North Carolina Story Collection Campaign on the Health Care Coverage Gap

Transcription

1 TOOLKIT North Carolina Story Collection Campaign on the Health Care Coverage Gap North Carolina Community Health Center Association 4917 Waters Edge Drive, Suite 165 Raleigh, NC Updated 11/10/15

2 Thank You Thank you for your willingness to support North Carolinians who fall in the Health Insurance Coverage Gap. This toolkit is designed to provide support for people across the state interacting with those in the Coverage Gap, so you can direct them to engaging on this issue. The focus of this particular engagement action is sharing his/her story so it can be highlighted in media or through contact with policy makers so they understand why closing the Coverage Gap in North Carolina is so important. This toolkit is meant to help you connect individuals you identify in the coverage gap with our organization and others working to Close the Coverage Gap. We hope this project will empower those in the Coverage Gap and help them to feel their concerns are heard. This toolkit is provided to help you feel more comfortable making this connection. CONTENTS: 1. Flyer about the Health Insurance Coverage Gap and Sharing Consumer Stories explains what the Coverage Gap is and how to share a story. 2. Draft script for asking a consumer if they are willing to participate in the Story Collection Project. 3. An authorization form this is a separate consent form specifically for the story collection effort. Scan it and send it to closethegapnc@gmail.com or fax it to Someone on the story collection team will follow up with the consumer. 4. A follow up letter for the consumer to thank them and to provide information about who is leading this project. 5. A request for individuals to share their pictures if they don t feel comfortable sharing their entire story. 6. A quick story form to gather information from individuals who don t have time to complete an interview. THANK YOU for helping us identify individuals in the Coverage Gap. We could not succeed with this project without your assistance. Sincerely,

3 Making the Ask Will you share your story? AFTER IDENTIFYING A PATIENT IS IN THE COVERAGE GAP, THIS IS ONE WAY TO ASK A CONSUMER IF HE/SHE WOULD BE WILLING TO PARTICIPATE IN THE STORY COLLECTION PROJECT: Mr. Smith, I m really sorry you don t qualify for subsidies on the federal marketplace. You are what we call the health insurance Coverage Gap. You don t have access to employer sponsored insurance, you don t qualify for Medicaid or Medicare, and your income is too low to get affordable coverage through HealthCare.gov. The federal government set aside funding for North Carolina to offer subsidies or Medicaid to people like you in the Coverage Gap but so far our state leaders have chosen not to do so. Advocates around the state are looking for personal Coverage Gap stories like to show how people and communities are impacted. Would you be interested in sharing your experience with advocates working on this issue? WAIT FOR THE ANSWER. IF YES: Thank you so much for your willingness. Signing this authorization form allows me to share your contact information with the NC Community Health Center Association, which is leading the Story Collection project. They may choose to use your story in a story booklet or connect you with other advocates working on this issue. However, we (or our colleagues at the NCCHCA) will be sure to double check with you first before your story is publicly shared. We want to make sure you are completely comfortable with how your story is used. IF NO: I understand. Health issues are very personal. If you change your mind, feel free to let me know. Another option is to share your photo. The advocates are collecting photos of individuals in the coverage gap to draw attention to the vast number of impacted. You can text a photo (or selfie) to (919) or send it via to closethegapnc@gmail.com. Please remember you can always come to our community health center for your primary care needs. We will do all we can to help. Thank you so much.

