Why Eligibility and Enrollment Services Should Be Top of Mind

Given the millions of people that have lost their jobs during this pandemic, your health system’s ability to improve its eligibility and enrollment processes in your revenue cycle is essential. Several recent reports illustrate the impact that the increased number of uninsured individuals is having on your payer mix. Now is the time to ensure your organization can effectively find third-party coverage for your uninsured patients through an advanced eligibility and enrollment program.

In September, the U.S. Census Bureau released its annual report on the uninsured for the year 2019. The Census Bureau said the number of uninsured Americans rose by about 1 million people in 2019 to more than 29.6 million, or 9.2 percent of the population, from 28.6 million, or 8.9 percent of the population, in 2018. That, of course, was before medical researchers confirmed the first case of COVID-19 in January 2020 in the U.S. Since then, that number has skyrocketed to more than 29 million confirmed cases of COVID by March 2021.

By improving the eligibility and enrollment programs at your health system, your organization can better help your uninsured patients obtain health benefits, provide them with peace of mind and help your financial performance.

The number of uninsured is also climbing as the direct result of people losing their jobs and their employer-sponsored insurance (ESI) due to COVID-19. In late August, the Economic Policy Institute (EPI) released an analysis of the impact of the outbreak on the health insurance market. EPI reported the impact of the ESI loss represented more than 12 million people from February to July 2020 with a large percentage of those becoming uninsured as they couldn’t or didn’t obtain coverage from another source.

In October 2020, the Commonwealth Fund, the Employee Benefit Research Institute and the W.E. Upjohn Institute for Employment Research published a joint analysis that said 7.7 million workers lost their ESI through the end of June 2020. When you add in the workers’ 6.9 million dependents, that number jumps to 14.6 million people without ESI. The Urban Institute estimates that during the last three quarters for 2020, on average only about a third of those who lose ESI coverage through pandemic-related job loss will become uninsured.  They estimate that more than 25% will be covered by Medicaid or the Children’s Health Insurance Program (CHIP).

The potential impact on your net revenue is clear: shifts in payer mix, increases in bad debt and charity from caring for more people without health insurance. That is, unless you do something about it – specifically invest in your eligibility and financial counseling programs. Two reports reveal how diligent eligibility and enrollment efforts can convert most uninsured patients into revenue-generating episodes of care.

National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention, conducted a survey on why adults (aged 18-64) did not have health care coverage.

Survey results on why adults did not have health care coverage:

73.7%said coverage was unaffordable

25.3%said they were not eligible for coverage

21.3%said they did not need or want coverage

18.4%said signing up for coverage was too difficult or confusing

18%said they couldn’t find coverage that meets their needs

8.5%said they’ve applied for coverage that hasn’t started yet

The Congressional Budget Office (CBO) also released a report in September 2020 that said of the 12 percent of people under 65 (about 29.8 million) who were not enrolled in a health insurance plan or a governmental program that provided financial protection from major medical risks in 2019, two-thirds were actually eligible for subsidized health insurance benefits from various sources.  Specifically, the CBO said:

  • 9.24 million, or 31 percent, were eligible for subsidized employment-based coverage
  • 5.66 million, or 19 percent, were eligible for subsidized coverage through state exchanges
  • 2.98 million, or 10 percent, were eligible for Medicaid or CHIP
  • 2.09 million, or 7 percent, were eligible for Medicaid via ACA-expanded Medicaid programs

Together, the NCHS and CBO reports gives support that by improving the eligibility and enrollment programs at your health system, your organization can better help your uninsured patients obtain health benefits, provide them with peace of mind and help your financial performance.

Three ways to boost your Eligibility and Enrollment program

Two women wearing face masks reviewing information on a laptop
With the number of uninsured people increasing due to COVID-19, it is critical that your organization work diligently to secure third-party coverage for them.


The number of Americans without health coverage is exploding as the pandemic takes away jobs and their employer-sponsored health insurance. To prevent those newly uninsured patients from increasing your bad debt costs, you need to optimize your eligibility and enrollment services. Those services may include enrolling patients in public insurance programs, determining patients’ eligibility for community and financial assistance programs, identifying low-cost health insurance options and educating patients on health insurance benefits, and helping them with enrollment processes.

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