Key Strategies That States Used for Managing Medicaid and Marketplace Enrollment During the COVID-19 PHE

Summary

An Issue Brief, Key Strategies That States Used for Managing Medicaid and Marketplace Enrollment During the COVID-19 PHE, OEI-09-20-00590, September 2023, under Ann Maxwell, Deputy Inspector General for Evaluation and Inspections. The brief states that it highlights strategies State Medicaid agencies and State-based Marketplaces described as beneficial during the COVID-19 Public Health Emergency and that it contains no recommendations from OIG. It states that the strategies are drawn from surveys of State Medicaid agencies (49 of 51) and all 18 State-based Marketplaces with their own enrollment platforms about experiences from January 2020 through February 2022. The executive summary begins with strategies including expanded outreach efforts.

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Issue Brief
Key Strategies That States Used for Managing
Medicaid and Marketplace Enrollment During the
COVID-19 PHE
Ann Maxwell
Deputy Inspector General
for Evaluation and Inspections
September 2023, OEI-09-20-00590

Key Strategies for Managing Enrollment
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How States Can Use This Resource
This brief highlights strategies that State Medicaid agencies
and State-based Marketplaces described as beneficial for their
applicants, enrollees, and enrollment staff during the COVID-19
Public Health Emergency (PHE).
Although this brief does not contain recommendations from
OIG, it does provide insights that State officials might find
helpful to consider for their program operations.
Reflecting on the challenges that States faced, and the
strategies they employed, may be useful as State Medicaid and
State-based Marketplace officials continue to adapt enrollment
processes and prepare for future public health emergencies.
“The public health
emergency has [had] a
silver lining in allowing us
to dive in deeper to
eligibility and enrollment
to identify what is and
isn't working well…This is
pretty significant as it not
only helps now but sets up
a better Medicaid for the
future.”
-Medicaid official, CO

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The strategies outlined in this
brief are drawn from surveys
of
• State Medicaid agencies
(49 of 51); and
• all 18 State-based
Marketplaces with their
own enrollment platforms
during the public health
emergency (PHE)
about their experiences from
January 2020 through
February 2022.
Executive Summary
The public health emergency
States used several strategies for addressing enrollment
created new challenges for Medicaid
challenges
and Marketplace enrollment
State Medicaid agencies and State-based
Expanded outreach efforts. States leveraged information from a variety of sources
Marketplaces—collectively, “States”—faced
to identify potential enrollment disparities and target their outreach.  They took
challenges in maintaining key enrollment
actions to address barriers to applicants being able to access information about
functions as a result of a rapidly changing
enrollment through outreach efforts and found different ways to connect with
landscape during the COVID-19 PHE.  States
existing enrollees and groups of people newly eligible to enroll.
could no longer rely on existing outreach
practices because patterns of work and life
Improved applications and support. States expanded options for receiving
shifted with the closure of workplaces and
application assistance; simplified their application processes; and updated their online
other community settings.  COVID-19 also
application features and tools to support their applicants and enrollees.
exacerbated ongoing staffing shortages.
Further, gaps in demographic data about
Simplified eligibility determination processes. States streamlined their Medicaid
applicants and enrollees limited States’ ability
and Marketplace eligibility determination processes while also being mindful of
to identify disparities and to support equitable
program integrity vulnerabilities.
access to enhanced coverage.
Adapted program operations. States introduced new ways of managing enrollment
At the same time, States faced a surge in
and modified their hiring and onboarding processes. States also reflected on their
demand for coverage and had to align their
experiences to help them reconsider program operations in preparation for another
enrollment and program operations with new
emergency.
Medicaid and Marketplace requirements and
eligibility options promulgated in response to
COVID-19.

