USER RESEARCH INSIGHTS

Mapping theapplicant experienceof benefit enrollment
A user research study for human-centered public services // October 2016

2

“It's hard enough living with a disability,
harder yet when living on a ﬁxed income.
But to get the run-around when you’re justtrying to get much need help…
…it makes things so much harder.”Medicaid applicant, Albuquerque, New Mexico

PROJECT MISSION

Accelerate opportunities for the federal
government to provide key technology
and service improvements to theexperience of accessing and enrollingin health and human service programs.

OVERVIEW

In the spring of 2016, the Centers for Medicaid and Medicare andthe U.S. Digital Service conducted an extensive qualitative user
research study in effort to better understand the steps and applicant
experiences in enrolling in public assistance programs.
Based on 82 contextual interviews, site visits and service trials withapplicants, non-profit enrollment assistors and local programadministrators across seven states, the study underscored the needfor simplified, streamlined and less burdensome application
processes.

Research focus
What are the steps and experienceof enrolling in – or supporting someone
to enroll in – multiple benefits?
USER RESEARCH GOALS➔ Investigate enrollment needs, pain points + best practices➔ Map user journey through the enrollment processes➔ Build greater understanding of people who use government
enrollment systems

Summary of findings

APPLICANT EXPERIENCE // KEY FINDINGS● Applicants have varying degrees● The notification of next steps andof familiarity with programs, but

renewal parts of any process are routinely

generally don’t know where to start,

the most problematic. Most programs rely

often relying on word-of-mouth toon mail to inform applicants, but many

determine where to go for info or what

people do not have stable addresses and/or

to apply for.

cannot read/understand language in notices.

● Government office experiences can● Technology access is a barrier to many,be very difficult, marked by long wait

therefore digital-only applications can betimes, hard-to-reach rural or limited

a challenge. In-person or phone support

transit locations, and dehumanizing

is necessary for some.

staff interactions.
● Long wait times for applications to
be reviewed causes financial burden● Third-party assistor support and multibenefit screening can greatly reducebarriers to enrollment.

and anxiety.
8

APPLICANT EXPERIENCE // USER STORIESAs an applicant, I need:➔ The option to determine my eligibility and apply
for one or more programs all in one place, in as few
steps as possible.
➔ Notifications and feedback loops about my benefits
that are reliable, timely, and easy to understand.
➔ To be able to interact with benefits programs
through the channel (phone, text, email, in-person)that makes the most sense for my life.
➔ Information that is clear, easy to find, andeasy to understand.

ENROLLMENT OPERATIONS // DESIGN PRINCIPLES
The most eﬃcient and family-centered programs...

➔ Take on the responsibility of verifying eligibility, either
manually or using existing data, to reduce the burden to applicants.
➔ Deeply invest in increasing eﬀiciency, continuously tracking
operations data and analyzing eﬀectiveness of their processes.
➔ Integrate program applications to help serve individuals
and families more holistically.
➔ Use technology and multi-channel touchpoints to communicate in waysthat help keep people from dropping out during enrollment or renewal.
➔ Empower staﬀ to use their judgment and discretion, moving away froma ‘line worker’ model, increasing eﬀectiveness and satisfaction for bothstaﬀ and applicants.

Methodology
A USER-CENTERED RESEARCH APPROACH

METHODOLOGY

User-centerd design + research
A QUICK INTRODUCTION

WHAT IS USER-CENTERED DESIGN?

A process for designing a system, service,
tool or experience from the perspective of thehuman users, which emphasizes uncovering
user need up front, rapidly designing quick
iterations and regularly gathering feedback
from users.

USER-CENTERED DESIGN FOR PRODUCT DEVELOPMENTWHY INVEST IN USER RESEARCH“Great products arise out of listening to [people]
describe their moments of deep personal pain,
as well as profound joy—paying attention to what
motivates and moves each of them, and committing
yourself to building something that will alleviate
their pain and maximize their happiness.”
LUCKY GUNASEKARA, COFOUNDER OF VULCAN LABS, HEALTH IT INNOVATION NON-PROFITWHY QUALITATIVE USER RESEARCH?
Historically, government agencies conduct surveys or focus groups
to understand our customer/client/users’ opinions about our services.
While this kind of data offers value, it does not provide deep insight
into the qualitative characteristics of a service experience or the
motivations, behaviors or capacities of our clients – the American people.
Design-driven user research approach is less concerned with opinions,and puts more focus on observed patterns of need and experience. Thisis accomplished by observing how people engage with, react to and makesense of our programs and tools in their native environments. Real-time
ethnographic field research in people's homes, at points of service, and atcommunity organizations gives us the ability to develop a complex andnuanced understanding of the way our users experience our services.

METHODOLOGYOur approach
OVERVIEW OF USER RESEARCH ACTIVITIES IN THIS STUDYUNDERSTANDING BENEFITS ENROLLMENT

USER RESEARCH // FIELD ACTIVITIES
1. Contextual interviews
Individual converstaions with applicants, assistors and local
government employees in their homes, workplaces or non-profits

2. Shadowing and service trials
Observing applicant interactions at assistor + government offices

3. Site visits
On-site in-depth walk throughs of government program operations

4. Co-design workshop
Mapping current enrollment pain points and designing ideal-statesolutions with local government and assistors

UNDERSTANDING BENEFITS ENROLLMENT

USER RESEARCH // USER RESEARCH PARTICIPANTS

40 applicants
42 assistors/community-based org staﬀ
6 federal agencies and departments
15 state and local administering agencies
13 think tanks and research organizations
9 startups and screening organizations

UNDERSTANDING BENEFITS ENROLLMENT

USER RESEARCH // LOCATIONSColorado
IdahoLouisiana
New Jersey
New Mexico
New York
Oregon20

The enrollment
experience
USER RESEARCH FINDINGSENROLLMENT EXPERIENCE

Applicant stories
A SNAPSHOT OF THE PEOPLE WE SERVE

THE ENROLLMENT EXPERIENCE // APPLICANT STORIESRACHELLE

PROFILE• 34-year-old veteran

New Orleans, LA•

Single mother of two
daughters“I’m not asking someone
to sponsor my life.
I’m just trying tofeed my kids.”•

Relies on the internet for
info, but doesn’t own acomputer

NEEDS
More clarity on which benefits
she is eligible for.
More support and empathetic
treatment from government
workers.
Data sharing across programs,
so she’s not reliant on
maintaining paper files to proveeligibility.

