Internal Considerations Illinois Providers Should Examine Regarding Exchange Enrollment

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A major goal of the Patient Protection and Affordable Care Act (ACA) is the near universal coverage of Americans by meaningful and adequate health insurance. The means by which the legislation and its implementing agency, the Department of Health and Human Services (HHS), elects to accomplish this goal is through the development of state-based health insurance exchanges (Exchange or the Exchanges) administered by states, the federal government or some combination thereof.1 While providers, rightfully, focus on the ACA's dramatic shift toward accountable care and changing payment models, providers must now consider their responsibilities and opportunities in eligible public exchange enrollment with the October 1, 2013 open enrollment date having arrived. The purpose of this e-alert is to suggest for consideration and discussion provider-based best practices and opportunities.

The initial open enrollment period began October 1, 2013 and extends through March 31, 2014. Coverage provided under the exchange becomes effective January 1, 2014. If eligible persons do not elect to enroll in exchange-based insurance products during the period, non-exchange based insurance products will be available for purchase both during the open enrollment period and after the initial open enrollment period concludes.

There are five major internal considerations a provider should examine in light of exchange enrollment: outreach staffing, technology, existing staffing, partnership opportunities and new consumer relationship building/management.

Outreach Staffing

As a threshold matter, it is worth considering whether a provider should add additional staffing to provide consumer assistance in enrollment, account for organizational time constraints otherwise imposed elsewhere in the absence of such staff and develop liaison relationships with outside entities primarily focused on enrollment. The primary advantages of retaining additional, enrollment-specific staff are building institutional knowledge and centralizing a process that may otherwise prove time consuming to other provider services not typically related to insurance enrollment. In some sense, the type of institutional knowledge necessary for success in Exchange enrollment is highly susceptible to assignment to one individual. What is initially a complicated, daunting task for the organization (and for each individual patient/consumer) becomes more routine and efficient with every enrollment undertaken by the assigned individual. This increases efficiency for the provider and consumer alike. This also provides the patient/consumer with a single point of contact as she/he moves through the health system for perhaps the first time outside an emergency care context. A single assigned enrollment coordinator can also provide regular and meaningful input to hospital management on resource management and allocation relating to Exchange enrollment.

Second, one of the most significant uncertainties of Exchange enrollment is the manner of initial interaction between the patient/consumer and health system. Surveys undertaken suggest consumers most wish to obtain enrollment information while visiting a provider, and least wish to obtain the information in the context of an emergency room visit. Similar to how the patient/consumer has many other priorities when receiving emergency treatment, the organization can avoid unnecessary distraction and diversion of other resources by simply designating a single contact point to develop appropriate process and procedure for this interaction.

Third, provider must consider the impact of the ACAʼs 90-day grace period for premium non-payment by individuals receiving advance payments of the premium tax credits. Plans are required to pay all appropriate claims within the first 30 days of nonpayment, but a structured grace period serves to pend claims for the remaining 60 days of the applicable period. Thus, communication with the consumer at time of enrollment of the importance of timely payment throughout the benefit year is in the mutual interest of the consumer and provider alike.


Exchange enrollment is designed to be user friendly, primarily through application of a Web-based enrollment portal. The provider should make available computers (additional as necessary), Exchange-provided enrollment materials and contact information in a kiosk environment throughout the system, as appropriate. Hospitals may wish to undertake development of a simple website, for example, that directs patient/consumers (under the assumption they are new to the system) to the proper facility and providing location/direction/appointment information as well. Because the Exchange does not envision a provider's core competency as enrollment, the technological investment need not be great or extensive—but it must be considered.

The system may also wish to use its internal data to help identify uninsured patients and offer them proactive enrollment assistance—this includes sliding scale payment patients. The benefit to such assistance, in theory, is a more favorable payor mix if properly conducted. Any specific technological efforts should be discussed and approved by legal counsel prior to implementation to ensure compliance with applicable HIPAA safeguards.

Existing Staffing

Invariably, hospital employees and partners will face questions regarding Exchange enrollment procedures. Receptionists and front desk staff, for example, should receive generalized training in eligibility requirements, referral sources and answers to basic questions about open enrollment. Beyond this, however, promoting knowledge of eligibility and enrollment procedures to patients in the course of existing treatment should be a priority. Staff with existing linguistic capabilities including, but not limited to, Spanish should be identified and provided with similar training.

At some level, all staff will need to possess basic referral capability, whether that is to an internal individual responsible for coordinating enrollment activities or external entities providing more detailed assistance through broader public awareness campaigns.

Partnership Opportunities

Hospitals should devise a proactive plan to approach social service agencies and other not-for-profit organizations in the greater community in order to develop a working referral relationship beginning with open enrollment. Stakeholders from each organization should meet to discuss core competencies, enrollment objectives and procedures, and ways in which each can best serve the area's substantial uninsured population. In Illinois, at least two distinct groups or partnerships designed to inform consumers and assist with enrollment are navigators and in-person counselors. These organizations have received funding from the federal and state governments to undertake extensive enrollment outreach efforts to various segments of the uninsured population—some on a statewide basis. For instance, one concrete way to boost the system's participation may be to co-sponsor and participate in town halls or informational sessions regarding health exchange enrollment. The provider perspective is valuable to these efforts and may provide additional information beyond the competency of the assisting entity. Similarly, hospitals may wish to consider establishing liaison relationships—or assister presence in facilities—to assist with enrollment in lieu of or to augment existing enrollment assistance staff. Please note use of space for these purposes would need to be carefully reviewed by legal counsel prior to implementation.

New Consumer Relationship Building/Management

Hospitals and health systems have an opportunity to help shape the impact of ACA open enrollment. By becoming active participants in enrollment activities, hospitals and health systems can develop and maintain long-term patient relationships outside their current audience. They have the opportunity to work with others to improve their own payor mix and enhance their reputation in the state as providers of high quality health care services.

Closing Thoughts

In addition to responsible organizational citizenship, providers should work to actively assist with enrollment to avoid increased subscription of services by uninsured patients. While hospitals, in many cases, have an affirmative obligation to treat emergency patients under the Emergency Medical Treatment and Labor Act (EMTALA), the provider receives more predictable payment resolution if the patient is insured than if not.

Successful exchanges require the participation of the entire community. Few organizations are more critical to that effort than hospitals and health systems.

If you have any questions regarding the above, please contact your Reinhart attorney, Christopher Kriva or any member of our Health Care team.

1 Illinois elected by state statute to develop a Partnership Exchange model, under which the federal and state governments share
responsibility for administration, implementation and oversight of the Exchange. In general, federal administration peaks at the
commencement of open enrollment with state oversight expected to increase over time.


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