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Study Methodology
The Office of Inspector General (OIG) collected survey
Our analysis revealed many parallels between enrollment
information between November 2021 and February 2022 from
experiences described by staff in State Medicaid agencies and
49 of 51 State Medicaid agencies including the District of
Marketplaces.  When both State Medicaid agencies and
Columbia and all 18 State-based Marketplaces that used their
Marketplaces have reported using the enrollment actions or
own enrollment platform at some point during the PHE. In
strategies described in this brief, we use the general term
these surveys, we asked Medicaid and State-based Marketplace
“States.”  We refer specifically to either State Medicaid agencies
(hereafter “Marketplace”) officials about their experiences with
or Marketplaces when describing actions that were unique to
enrollment processes during the PHE, from January 2020 to the
one of those programs (e.g., actions related to Medicaid’s
time of their survey response.
continuous enrollment requirement and enhanced financial
assistance for Marketplace Qualified Health Plans), or those
We separately analyzed the Medicaid and Marketplace survey
actions that were only mentioned in survey responses from one
responses to identify: 1) challenges that Medicaid agencies and
of the programs.
Marketplaces experienced during the COVID-19 PHE;
2) strategies they implemented or maintained to address these
OIG relied on survey responses from State Medicaid agencies
challenges; and 3) the perceived impact of any changes they
and Marketplaces about their experiences during the PHE and
made to enrollment, including potential vulnerabilities
did not independently evaluate the implementation or
introduced to their programs.
effectiveness of reported strategies.
Our analysis examined common themes and actions, ultimately
identifying 12 strategies that State Medicaid agencies and
Marketplaces used and described as beneficial to their
enrollment processes during the PHE.  We organized these
We conducted this study in accordance with the Quality
12 strategies into 4 themes reflecting different aspects of the
Standards for Inspection and Evaluation issued by the Council of
enrollment process.  The specific actions listed in this resource
the Inspectors General on Integrity and Efficiency.
guide reflect statements from one or more State Medicaid
agencies or Marketplaces.

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At a Glance: Strategies Used by States During the PHE
Expanded Outreach
Efforts
Strategy 1.
Gathered additional data to help
identify and reduce potential
disparities
Strategy 2.
Addressed barriers to applicants
accessing enrollment information
Strategy 3.
Altered their outreach efforts to
adapt to changing circumstances
Improved Applications
and Support
Strategy 4.
Expanded options for receiving
application support
Strategy 5.
Simplified application and renewal
processes for applicants
Strategy 6.
Updated online application
features and tools
Strategy 7.
Extended Medicaid eligibility and
Marketplace enrollment
opportunities
Simplified Eligibility
Determinations
Strategy 8.
Streamlined eligibility
determination processes for
applicants
Strategy 9.
Identified and tracked potential
program integrity vulnerabilities
Adapted Program
Operations
Strategy 10.
Modified hiring and onboarding
protocols to maintain staffing
Strategy 11.
Introduced new ways of working
and managing enrollment
functions
Strategy 12.
Collected lessons learned about
emergency preparedness
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Expanded Outreach Efforts
States reported experiencing the following challenges that
affected their ability to notify current enrollees and prospective
applicants about the availability of coverage and program
changes:
Incomplete data to target outreach. States shared
Limitations of traditional outreach. Established
that they did not have complete data to identify and address
outreach efforts were no longer available or effective because
enrollment disparities during the PHE.  For example,
the media use and preferences of prospective applicants
demographic data is often missing on applications for
shifted during the PHE.  For example, radio announcements
Medicaid and Marketplace.
were less effective as radio consumption dropped.  States were
also unable to hold planned in-person outreach events to share
Difficulty reaching all prospective applicants.
information about enrollment options.  Further, the
According to States, enrollment during the PHE may have
unprecedented nature of the pandemic and related job losses
become particularly challenging for people who lacked
meant that States had to reach new populations that may have
resources to access information and applications online, such
had little awareness of options for Medicaid and Marketplace
as Internet access or laptop computers or tablets, and to those
coverage.
with limited technological or English proficiency.
Difficulty maintaining contact with enrollees.
Maintaining accurate, updated contact information for
enrollees became more challenging as some relocated during
the pandemic and Medicaid renewal processes changed.