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5 AUTHORIZATION AND RELEASE FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI) AND RELEASE OF RIGHTS AUTHORIZATION AND RELEASE FOR USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI) AND RELEASE OF RIGHTS Section A: This section must be completed for all Authorizations I authorize Community Health Center (CHC),, and the North Carolina Community Health Center Association (NCCHCA) to use or disclose the specific Information about me described below, for the Purpose(s) described below. Patient name: Birth Date: Phone Number: Patient Address: E mail address: Information To Be Used Or Disclosed My name and any photograph or video in which I may appear. Protected health information about me (as defined in the Federal Health Insurance Portability and Accountability Act (HIPAA)). This may include information about my access to care, the care I have received, my clinical outcomes, my health conditions, my income, and my insurance status. Any other information I may share during an interview. Purpose(s) For The Use Or Disclosure I acknowledge and agree that the CHC or NCCHCA may use and disclose all or any part of the Information described above, including protected health information: for marketing, educational, policy advocacy, and public relations purposes; and in press releases, print and online publications, public service announcements, and other materials ( Materials ), any or all of which may be printed, transmitted, broadcast, posted online, or otherwise published in any type of media. Release of Rights I hereby grant to NCCHCA any and all rights I may have with regard to any Materials, including any copyright in them. On behalf of myself and any family member about whom I may share information, and to the fullest extent permitted by law, I waive all rights and release any claim based upon or relating to the use or disclosure of the Information as set forth above. This waiver of rights and release of claims shall include, but not necessarily be limited to: Claims against the CHC, NCCHCA, NCCHCA's members, and any of their agents, employees, directors, officers, successors and assigns; Claims for invasion of any right to privacy, violation of any right of publicity, violation of any law regarding protected health information, or any similar matter; and Claims that may have been unknown or unforeseenonthedateisignedthisauthorization. I understand that: 1. I may refuse to sign this authorization and that this authorization is strictly voluntary. 2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization. 3. I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any Materials published or actions taken by the PCC or NCCHCA before the organization received the revocation. (To revoke this authorization, please contact NCCHCA at (919) or contact your CHC directly.) 4. Unless I choose to revoke this authorization, it remains in effect and will not expire until the CHC or NCCHCA decide to no longer publish or use any Information. 5. Once released, my information may no longer be protected by federal privacy regulations and may be re disclosed. 6. I understand that I may see and obtain a copy of the information described on this form or a copy of this form, if I ask for it. 7. This authorization is given without any promise that I will receive compensation. Section B: Signature I have read the above and authorize the disclosure of the protected health information as stated. Signature of Patient/Guardian/Patient Representative: Date: Print Name of Patient/Patient Representative Relationship or scope of your legal authority to act on the patient s behalf:

6 The Story Collection Project Closing the Coverage Gap in NC Hello! Thank you for being willing to share your health care experiences with us. We believe sharing stories of real people who cannot access needed health care services will be a powerful way to show how increasing access to insurance coverage can positively impact the lives of more than 400,000 North Carolinians. By giving your contact information to one of our health center colleagues, you are giving them permission to share it with us. A number of organizations across the state are working to encourage our state leaders to increase access to insurance coverage for those in the coverage gap population, meaning they make less than 100% of the federal poverty level and do not qualify for insurance through an employer, the Affordable Care Act, Medicaid, or Medicare. Next, you can call (919) and leave a message with information about your health care coverage story. If we don t hear from you directly, one of the organizations connected with this work, most likely the NC Community Health Center Association, will contact you to learn more about your experiences. Below is the contact information for our organization and our address. Feel free to call us directly, otherwise, you can expect a call from us soon. Thank you for your participation! Kristen Dubay NC Community Health Center Association, closethegapnc@gmail.com To get help telling the story of your struggle to access affordable health care coverage, call (919)

7 Don t want to share your story but still want to help? Share your picture! We are compiling photos showing faces of those in the coverage gap. If you would be willing to share a picture of yourself, consider taking one of these two actions: A) Take a selfie or have a friend take your picture and it to us at closethegapnc@gmail.com or text it to us at (919) B) If you are unable to or text your picture, give us a call at (919) , leave a message with your name and contact information, and we will call you back with details about collecting your picture for this project. Thank you for your participation! NC Community Health Center Association, To get help telling the story of your struggle to access affordable health care coverage, call (919)

8 Don t have time for an interview but still want to tell your story? Complete this quick story form! Name: Age: Community of Residence: Occupation: Phone: Address or 1. How long have you been uninsured? 2. How do you access the health care you need? What care are you UNABLE to access? 3. How does your lack of health insurance impact your life? 1. If you could communicate with NC legislators about expanding insurance coverage, what would you tell them? 5. Being uninsured keeps me from. Thank you for your participation! Kristen Dubay NC Community Health Center Association, closethegapnc@gmail.com To get help telling the story of your struggle to access affordable health care coverage, call (919)