Form 28 OE Progress_Report (track changes)

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration HEALTH CENTER OUTREACH AND ENROLLMENT (O/E) QUARTERLY SUPPLEMENTALPROGRESS REPORT (QPR)	FOR HRSA USE ONLY
	Application Tracking Number	Grant Number

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

Outreach and Enrollment ActivitiesProgress toward O/E Projection	Previous Reporting Period	Current reporting period	Cumulative Total # of individuals assisted with O/E Beginning 10/1/2014
1a. Number Trained Number of assisters O/E working on behalf of the health center who have successfully ers who completed all required federal and/or state HHS training (certified application counselor or equivalent, at a minimum) to assist individuals with enrollment through Federal, state-based, or state partnership marketplaces for the 2015 open enrollment period. in previous quarter	ers in previous quarter		Budget period projection of individuals to be assisted with O/E To be calculated by HRSA
1b. Assists Provided Number of unique individuals assists provided* by trained assistersO/E working on behalf of the health center to support individuals with actual or potential enrollment or reenrollment in health insurance available through Marketplace qualified health plans and/or through Medicaid or CHIP. Include assistance with activities such as: Understanding health insurance options through one-on-one or other customizable education Creating a user account in the Marketplace Updating an account profile and/or income information Filing an exemption or appeal Understanding Marketplace auto-enrollment notices Submitting an application to/through the Marketplace or directly to the state Medicaid agency (also include as an application submitted) Understanding an eligibility determination Selecting a new or different Marketplace plan Report the number of lives assisted, e.g., assistance provided that would cover a mother and two children = 3. Report assistance by session, e.g., one session providing assistance to one individual with one or more of the activities above=1.			To be calculated by HRSA
1c. Applications Submitted Number of applications submitted to the Marketplace and/or directly to state Medicaid agency for coverage in Marketplace qualified health plans and/or Medicaid or CHIP with the help of a trained assister working on behalf of the health center. Include the following: Applications submitted for enrollment in a new or different Marketplace plan, even by individuals previously enrolled, and Medicaid/CHIP renewals/re-enrollments. Report the number of lives covered by each application, e.g., an application covering a mother and two children = 3.			To be calculated by HRSA
1d. Estimated Enrolled Number of individuals estimated to be enrolled through the Marketplace, Medicaid, and/or CHIP with the help of a trained assister working on behalf of the health center. Report the number of individuals determined or presumed to be eligible for coverage and for whom the assister has confirmation or reasonable confidence of an intent on the part of the consumer to complete the enrollment process (e.g., the consumer has selected a Marketplace plan and has been informed about how to pay the premium or has submitted a complete application to the state Medicaid agency). Report the number of lives estimated to be enrolled, e.g., enrollment that covers a mother and two children = 3.Whole numbers only	Whole numbers only	Auto-calculate from past submissions.	To be calculated by HRSA Prepopulate with projection in application.

2. Coordination of Efforts

How have you coordinated your O/E efforts with other health centers and with other state or local efforts?

1500 characters (1/2 page)

23. Issues/Barriers (for the current reporting period only)

For the current reporting period, describe up to three Describe any major O/E issues/barriers that you experienced while conducting outreach and enrollment activitieshave encountered.

Required; up to 2500 1500 characters (1/2 page)

34. Key Strategies and Lessons Learned (for the current reporting period only)

For the current reporting period, describe up to three Describe key strategies and lessons learned that have contributed most to the success of your outreach and enrollment O/E efforts.

Required; up to 2500 1500 characters (1/2 page)

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