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Strategy 1. States gathered additional data to
help identify and reduce potential disparities
States reported taking actions to supplement incomplete data and
better understand how to reach all prospective applicants:
Used a statewide pulse survey to collect information to learn more about health disparities and
how people in different demographic groups, such as the uninsured, understand the Marketplace.
Used focus groups to learn how different communities understood coverage options, such as the
affordability of Qualified Health Plans, to help Marketplaces target messaging about the availability
of program offerings.
Gathered information from partners who had direct contact with applicants to identify
disparities in access to coverage or assistance through the experiences of navigators, assistors,
and community groups.  This provided insights about people who may have been facing unique
access challenges.
Collected feedback from tribal communities, during tribal consultation meetings, about changing
eligibility policies and practices.
“Imperfect/incomplete race,
ethnicity, and language data
among enrollees [is a
challenge] –since the
application field asking for
race/ethnicity data is
optional, we have very
incomplete data which
makes it difficult to know if
we are enrolling
the…individuals our
outreach is designed to
reach.”
-Marketplace official, MA
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Strategy 2. States addressed barriers to applicants
accessing enrollment information
States reported taking action to address barriers to applicants
receiving information about enrollment through outreach efforts:
Partnered with trusted community-based groups with a history of working in local communities,
to connect with people who may not have been reached by other outreach efforts.
Focused outreach on people who were most likely to benefit from new enrollment options or
special support.
Translated enrollment materials into multiple languages, and integrated a translation tool into the
website so people could access information in their preferred language.
Provided translation services at community events to ensure that all attendees could access
important information.
Provided access to immigration attorneys to answer legal questions about eligibility for
enrollment and to address any  concerns applicants may have had about applying for coverage or
financial assistance.
“Reaching consumers directly
was a challenge, particularly
residents in underserved
communities. Where
technology or Internet access
could be limited.”
-Marketplace official, CT
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Strategy 3. States altered their outreach efforts to
adapt to changing circumstances
States reported taking action to address the loss of contact with
enrollees and limitations of traditional outreach:
Leveraged other government agencies, such as employment offices, to target outreach, for
example, to people who may have recently lost their jobs and health insurance coverage.
Conducted outreach in community settings to connect directly with potential applicants.
Modified media strategy as work and commute patterns changed to shift advertising and public
service announcements towards more widely used platforms, such as social and streaming media.
Expanded direct contacts with applicants and enrollees through text messages and emails to
increase the chance that people would receive information about enrollment opportunities and
program updates.
Hosted virtual outreach events to connect with potential applicants, even when offices and other
public settings were closed.
“The agency works very
closely with the hospitals,
FQHCS, rural health clinics,
advocates and community
partners. We trained their
staff on how to assist folks to
apply online and general
eligibility requirements for
our programs as they were
seeing families in their
biggest time of need during
the public health
emergency.”
-Medicaid official, MO
“The ability to have more
interactions virtually...
minimized travel time and
scheduling conflicts. We
were able to consistently
reach more community
partners virtually. Because
many of the marketing
changes we made moved to
more digital and measurable
platforms, we are able to
measure behaviors in new
and different ways, setting
new benchmarks that we can
measure against moving
forward.”
-Marketplace official, CT
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Improved Applications and Support
States reported experiencing the following challenges that
affected the ability of applicants and enrollees to access
applications and support from State staff and to obtain
coverage:
Reduced in-person support for applications.
Other barriers to applying for coverage. Potential
Offices and organizations that facilitate enrollment reduced or
enrollees faced other circumstances that curtailed their ability
temporarily eliminated options for in-person support and
to obtain coverage during the PHE.  For Medicaid, not everyone
appointments due to concerns about the spread of COVID-19.
who needed COVID-19 care met established eligibility criteria.
For Marketplace coverage, some potential enrollees may have
Procedural barriers to applying. Some established
perceived that the cost of coverage was not affordable.  Also,
procedures, such as reliance on paper documentation and in-
Marketplace enrollment is typically limited to certain times a
person interviews, remained by requirement or convention and
year.
heightened access barriers during the PHE.  Existing
requirements for wet signatures (i.e., not electronic) and limits to
approvals by enrollees’ representatives were especially
challenging for some applicants, such as those residing in
nursing facilities.

