Form 1 Rural Health Care Services Outreach Supplement Performan

Affordable Care Act (ACA) Outreach and
Enrollment Supplemental Funding
Data Collection Measures
Using the following measures, please report only on the activities that are supported by
the Affordable Care Act (ACA) Outreach and Education Supplemental Funding.

Part 1: Organization Details
1. Reporting Period

2.
3.
4.
5.

Data Collection Period

Data Reporting Period

October 1st, 2013- December 31st, 2013

January 13-31st, 2014

January 1st, 2014- April 30th, 2014

May 1st, 2014- May 31st, 2014

Grantee Organization- Select from a Drop Down Menu
Organization Type- Select from a Drop Down Menu
Did your state expand Medicaid? Yes/No
Did you state create an Insurance Exchange? Yes/No

Part 2: Outreach & Enrollment Personnel
1. Number of Outreach and Enrollment assistance workers that have successfully
completed all required federal and/or state training
2. Number of general educators who provide information to consumers to raise
awareness
Part 3: Outreach and Education
1. Events - Includes presentations at community events such as health fairs, civic
clubs, school events, partner meetings, etc.
 Number of Events
 Total number reached
2. Education Materials - Includes brochures, flyers, radio and television spots aired,
billboards and any other materials purchased, created and disseminated.
 Number of educational materials
 Number of radio spots aired
 Number of TV spots aired
 Number of other materials

Affordable Care Act (ACA) Outreach and
Enrollment Supplemental Funding
 Other materials? Provide an explanation
3. One-on-One Counseling - Individual counseling sessions for raising awareness
and enrollment assistance.
 Number of individuals educated on health insurance options
 Number of individuals assisted with enrollment by a trained Outreach and
Enrollment assistance worker
4. Referrals
 Number of individuals who receive eligibility determination for the Federal
Health Insurance Marketplace by a trained Outreach & Enrollment assistance
worker
 Number of individuals who receive eligibility determination for the State
Health Insurance Marketplace by a trained Outreach & Enrollment assistance
worker
 Number of individuals who receive eligibility determination for the Medicaid by
a trained Outreach & Enrollment assistance worker
 Number of individuals who receive eligibility determination for the Medicaid by
a trained Outreach & Enrollment assistance worker
 Number of individuals referred to a trained Outreach & Enrollment assistance
worker
Part 4: Enrollment
1. Number of individuals who enroll in the Federal Health Insurance Marketplace
with the assistance of a trained Outreach/Enrollment assistance worker
2. Number of individuals who enroll in the State Health Insurance Marketplace with
the assistance of a trained Outreach/Enrollment assistance worker
3. Number of individuals who enroll in Medicaid with the assistance of a trained
Outreach/Enrollment assistance worker
Part 5: Additional Resources


Has your organization received any other funding to promote the Affordable Care Act other
than the $25,000 supplemental funding related to your Outreach grant? Yes/No



If so, how much additional funding did your organization receive? Enter Amount:



Did having received the Outreach supplemental funding contribute to your being able to
obtain this additional funding? YesNo