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 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).  
The public health 
Although this brief does not contain recommendations from 
emergency has [had] a 
OIG, it does provide insights that State officials might find 
silver lining in allowing us 
helpful to consider for their program operations.
to dive in deeper to 
eligibility and enrollment 
Reflecting on the challenges that States faced, and the 
to identify what is and 
strategies they employed, may be useful as State Medicaid and 
State-based Marketplace officials continue to adapt enrollment  isn't working well...This is 
processes and prepare for future public health emergencies. pretty significant as it not 
only helps now but sets up 
a better Medicaid for the 
future.
-Medicaid official, CO
Key Strategies for Managing Enrollment
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OEI-09-20-00590 Executive Summary
The public health emergency  States used several strategies for addressing enrollment 
created new challenges for Medicaid  challenges
and Marketplace enrollment
The strategies outlined in this  State Medicaid agencies and State-based  Expanded outreach efforts. States leveraged information from a variety of sources 
brief are drawn from surveys  Marketplacescollectively, Statesfaced  to identify potential enrollment disparities and target their outreach.  They took 
of 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 
 State Medicaid agencies  landscape during the COVID-19 PHE.  States  existing enrollees and groups of people newly eligible to enroll.
could no longer rely on existing outreach 
(49 of 51); and
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 
 all 18 State-based 
other community settings.  COVID-19 also  application features and tools to support their applicants and enrollees.
Marketplaces with their 
exacerbated ongoing staffing shortages.  
own enrollment platforms 
Further, gaps in demographic data about  Simplified eligibility determination processes. States streamlined their Medicaid 
during the public health  applicants and enrollees limited States ability  and Marketplace eligibility determination processes while also being mindful of 
emergency (PHE) to identify disparities and to support equitable  program integrity vulnerabilities. 
access to enhanced coverage.  
about their experiences from  Adapted program operations. States introduced new ways of managing enrollment 
January 2020 through  At the same time, States faced a surge in  and modified their hiring and onboarding processes. States also reflected on their 
February 2022. 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.
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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 Medicaids 
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 Evaluationissued 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.
Key Strategies for Managing Enrollment
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OEI-09-20-00590 At a Glance: Strategies Used by States During the PHE
Expanded Outreach  Improved Applications  Simplified Eligibility  Adapted Program 
Efforts and Support Determinations Operations
Strategy 1. Strategy 4.  Strategy 8. Strategy 10.
Gathered additional data to help  Expanded options for receiving  Streamlined eligibility  Modified hiring and onboarding 
identify and reduce potential  application support determination processes for  protocols to maintain staffing
disparities applicants
Strategy 5. Strategy 11.
Strategy 2. Simplified application and renewal  Strategy 9. Introduced new ways of working 
Addressed barriers to applicants  processes for applicants Identified and tracked potential  and managing enrollment 
accessing enrollment information program integrity vulnerabilities functions
Strategy 6.
Strategy 3. Updated online application  Strategy 12.  
Altered their outreach efforts to  features and tools Collected lessons learned about 
adapt to changing circumstances emergency preparedness 
Strategy 7.
Extended Medicaid eligibility and 
Marketplace enrollment 
opportunities
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OEI-09-20-00590 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 natureof 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.  
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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: 
Imperfect/incomplete race, 
Used a statewide pulse surveyto collect information to learn more about health disparities and 
ethnicity, and language data 
how people in different demographic groups, such as the uninsured, understand the Marketplace. 
among enrollees [is a 
challenge] since the 
Used focus groupsto learn how different communities understood coverage options, such as the 
application field asking for 
affordability of Qualified Health Plans, to help Marketplaces target messaging about the availability 
race/ethnicity data is 
of program offerings. 
optional, we have very 
incomplete data which 
Gathered information from partners who had direct contact with applicants to identify 
makes it difficult to know if 
disparities in access to coverage or assistancethrough the experiences of navigators, assistors, 
we are enrolling 
and community groups.  This provided insights about people who may have been facing unique 
the...individuals our 
access challenges.
outreach is designed to 
reach.  Collected feedback from tribal communities, during tribal consultation meetings,about changing 
eligibility policies and practices.
