Using Emails and Personalized Phone Calls to Increase Affordable Care Act Marketplace Enrollment Among Households Losing Medicaid

Since its passage in 2010, the Affordable Care Act (ACA) has helped reduce the uninsured rate to record lows, but changes in insurance coverage over time, known as churn, remain a concern. A recent survey found that nearly 25 percent of respondents reported a change in coverage over the previous twelve months. Among the most common reasons for churn is the loss of Medicaid eligibility, placing low-income populations at risk of a coverage gap. To date, little evidence exists on effective strategies states can use to facilitate Medicaid to Marketplace coverage transitions, an issue that has become more pressing amid projections that upwards of 15 million people could lose Medicaid eligibility once the COVID-19 public health emergency expires.

To address this gap and to inform Marketplace administrators, during a Special Enrollment Period (SEP) in 2017 in California's ACA Marketplace, we conducted a randomized controlled trial to examine the effect of email reminders, personalized telephone outreach, as well as the combination of the two forms of outreach on ACA enrollment among households who recently lost Medicaid and became eligible for subsidized Marketplace coverage.

During the SEP at the end of August 2017, the investigators randomly assigned households to one of four arms based on the last digit of their household identifier: a control group assigned to receive no outreach beyond an initial eligibility determination notice; an email-only group assigned to receive an initial eligibility determination plus email reminders about signing up for marketplace coverage; a phone-only group assigned to receive an initial eligibility determination plus a phone call offering enrollment assistance from a service center representative (SCR); a phone + email group assigned to receive an initial eligibility determination, email reminders about signing up for marketplace coverage and a phone call offering enrollment assistance.

Study Overview

• Status: Completed
• Conditions: Health Behavior
• Intervention / Treatment: Behavioral: Control group; Behavioral: Email only; Behavioral: Phone only; Behavioral: Phone and email

• Study Type: Interventional
• Enrollment (Actual): 2173
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Sacramento, California, United States, 95815
      • Covered California

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Those who recently lost Medicaid eligibility and became eligible for subsidized Affordable Care Act coverage

Exclusion Criteria:

• Those who recently lost Medicaid eligibility and were found ineligible for subsidies.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Control; The control group was assigned to receive no outreach beyond an initial eligibility determination notice	Behavioral: Control group; No outreach during the intervention period beyond an initial eligibility notice.; Other Names: No outreach
Experimental: Email-only; An email-only group assigned to receive an initial eligibility determination plus email reminders about signing up for marketplace coverage	Behavioral: Email only; Email reminders in addition to an initial eligibility notice.
Experimental: Phone-only; A phone-only group assigned to receive an initial eligibility determination plus a phone call offering enrollment assistance from a service center representative (SCR);	Behavioral: Phone only; Phone call offering enrollment assistance in addition to an initial eligibility notice.
Experimental: Phone and email; A phone + email group assigned to receive an initial eligibility determination, email reminders about signing up for marketplace coverage and a phone call offering enrollment assistance.	Behavioral: Phone and email; Phone call and email reminders in addition to an initial eligibility notice.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of households enrolled in an ACA plan by the end of the October 2017	Percent of households enrolled in an ACA plan during the intervention period	Two months

Collaborators and Investigators

• Sponsor: Office of Evaluation Sciences
• Investigators: Principal Investigator: Andrew Feher, PhD, Covered California

Study record dates

Study Major Dates

• Study Start (Actual): August 30, 2017
• Primary Completion (Actual): October 30, 2017
• Study Completion (Actual): November 17, 2017

Study Registration Dates

• First Submitted: April 7, 2022
• First Submitted That Met QC Criteria: April 7, 2022
• First Posted (Actual): April 14, 2022

Study Record Updates

• Last Update Posted (Actual): June 16, 2022
• Last Update Submitted That Met QC Criteria: June 13, 2022
• Last Verified: June 1, 2022

More Information

Terms related to this study

• Keywords: randomized controlled trial; Medicaid; Affordable Care Act
• Other Study ID Numbers: 042022

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The researchers are committed to sharing as much data as possible for replication, consistent with the privacy and security requirements of the state agency that govern the re-disclosure of the data.
• IPD Sharing Time Frame: Data will be available with investigator support upon publication.
• IPD Sharing Access Criteria: Replication data can be accessed via request to the primary investigator upon publication.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No