkedIn, and YouTube.
  • Navigators, In-Person Assisters and Certified Application Counselors—In Kentucky, the state awarded $6.45 million in grants last year to five "kynector" organizations to provide education and enrollment assistance to individuals and small businesses in the state’s eight Medicaid regions. Across the country, nearly 44,000 Idahoans have selected a health insurance plan on “Your Health Idaho,” making Idaho second in the nation, per capita, for enrollments. This is in large part to in-person assistors, agents and brokers, also known as consumer connectors, who have set up shop in almost 150 locations around the state. Program managers also recently attributed success to public outreach efforts, including more than 100 meetings and sign-up events across the state.
  • Store-Fronts—In Connecticut, Access Health CT has applied the Apple Store model to enroll people in the state’s marketplace.  “Store front” enrollment locations in New Haven and New Britain were enrolling 300 to 400 people per day, according to Access Health CT CEO Kevin Counihan.

State Legislative Actions

Navigators (and counselors and assisters who perform similar duties), play a key role in helping consumers to complete applications, compare options and select coverage. These functions are not only complex, but they also involve the handling of sensitive, personal information. In response, states have considered a wide range of legislation aimed at regulating and licensing navigators, defining the scope of their activities, and establishing training requirements.

Since 2012, at least 25 states have enacted state laws regulating or restricting navigators, in-person assisters and/or certified application counselors

For example: At least six states require navigators to be licensed in the state. Arkansas is one of the six. Their new law (SB 1189) requires a person to pass an exam with standards set by the insurance commissioner, pass a criminal and regulatory background check, and pay an annual fee to be licensed as a navigator in the state.

Some recent laws place restrictions on the role of navigators. Georgia, *Missouri, Ohio, and *Tennessee enacted laws restricting navigators from giving advice about the benefits, terms, and features of a particular health plan. The Missouri and Tennessee laws are temporarily blocked by the courts.

For a comprehensive list of health reform legislation from previous legislative sessions, please visit NCSL’s 2011-2013 Health Reform State Legislative Tracking Database.

2014 Legislative Tracking

NCSL is tracking over 100 bills in 33 states related to outreach and enrollment in 2014. Most of the bills introduced this year are related to privacy of sensitive information and the regulation of navigators, in-person assisters and/or certified application counselors. The following chart reflects outreach and enrollment legislation that has passed at least one chamber in its respective legislature. For full legislative tracking, visit NCSL’s 2014 Health Reform State Legislative Tracking Database.

State Bill and Status

House Bill 2508- Insurance Navigators and Application Counselors

Requires navigators and certified application counselors to be licensed by the Department of Insurance in order to act or claim to be a navigator or certified application counselor, prescribes licensure requirements including background checks, outlines prohibitions and authorizes the adoption of rules.

Status- Signed by the Governor, Act Number 153 (04/22/2014)


House Bill 1130- Department of Health Appropriation

Prohibits the Department of Health from using appropriations to "promote or encourage enrollment in the Arkansas Health Insurance Marketplace or the Health Care Independence Program."

Status- Signed by the Governor, Act Number 283 (03/13/2014)


Senate Bill 111- Department of Human Services and Medical Services

Prohibits the Department of Human Services, Division of Medical Services from using appropriations to "promote or encourage enrollment in the Arkansas Health Insurance Marketplace or the Health Care Independence Program."

Status- Signed by the Governor, Act Number 257 (03/07/2014)


Senate Bill 362—Navigator Background Check Act

Would create the Health Care Insurance Navigator Registration Act and require health care insurance navigators to register on or before July 1, 2015, with the Attorney General prior to performing services or offering to perform services under the health care exchange requirements of the federal Affordable Care Act.

Status- To House Committee on Health and Human Services (03/17/2014)


House Bill 764—Health Insurance Navigators

Requires licensing of health insurance navigators and registration of non‑navigator personnel by the Commissioner of Insurance; provides for qualification, education, reporting and fingerprint requirements; repeals certain provisions concerning life insurance.

Status- Reported Favorably from Senate Committee on Insurance; Referred to Legislative Bureau (05/15/2014)


House Bill 4111—Supplemental Appropriations

Makes supplemental appropriations for 2012‑13 fiscal year; provides that all navigators and in‑person assistors shall undergo criminal and regulatory background screening before being allowed to operate in this state; provides that the department of licensing and regulatory affairs shall work to ensure that the privacy of individual citizens is protected in all aspects of the partnership exchange.

Status- To Senate, on Second Reading (03/05/2014)


Senate Bill 498—Health Insurance Navigators Bond Requirement

Requires health insurance navigators must be bonded; creates a private cause of action against navigators for unlawful release of private identifying information has been released to anyone other than necessary state agencies, federal agencies, insurance companies, or other entities with lawful access to the information for the purpose of obtaining health insurance; provides the action does not require intent to release the information or proof of injury; proscribes damages plus attorney fees.