-Marketplace official, MA
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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:
Reaching consumers directly 
Partnered with trusted community-basedgroups with a history of working in local communities, 
was a challenge, particularly 
residents in underserved  to connect with people who may not have been reached by other outreach efforts.
communities. Where 
Focused outreachon people who were most likely to benefit from new enrollment options or 
technology or Internet access 
special support.
could be limited.
-Marketplace official, CT Translated enrollment materialsinto 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 attorneysto answer legal questions about eligibility for 
enrollment and to address any  concerns applicants may have had about applying for coverage or 
financial assistance. 
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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:
The agency works very 
Leveraged other government agencies, such as employment offices, to target outreach, for 
closely with the hospitals, 
example, to people who may have recently lost their jobs and health insurance coverage.
FQHCS, rural health clinics, 
advocates and community 
Conducted outreach in community settingsto connect directly with potential applicants. The ability to have more 
partners. We trained their 
interactions virtually... 
staff on how to assist folks to  Modified media strategyas work and commute patterns changed to shift advertising and public  minimized travel time and 
apply online and general  service announcements towards more widely used platforms, such as social and streaming media.  scheduling conflicts. We 
eligibility requirements for 
were able to consistently 
our programs as they were  Expanded direct contactswith applicants and enrollees through text messages and emails to 
reach more community 
seeing families in their  increase the chance that people would receive information about enrollment opportunities and 
partners virtually. Because 
biggest time of need during  program updates.
many of the marketing 
the public health 
changes we made moved to 
Hosted virtual outreach eventsto connect with potential applicants, even when offices and other 
emergency.
more digital and measurable 
public settings were closed.
-Medicaid official, MO 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
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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.  
Key Strategies for Managing Enrollment
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OEI-09-20-00590 Strategy 4. States expanded options for 
receiving application support
States reported taking action to compensate for reductions to in-
[Our State] offers multiple 
person support: 
avenues for clients to apply 
for and enroll in Medicaid.  
Expanded the availability of telephone and other remote appointmentswith eligibility and 
Applications are accepted 
enrollment staff when offices closed due to safety concerns.  
online, in person, by 
telephone, and mail.  We  Worked with navigators, assisters, and insurance brokersentities that help people with their 
have a contract for language 
applications to ensure that they had processes for providing remote assistance to applicants.
translation that staff have 
access to and use as needed  Provided scheduled appointmentsto help staff plan for the number of people arriving for in-
to assist clients...We operate  person assistance.
a toll free call center for 
Hosted webinars and other virtual eventsto share general information about coverage options to 
Medicaid questions.  We 
compensate for the reduction of in-person events.
have kiosks in every county 
for clients who would like 
Expanded or established call centersto field growing requests for information and assistance.
online access but don't have 
it available at home.  County  Integrated real-time language translation tools into online applications and guidance to make 
office staff are also available  them more accessible to a larger number of people.
to assist individuals either at 
the kiosk or with completing 
paper applications as 
needed.
-Medicaid official, AR
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OEI-09-20-00590 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:
We are more focused than 
before on member 
Shifted in-person interviews to audio or video callsfor applicants who required or requested a 
experience and reducing 
meeting as part of their application process.
administrative burdens, 
which may not be a direct 
Allowed applicants and enrollees more time to submit requested documentation before canceling 
result of the pandemic, but I 
their application or flagging their enrollment.
think the pandemic has 
heightened our interest in  Used integrated eligibility and enrollment processes from a range of State and Federal   The benefits of making 
making sure that the  assistance programs to help applicants to apply for and receive information about Medicaid and  these changes [to our 
exchange experience and  Marketplace coverage through a single point of entry. application processes] were 
enrollment process is as easy, 
giving customers alternate 
smooth, and non-abrasive as  Introduced or expanded use of drop boxes as another option for people to submit applications 
methods of accepting their 
possible for people given how  and supporting documentation.
information and obtaining 
many other demands people  services, rather than 
Provided kiosks at community locations, making online access to applications available to people 
have on their time and  eliminating normal 
who lacked personal computers or Internet access.
energies, and how important  methods...particularly for 
it is not to let people fall  Allowed e-signatures and verbal authorizations for documents which, in some cases, required  persons who have disabilities 
out of coverage for  seeking a policy change within their State, but helped to simplify the process of applying. or dont have or cant get to 
administrative reasons. a place with Internet access.