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Strategy 4. States expanded options for
receiving application support
States reported taking action to compensate for reductions to in-
person support:
Expanded the availability of telephone and other remote appointments with eligibility and
enrollment staff when offices closed due to safety concerns.
Worked with navigators, assisters, and insurance brokers—entities that help people with their
applications— to ensure that they had processes for providing remote assistance to applicants.
Provided scheduled appointments to help staff plan for the number of people arriving for in-
person assistance.
Hosted webinars and other virtual events to share general information about coverage options to
compensate for the reduction of in-person events.
Expanded or established call centers to field growing requests for information and assistance.
Integrated real-time language translation tools into online applications and guidance to make
them more accessible to a larger number of people.
“[Our State] offers multiple
avenues for clients to apply
for and enroll in Medicaid.
Applications are accepted
online, in person, by
telephone, and mail.  We
have a contract for language
translation that staff have
access to and use as needed
to assist clients…We operate
a toll free call center for
Medicaid questions.  We
have kiosks in every county
for clients who would like
online access but don't have
it available at home.  County
office staff are also available
to assist individuals either at
the kiosk or with completing
paper applications as
needed.”
-Medicaid official, AR
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Strategy 5. States simplified application and
renewal processes for applicants
States reported taking actions to make it easier for applicants to
enroll by reducing procedural barriers:
Shifted in-person interviews to audio or video calls for applicants who required or requested a
meeting as part of their application process.
Allowed applicants and enrollees more time to submit requested documentation before canceling
their application or flagging their enrollment.
Used integrated eligibility and enrollment processes from a range of State and Federal
assistance programs to help applicants to apply for and receive information about Medicaid and
Marketplace coverage through a single point of entry.
Introduced or expanded use of drop boxes as another option for people to submit applications
and supporting documentation.
Provided kiosks at community locations, making online access to applications available to people
who lacked personal computers or Internet access.
Allowed e-signatures and verbal authorizations for documents which, in some cases, required
seeking a policy change within their State, but helped to simplify the process of applying.
“We are more focused than
before on member
experience and reducing
administrative burdens,
which may not be a direct
result of the pandemic, but I
think the pandemic has
heightened our interest in
making sure that the
exchange experience and
enrollment process is as easy,
smooth, and non-abrasive as
possible for people given how
many other demands people
have on their time and
energies, and how important
it is not to let people ‘fall
out’ of coverage for
administrative reasons.”
-Marketplace official, MA
“The benefits of making
these changes [to our
application processes] were
giving customers alternate
methods of accepting their
information and obtaining
services, rather than
eliminating normal
methods…particularly for
persons who have disabilities
or don’t have or can’t get to
a place with Internet access.”
-Medicaid official, GA
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Strategy 6. States updated online application
features and tools
States reported improving online tools and information when in-
person support for applications was less available:
Updated online applications and enrollment portals to provide more information and make them
more user-friendly.
•
Added document upload function to online applications.
