27 Outreach and Enrollment Supplemental 2017 Final

OMB No.: 0915-0285     Expiration Date: XX/XX/20XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration HEALTH CENTER PROGRAM: OUTREACH AND ENROLLMENT SUPPLEMENTAL	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

Grantee Information
Grantee Name, City, State:	Application Tracking Number:

Budget Information
Requested Amount		Maximum Eligible Amount

1. Outreach and Enrollment (O/E) Strategy Summary

*How will you use O/E funding and leverage current resources to meet the new eligibility assistance and enrollment needs for both patients served by your health center and individuals in your approved service area? (Maximum 1500 characters)

2. Coordination and Collaboration

*How will you coordinate O/E efforts with other health centers (Health Center Program grantees and look-alikes) and with other state, local, and regional O/E efforts? (Maximum 1500 characters)

3. Projected Impact—Within 12 Months of Award

NEW FTEs *Projected # of additional funded O/E assistance FTEs.1 “Additional funded FTEs” refer only to those FTEs supported by this O/E supplement.
TRAINING *Projected # of health center O/E assistance workers who will complete all required and applicable federal and/or state consumer assistance training. This includes additional funded O/E FTEs and current O/E assistance workers, including volunteers, who will dedicate some or all of their time to O/E activities.
ASSISTANCE *Projected # of individuals to be assisted by all health center O/E assistance workers. Count as “to be assisted” the number of individuals to be assisted in any part of the enrollment process, i.e., being educated about affordable insurance coverage options, setting up a profile in the portal, filing affordability assistance information, receiving an eligibility determination, and/or enrolling in affordable health insurance. Include individuals to be assisted by any trained O/E assistance workers (funded FTEs and current O/E assistance workers, including volunteers).
*ENROLLMENT Projected # of individuals to be enrolled with the assistance of all health center O/E assistance workers. Count as “to be enrolled” the number of individuals assisted (see above) who will enroll in affordable insurance coverage. The number to be enrolled is a subset of the number to be assisted. Include individuals enrolled by any trained O/E assistance workers (funded FTEs and current O/E assistance workers, including volunteers).

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857

1 Outreach workers are defined by HRSA’s Uniform Data System as individuals conducting case finding, education, or other services to identify potential clients, and/or facilitate access/referral of clients to available health center services. Eligibility assistance workers are defined by HRSA’s Uniform Data system as staff providing assistance in securing access to available health, social service, pharmacy and other assistance programs, including Medicaid, WIC, SSI, food stamps, TANF, Pharmacy Assistance Programs, and related assistance programs. These include: Benefits Assistance Workers, Pharmacy Assistance Program Eligibility Workers, Eligibility Workers, Patient Navigators, Patient Advocates, and Registration Clerks.