-Marketplace official, MA -Medicaid official, GA
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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:
By adopting standardized 
Updated online applications and enrollment portalsto provide more information and make them 
navigation throughout the 
more user-friendly.
application, we have made it 
more intuitive for customers 
 Added document upload function to online applications.
to understand where they 
are in the application   Clarified or improved instructions in the online application.
process, and which steps 
remain to complete the   Introduced chat boxes for live and automated support.
application. The updated 
 Updated the Marketplace portal to allow prospective applicants to more easily review coverage 
navigation increases 
options and estimate financial assistance.
accessibility for all users of 
the application.  Allowed enrollees to update their own Marketplace enrollment information without having to 
-Marketplace official, DC contact a call center.
Created an email inbox for applicantsand those assisting them to use when communicating 
questions and changes with enrollment staff.
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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:
We implemented 
Used available flexibility to create a new Medicaid eligibility group. For example, the Families First 
additional qualifying life 
Coronavirus Response Act and the American Rescue Act allowed Medicaid agencies to enroll people into a 
eventsin order to grant 
designated eligibility group the COVID-19 Uninsured Groupto provide access to coverage for medically 
consumers access to 
necessary COVID-19-related services to uninsured individuals in their State.
[qualified] health plans 
during the public health 
Opened Marketplace Special Enrollment Periods to allow people without health insurance to gain 
emergency to ensure 
coverage through Marketplaces without having to wait until the end-of-year Open Enrollment.
greater community health 
outcomes. Worked directly with Marketplace insurers to:
-Marketplace official, CA  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 coverageeven 
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.
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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. 
Key Strategies for Managing Enrollment
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OEI-09-20-00590 Strategy 8. States streamlined eligibility 
determination processes for applicants
States reported taking actions in response to difficulty in obtaining 
documentation and changing  requirements: 
Streamlined eligibility 
Expanded use of presumptive eligibilitythrough which applicants can become enrolled 
procedures/policies allowed 
temporarily after being screened by qualified entities, such as hospitals.  Presumptive eligibility can 
for faster enrollment of 
provide timely access to care for applicants while a final determination is made and offer additional 
beneficiaries during a time 
channels through which individuals can apply.
where health coverage and 
service access was 
Increased use of self-attestation, an existing authority that allows States to enroll applicants on the 
paramount.  These changes, 
basis of certain declared information, such as residency and family composition, and verify the 
in conjunction with the 
attested information post-enrollment.
continuous eligibility 
provisions that reduced 
Updated enrollment systems and algorithmsto account for policy changessuch as increased 
renewal volumes allowed us 
financial assistance for Marketplace plans and exclusion of certain unemployment income from 
to ensure that there was 
eligibility calculationsso that applicants and enrollees could benefit from these changes 
Streamlining the eligibility 
sufficient staff to rapidly 
automatically instead of having to manually update their records or submit new supporting 
process has removed 
process requests for 
documentation.
barriers to enrollment for 
assistance during a period of 
applicants/recipients and 
significant change in  Relied more heavily on available electronic records and datato verify information included in 
reduced administrative 
operational approach.  applications instead of asking applicants and enrollees to submit paper copies of supporting 
burden for the agency.
-Medicaid official, CT documentation.
-Marketplace official, NY
Key Strategies for Managing Enrollment
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OEI-09-20-00590 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 
We have been tracking all  and determinations: 
work processes and system 
adjustments. We have a  Implemented periodic data matchingto flag enrollees who were deceased or enrolled in 
resolution plan based on  Medicare.
guidance from CMS and 
meet weekly to discuss  Created flags to help staff prioritize cases for redeterminationat the end of the PHE, such as 
changes, new requirements,  those of enrollees who had provided new information indicating that they were no longer eligible 
and risks. for Medicaid but who could not be disenrolled during the PHE.
-Medicaid official, ME 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.
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OEI-09-20-00590 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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OEI-09-20-00590 Strategy 10. States modified hiring and 
onboarding protocols to maintain staffing
States reported taking actions to improve staff retention and 
hiring:
We are increasing hiring 
Increased employee compensation and incentivesto help limit turnover and make enrollment-
efforts by preparing a 
related positions more attractive.
staffing request for the 
upcoming legislative session, 
Leveraged remote workas an opportunity to recruit new employees who would otherwise have to 
hiring contract workers, and 
relocate.
temporarily shifting existing 
workers to process eligibility  Contracted with staffing vendors to help manage workloads and prevent enrollment backlogs.
applications.