•
Clarified or improved instructions in the online application.
•
Introduced chat boxes for live and automated support.
•
Updated the Marketplace portal to allow prospective applicants to more easily review coverage
options and estimate financial assistance.
•
Allowed enrollees to update their own Marketplace enrollment information without having to
contact a call center.
Created an email inbox for applicants and those assisting them to use when communicating
questions and changes with enrollment staff.
“By adopting standardized
navigation throughout the
application, we have made it
more intuitive for customers
to understand where they
are in the application
process, and which steps
remain to complete the
application. The updated
navigation increases
accessibility for all users of
the application.”
-Marketplace official, DC
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Strategy 7. States extended Medicaid eligibility and
Marketplace enrollment opportunities
States reported taking actions to expand eligibility and enrollment
options using new and existing enrollment flexibilities and options:
Used available flexibility to create a new Medicaid eligibility group. For example, the Families First
Coronavirus Response Act and the American Rescue Act allowed Medicaid agencies to enroll people into a
designated eligibility group— the COVID-19 Uninsured Group— to provide access to coverage for medically
necessary COVID-19-related services to uninsured individuals in their State.
Opened Marketplace Special Enrollment Periods to allow people without health insurance to gain
coverage through Marketplaces without having to wait until the end-of-year Open Enrollment.
Worked directly with Marketplace insurers to:
•
Re-enroll people who were improperly disenrolled from plans; and
•
Allow enrollees to maintain payments made towards their deductibles even when changing plans
during Special Enrollment Periods.
Allowed people employed by small businesses and nonprofits to enroll in Marketplace coverage even
if employers could not contribute their share of the premium.
Introduced additional qualifying life events for Marketplace enrollment, such as being uninsured, to
allow people to enroll in Qualified Health Plans.
Introduced new State Marketplace financial assistance to expand access to coverage by helping more
people afford the cost of enrolling in Qualified Health Plans through the Marketplace.
“We implemented
additional qualifying life
events in order to grant
consumers access to
[qualified] health plans
during the public health
emergency to ensure
greater community health
outcomes.”
-Marketplace official, CA
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Simplified Eligibility Determinations
States reported experiencing the following challenges in
making eligibility determinations for program enrollment
and/or financial assistance:
Difficulty obtaining documentation to support
Potential for program integrity vulnerabilities.
eligibility. Government agencies and/or applicants’
Some States continued eligibility verification activities.  Other
States exercised flexibilities that were allowed during the PHE
employers, which would typically provide documentation in
to temporarily pause some of their pre-enrollment and renewal
support of eligibility, experienced office closures and disrupted
verification activities.
operations during the PHE.  Applicants and enrollees faced
difficulty gathering the physical records they needed to
support information in their applications, such as income
statements, because many businesses closed their offices or
reduced hours.
Changing requirements for eligibility and
financial assistance. Federal changes that affected
eligibility, such as the continuous enrollment requirement,
required changes to eligibility determination processes.
Existing system algorithms and other tools for calculating
eligibility and premium assistance were no longer accurate
because of the availability of enhanced subsidies and changes
to how some unemployment insurance income was considered.