Status- Failed; Adjourned (05/16/2014)


Senate Bill 508—Navigator License Applicant Exam Requirement

Requires that an applicant for a navigator license must take an exam created by the Department of Insurance and submit to a criminal background check.

Status- Truly Agreed To and Finally Passed (05/15/2014)

New Jersey

Assembly Resolution 40—Patient Protection and Affordable Care Act Outreach

Urges the Governor to use federal grant allocated for Patient Protection and Affordable Care Act outreach.

Status- Passed Assembly, To Senate (02/27/2014)


House Bill 3286—Insurance

Requires navigators that provide certain services to be licensed; provides license application requirements; requires examination; requires certain instruction; requires certain qualifications; requires continuing education for renewal license; provides penalties for certain violations; prohibits certain solicitation activities; prohibits compensation in certain circumstances.

Status- To Governor (05/16/2014)


House Bill 2248—Local Education Agencies

Prohibits Local Education Agencies from including information on the Affordable Care Act in mailings to families of students concerning TennCare and CHIP.

Status- Failed; Adjourned (04/17/2014)


House Bill 76—Insurance Code

Requires additional training for all navigators, including at least 21 credit hours of training before obtaining a license; at least 1 credit hour on defined contribution arrangement and the state-run small employer Health Insurance Exchange, in addition to the navigator training and certification program developed by the Centers for Medicare and Medicaid Services.

Status- Signed by Governor (04/01/2014), Chaptered. Chapter Number 300 (04/07/2014)


House Bill 141—Health Care Reform

Amends provisions related to health insurance and state and federal health care reform; amends the period of time in which an employee of a state contractor must be enrolled in health insurance to conform to federal law; amends the State Health Data Authority Act to facilitate the coordination of eligibility for health insurance benefits, costs and quality reports for episodes of care; amends the health insurance navigator license chapter of the Insurance Code to create two types of navigator licenses.

Status- Signed by Governor (04/02/2014), Chaptered. Chapter Number 425 (04/07/2014)


House Bill 1043—Health Benefit Exchanges

Requires navigators to be registered with the State Corporation Commission, in addition to being certified by the federal Department of Health and Human Services; provides that the Commission shall register an individual if the applicant meets specified requirements; authorizes the Commission to investigate the affairs of any person in navigator duties; provides grounds for registration termination, probation, or suspension.
Status- Signed by Governor (04/07/2014), Chaptered. Chapter Number 769 (04/07/2014)


Senate Bill 542—Navigator Regulation

Requires navigators to be registered with the State Corporation Commission, in addition to being certified by the federal Department of Health and Human Services; provides that the Commission shall register an individual if the applicant meets specified requirements; authorizes the Commission to investigate the affairs of any person in navigator duties; provides grounds for registration termination, probation, or suspension.
Status- Signed by Governor (04/07/2014), Chaptered. Chapter Number 752 (04/07/2014)

Individuals Who Have Selected a Plan Through the Marketplace

HHS released the final marketplace enrollment numbers for the first open enrollment period on May 1, 2014. Between October 1, 2013 and April 19, 2014, 8,019,763 people selected a marketplace plan through the online marketplaces. 2,573,585 people did so in state-based marketplaces and 5,446,178 selected plans in the Federally Facilitated Marketplace. Of the more than 8 million:

  • 54 percent are female and 46 percent are male;
  • 85 percent selected a Marketplace Plan with Financial Assistance
  • An additional 6.7 million people also received Medicaid or CHIP Determinations through the Marketplaces (this number does not include individuals applying through State Medicaid/CHIP agencies.)

Percentage of Estimated Total Eligible Who Have Selected a Plan Through the Marketplace

Using data estimates from the Kaiser Family Foundation, NCSL created the following map, which shows the estimated percentage of eligible individuals who selected plans through the health insurance marketplace between October 1, 2013 and April 19, 2014.

Percentage of Those Who Have Selected a Plan Through the Marketplace Ages 18-34

Key to the challenge of outreach and enrollment is signing up young adults. As a whole, those ages 18-34 tend to be healthier and less costly, a trait important to marketplaces seeking to reduce their risk by enrolling more healthy people to offset the cost of coverage for the less healthy. People in this age group are also more likely to choose to go without health insurance. For these reasons, young adults have been a priority for enrollment in the health insurance marketplaces or exchanges.

enrollment map

Change in Medicaid/CHIP Enrollment

Also included in the final numbers for the first open enrollment period released by HHS on May 1, 2014 were the change Medicaid/CHIP enrollments between March 2014 enrollment and Pre-ACA Monthly Average Medicaid and CHIP Enrollment (July-Sept 2013).

Medicaid/CHIP Enrollment Map

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