Maintained a contract with a staffing vendor incase surge staffing was needed.
-Medicaid official, OR
A customer service contractor that staffed Marketplace call centers hired more people with 
each cohort of new employees to for expected attrition, andcondensed the length of training  Moving to a remote work 
protocols for newly hired employees. 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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OEI-09-20-00590 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 
As the pandemic began,  
caseloads:
[the Marketplace] went fully 
virtual and prioritized 
Prioritized investments in technologythat allowed staff to work remotely, such as laptops.  
resources needed to perform 
core functions to support  Developed new internal tools, such as instant messaging, to allow staff to communicate more 
expansion and maintenance  effectively to resolve issues more quickly.
of health insurance 
coverage. Provided staff with remote access to a verification system which allowed them to continue 
completing eligibility determinations when away from physical offices.
-Marketplace official, DC
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 
Moving all of our own staff  allowed staff to more easily manage illnesses and family responsibilities and continue work duties.
to remote working
(teleworking) has proven to  Organized more regular meetingsfor managers to review metrics and emerging customer issues.
Technology, connectivity, 
work better than originally 
and equipment are key to 
Modified staff assignments and workflows to prioritize critical functions, such as those that allowed 
expected, andis likely to 
ensuring operations are 
States to get people enrolled more quickly.
continue after the PHE ends.
maintained.
-Medicaid official, UT Redistributed work within and across regional offices or divisionsto manage increasing demands 
-Medicaid official, SD
for assistance.
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OEI-09-20-00590 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 
The most significant 
needed to account for any emergency duration and potential degree of disruption. 
change to our Medicaid 
program is understanding 
Understanding that temporary measures taken during an emergency response may have longer-
that it is not immune to 
term consequences. For example, using short-term workarounds to adhere to the continuous 
emergenciesit has tobe 
enrollment requirement may have created more work for Medicaid agencies at the end of the PHE than 
flexible in times of an 
implementing a more resource-intensive, long-term change.  
emergency, and it must 
sustain itself no matter how  Building flexibility into enrollment processes and operationsallowed States to adapt to changing 
long that emergency lasts.   requirements and respond to dynamic emergency conditions, such as office closures and surges in 
Staff must be ready to  demand for coverage.
understand communications 
that have to be made quickly  Coordinating across programs and agencieswas needed to ensure that States actions during the 
and they have tobe flexible  PHE were aligned with other healthcare coverage programs, government agencies (e.g., the 
to take the actions conveyed  Department of Labor), and social supports needed by enrollees (e.g., the Supplemental Food Assistance 
to them quickly. Program and Temporary Assistance for Needy Families.) It is critical to look at 
policy, IT, processes, and 
-Medicaid official, GA
Maintaining regular communication with staff, enrollees, and prospective applicantswas  other changes through an 
important to explain changes in policy and procedures, and to help prevent enrollees from falling out  equity lens.
of coverage.
-Marketplace official, DC
Considering the equity impact of policy and process changeswas important to ensure that 
emergency response decisions did not worsen disparities in access to coverage or assistance.
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OEI-09-20-00590 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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OEI-09-20-00590 Acknowledgments  Contact
Camille Harper served as the team leader for this study, and Emily Borgelt and  To obtain additional information concerning this report, 
Michelle Goodwin served as lead analysts.  Others in the Office of Evaluation and Inspections San  contact the Office of Public Affairs at 
Francisco Regional Office who conducted the study include Sanaea Cowasjee, with support from  Public.Affairs@oig.hhs.gov. OIG reports and other 
Data Visualization Technical Expert China Tantameng.  Office of Evaluation and Inspections  information can be found on the OIG website at oig.hhs.gov.
headquarters staff who provided support include Althea Hosein, Lyndsay Hopper, Kevin Manley, 
and Sarah Swisher.  Office of Inspector General
U.S. Department of Health and Human Services
This report was prepared under the direction of Blaine Collins, Regional Inspector General for  330 Independence Avenue, SW
Evaluation and Inspections in the San Francisco Regional Office, and Abigail Amoroso, Deputy  Washington, DC 20201
Regional Inspector General.
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OEI-09-20-00590