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Strategy 8. States streamlined eligibility
determination processes for applicants
States reported taking actions in response to difficulty in obtaining
documentation and changing  requirements:
Expanded use of presumptive eligibility through which applicants can become enrolled
temporarily after being screened by qualified entities, such as hospitals.  Presumptive eligibility can
provide timely access to care for applicants while a final determination is made and offer additional
channels through which individuals can apply.
Increased use of self-attestation, an existing authority that allows States to enroll applicants on the
basis of certain declared information, such as residency and family composition, and verify the
attested information post-enrollment.
Updated enrollment systems and algorithms to account for policy changes—such as increased
financial assistance for Marketplace plans and exclusion of certain unemployment income from
eligibility calculations—so that applicants and enrollees could benefit from these changes
automatically instead of having to manually update their records or submit new supporting
documentation.
Relied more heavily on available electronic records and data to verify information included in
applications instead of asking applicants and enrollees to submit paper copies of supporting
documentation.
“Streamlined eligibility
procedures/policies allowed
for faster enrollment of
beneficiaries during a time
where health coverage and
service access was
paramount.  These changes,
in conjunction with the
continuous eligibility
provisions that reduced
renewal volumes allowed us
to ensure that there was
sufficient staff to rapidly
process requests for
assistance during a period of
significant change in
operational approach.”
-Medicaid official, CT
“Streamlining the eligibility
process has removed
barriers to enrollment for
applicants/recipients and
reduced administrative
burden for the agency.”
-Marketplace official, NY
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Strategy 9. States identified and tracked
potential program integrity vulnerabilities
States reported taking actions to limit potential program integrity
vulnerabilities introduced by changes to eligibility requirements
and determinations:
Implemented periodic data matching to flag enrollees who were deceased or enrolled in
Medicare.
Created flags to help staff prioritize cases for redetermination at the end of the PHE, such as
those of enrollees who had provided new information indicating that they were no longer eligible
for Medicaid but who could not be disenrolled during the PHE.
Modified eligibility and enrollment processes, including by implementing temporary
workarounds and making more permanent changes to legacy systems, to ensure that processes
aligned with the latest requirements and policy changes.
“We have been tracking all
work processes and system
adjustments. We have a
resolution plan based on
guidance from CMS and
meet weekly to discuss
changes, new requirements,
and risks.”
-Medicaid official, ME
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Adapted Program Operations
States reported experiencing the following challenges in
responding to emergency conditions and implementing
necessary changes to program operations:
Staff turnover and hiring difficulties. States faced
Growing caseloads. States had to find a way to manage
high levels of resignations and State employment layoffs.
larger caseloads, often with staffing shortages.  More people
States received few, if any, applicants in response to job
were applying for and remaining enrolled in Medicaid and
postings; found that newly hired staff did not show up to work
Marketplace Qualified Health Plans.  This led to an increase in
or left before completing training; and faced competition with
the number of applications that staff had to process and
other employers for qualified applicants.
review.
Disruption to normal workflows. Enrollment centers
Misaligned systems and processes. States
were required to manage a heavy workload even when faced
experienced challenges while trying to adapt their systems to
with temporary absences and inconsistent work schedules
changing enrollment requirements, including the continuous
among staff due to illness and caregiving responsibilities.
enrollment requirement.  Existing system algorithms and other
States had to adapt their operations to ensure that staff could
tools for calculating eligibility and premium assistance were no
complete their work remotely, while they imposed office
longer accurate because of the availability of enhanced
closures to keep staff and applicants safe by reducing the
subsidies and changes to how expanded unemployment
spread of COVID-19.
insurance income was considered.
PHE uncertainty. The indefinite length of the PHE and
evolving emergency conditions and requirements made it
challenging for States to determine how much to invest in
permanent changes to enrollment processes versus temporary
workarounds.

