Title X Outreach and Enrollment Report

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


TITLE X OUTREACH AND ENROLLMENT (O/E) PROGRESS  REPORT
FOR OPA USE ONLY

Grant Number



Grantee Information
Grantee Name, City, State:

Number of Service Sites for which data is reported: ______

    1. O/E Activities
Current reporting period
1a.
Number of O/E assistance workers1 that have successfully completed all required federal and/or state training.


Number of O/E assistance workers that have successfully completed all required federal and/or state training for full Medicaid (only).


Number of O/E assistance workers that have successfully completed all required federal and/or state training for partial Medicaid programs (ex: Family Planning Waiver Program).


Number of O/E assistance workers that have successfully completed all required federal and/or state training for other state special programs.


Number of O/E assistance workers that have successfully completed all required federal and/or state training for the Health Insurance Marketplace.


Number of O/E assistance workers that have successfully completed all required federal and/or state training for all of the above.

1b.
Number of individuals assisted2 by a trained O/E assistance worker.


Number of individuals assisted by a trained O/E assistance worker for Medicaid only. (OPTIONAL)


Number of individuals assisted by a trained O/E assistance worker for partial Medicaid (Family Planning Waiver Program or SPA). (OPTIONAL)


Number of individuals assisted by a trained O/E assistance worker for the health insurance marketplace only. (OPTIONAL)

1c.
Number of individuals who receive an eligibility determination3 for the Marketplace, Medicaid, or CHIP with the assistance of a trained O/E assistance worker.


Number of individuals who receive an eligibility determination  with the assistance of a trained O/E assistance worker for Medicaid only. (OPTIONAL)


Number of individual who receive an eligibility determination with the assistance of a trained O/E assistance worker for partial Medicaid (Family Planning Waiver Program or SPA). (OPTIONAL)


Number of individuals assisted by a trained O/E assistance worker for the health insurance marketplace only. (OPTIONAL)

1d.
Number of individuals who enroll in any plan (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained O/E assistance worker.


Number of individuals who enroll in a partial Medicaid  with the assistance of a trained O/E assistance worker.4 (OPTIONAL)


Number of individuals who enroll in full Medicaid or other public insurance plan (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained O/E assistance worker.4 (OPTIONAL)


Number of individuals who enroll in a private plan (e.g., select a plan purchased in an exchange/marketplace or through private insurance) with the assistance of a trained/OE assistance worker.4 (OPTIONAL)


2. Barriers (for the current reporting period only)
Describe any major outreach and enrollment barriers you have encountered.


Required; up to 1500 characters (1/2 page)


3. Key Strategies and Lessons Learned (for the current reporting period only)
Describe key strategies and lessons learned that have contributed to the success of your outreach and enrollment efforts.


Required; up to 1500 characters (1/2 page)