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Strategy 10. States modified hiring and
onboarding protocols to maintain staffing
States reported taking actions to improve staff retention and
hiring:
Increased employee compensation and incentives to help limit turnover and make enrollment-
related positions more attractive.
Leveraged remote work as an opportunity to recruit new employees who would otherwise have to
relocate.
Contracted with staffing vendors to help manage workloads and prevent enrollment backlogs.
Maintained a contract with a staffing vendor in case surge staffing was needed.
A customer service contractor that staffed Marketplace call centers hired more people with
each cohort of new employees to for expected attrition, and condensed the length of training
protocols for newly hired employees.
“We are increasing hiring
efforts by preparing a
staffing request for the
upcoming legislative session,
hiring contract workers, and
temporarily shifting existing
workers to process eligibility
applications.”
-Medicaid official, OR
“Moving to a remote work
model allowed us to recruit
individuals who may not
have been willing to relocate,
but who brought immediate
relevant experience and
expertise to our team.”
-Marketplace official, ME
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Strategy 11. States introduced new ways of
working and managing enrollment functions
States reported taking actions to address disruptions to their normal
workflows, adapt to changing requirements, and manage growing
caseloads:
Prioritized investments in technology that allowed staff to work remotely, such as laptops.
Developed new internal tools, such as instant messaging, to allow staff to communicate more
effectively to resolve issues more quickly.
Provided staff with remote access to a verification system which allowed them to continue
completing eligibility determinations when away from physical offices.
Developed new work aids and guidance for staff, which detailed the latest system and process
changes to help ensure that staff were implementing them appropriately.
Introduced flexible work arrangements, including remote work options and flexible schedules which
allowed staff to more easily manage illnesses and family responsibilities and continue work duties.
Organized more regular meetings for managers to review metrics and emerging customer issues.
Modified staff assignments and workflows to prioritize critical functions, such as those that allowed
States to get people enrolled more quickly.
Redistributed work within and across regional offices or divisions to manage increasing demands
for assistance.
“As the pandemic began,
[the Marketplace] went fully
virtual and prioritized
resources needed to perform
core functions to support
expansion and maintenance
of health insurance
coverage.”
-Marketplace official, DC
“Moving all of our own staff
to remote working
(teleworking) has proven to
work better than originally
expected, and is likely to
continue after the PHE ends.”
-Medicaid official, UT
“Technology, connectivity,
and equipment are key to
ensuring operations are
maintained.”
-Medicaid official, SD
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Strategy 12. States collected lessons learned
about emergency preparedness
States reported identifying lessons about how to deal with
uncertainty and changing requirements during an emergency:
Emergency planning was more critical for programs than previously understood, and States
needed to account for any emergency duration and potential degree of disruption.
Understanding that temporary measures taken during an emergency response may have longer-
term consequences. For example, using short-term workarounds to adhere to the continuous
enrollment requirement may have created more work for Medicaid agencies at the end of the PHE than
implementing a more resource-intensive, long-term change.
Building flexibility into enrollment processes and operations allowed States to adapt to changing
requirements and respond to dynamic emergency conditions, such as office closures and surges in
demand for coverage.
Coordinating across programs and agencies was needed to ensure that States’ actions during the
PHE were aligned with other healthcare coverage programs, government agencies (e.g., the
Department of Labor), and social supports needed by enrollees (e.g., the Supplemental Food Assistance
Program and Temporary Assistance for Needy Families.)
Maintaining regular communication with staff, enrollees, and prospective applicants was
important to explain changes in policy and procedures, and to help prevent enrollees from falling out
of coverage.
Considering the equity impact of policy and process changes was important to ensure that
emergency response decisions did not worsen disparities in access to coverage or assistance.
“The most significant
change to our Medicaid
program is understanding
that it is not immune to
emergencies—it has to be
flexible in times of an
emergency, and it must
sustain itself no matter how
long that emergency lasts.
Staff must be ready to
understand communications
that have to be made quickly
and they have to be flexible
to take the actions conveyed
to them quickly.”
-Medicaid official, GA
“It is critical to look at
policy, IT, processes, and
other changes through an
equity lens.”
-Marketplace official, DC
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Conclusion
The insights and lessons presented here, drawn from States’
experiences responding to the dramatic disruptions and
increased demands caused by COVID-19, can inform other
States’ efforts to improve their current processes and help
them prepare for future local, State, or Federal emergencies.
OIG recognizes that Medicaid agencies and Marketplaces must
weigh many factors when changing their enrollment practices.
Enrollment systems involve complex processes; procedural
changes can have cascading and sometimes unintended
consequences.  Before making changes to their enrollment
processes, States will need to consider several factors, such as
how or whether to invest new resources and how to address
program integrity concerns.  With careful planning and
reflection, State Medicaid agencies and Marketplaces may be
able to strengthen their enrollment processes, using the
insights provided here, in a way that benefits applicants and
enrollees as well as the programs and staff that administer
them.

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Acknowledgments
Camille Harper served as the team leader for this study, and Emily Borgelt and
Michelle Goodwin served as lead analysts.  Others in the Office of Evaluation and Inspections San
Francisco Regional Office who conducted the study include Sanaea Cowasjee, with support from
Data Visualization Technical Expert China Tantameng.  Office of Evaluation and Inspections
headquarters staff who provided support include Althea Hosein, Lyndsay Hopper, Kevin Manley,
and Sarah Swisher.
This report was prepared under the direction of Blaine Collins, Regional Inspector General for
Evaluation and Inspections in the San Francisco Regional Office, and Abigail Amoroso, Deputy
Regional Inspector General.
Contact
To obtain additional information concerning this report,
contact the Office of Public Affairs at
Public.Affairs@oig.hhs.gov. OIG reports and other
information can be found on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Key Strategies for Managing Enrollment
OEI-09-20-00590

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