ATTITUDES
Frustration with eligibility
requirements that don’t feelreasonable.
Feels grateful for the support ofher local CBOs in New Orleans.
A lingering fear that she’s never
many steps away from having tolive on the street.

RACHELLE’S STORY
Rachelle, a military veteran originally from St. Louis,
ended up homeless in New Orleans in her late teens.
She eventually returned to St. Louis to be with herfamily, but was displaced after a house fire last year,
at which point Rachelle and her daughters returned to
New Orleans. Once there, she reconnected with theextremely supportive network of community-basedorganizations who helped her back in her teens, andhas felt significantly more supported and in control ofher life circumstances since then.
Even though she’s connected with local organizations,
Rachelle has struggled to enroll in benefits over theyears. She feels judged and disrespected by theenrollment staff she’s had contact with, and feels likeno matter how hard she prepares to bring the right
papers, it always seems like it’s not enough.
Rachelle experienced sexual abuse during her military
service, and suspects her difficulty receiving VA
benefits may be influenced by the fact that shereported her abuse. Additionally, securing a new job
ultimately disqualified her from continuing her foodstamps assistance, which she still needed to makeends meet. Losing her paperwork in the house fire
has made proving her eligibility more difficult.
Despite her struggles, Rachelle has taken college
courses and recently graduated from a hospitality
program, has a good job at a new hotel, and has herdaughter in good schools.

THE ENROLLMENT EXPERIENCE // APPLICANT STORIESGEORGEPROFILE• 35-year-old single father

New York, NY•

He and his son suﬀer frommultiple health issues“Sometimes,
I don’t know how
to ask for help.”•

Very comfortable withtechnology

NEEDS
Ability to check case status
more easily
More frequent, informative
notifications, through multiple
channels such as email and text.
Awareness of the channels
through which he can learn about
and apply for benefits.

ATTITUDESHe prefers to figure things out forhimself and doesn't want to feellike a burden to anyone or takeadvantage of the system.
Eager to move out on his own
with his son and provide a goodlife for him

GEORGE’S STORY
George was living in Oakland, CA when his girlfriend
had a severe bipolar episode a week after their son’sbirth. As a result, he was unexpectedly given solecustody of his newborn son. He managed to get by
until his landlord defaulted on his mortgage andevicted George. He returned to NYC to live with his
mom and grandmother, who are both receiving public
assistance, only to find they were about to be evicted

Most of their care comes from the ER. It’s difficult for
George to stay on top of things since his energy goes tokeeping himself and his son healthy.

for not making rent payments. He and his brother paid
off their overdue rent using cash assistance.

him enroll. He really has very little idea of what
programs are available to him. Despite the fact that
William is tech-savvy, most correspondence withassistance programs comes through the mail, whichadds to his burden.

George has diabetes and stage 3-4 kidney failure/chronic kidney disease, and his young son has asthma
and epilepsy. Their health issues prevent them fromstaying at local shelters when needed.

George has dreams for his future, and is taking college
prep courses. He visits a therapist and counselor at thecenter where he takes classes. They point him
towards assistance programs, but they can’t help

THE ENROLLMENT EXPERIENCE // APPLICANT STORIESSARAHNew York, NY“The day I got
Medicaid was thebest day of my life.”

PROFILE• 29-years old expecting
mother•Pursuing a Master’sin social work•

Very comfortable withtechnology

NEEDS
Awareness of the various
channels through which she canapply for benefits.

ATTITUDES
Appreciates the hard work that
goes into supporting people
through tough times.

Assistance traveling back andforth from medical appointments
and agencies.

Values community and relies
heavily on personal networks
for support.

Information about how totransfer her benefits when she
moves home to PA.

As a digital native, wishes
government programs weremore “with the times.”

SARAH’S STORY
Sarah came to New York City to continue her career insocial work. Right before she was set to start her
graduate studies in social work, however, Sarah foundout she was unexpectedly pregnant. Sarah didn't know
how she would afford school while raising a baby on
her own. Feeling desperate, daunted, andoverwhelmed, she reached out in many directions,
including sending a letter to President Obama, which
is how we connected with her.
During this time, Sarah found support in her local
Mormon community. As a social worker, she had asense of what was available to her, so she knew sheneeded to enroll in WIC and Medicaid, though she
wasn’t totally sure where to start.

A friend recommended she go to Planned Parenthoodfor Medicaid, which she described as an incredibly
helpful, simple process. “I walked in and walked out
with Medicaid that day.”
WIC was much harder to figure out on her own. As asingle, pregnant woman with limited income, shestruggled to trek to different offices for regular WIC
appointments and has experienced humiliation inusing her WIC benefits in grocery stores. Sarah isaware of her own privileges and awareness, and her
background in social work gives her empathy andcompassion for others in her shoes.

THE ENROLLMENT EXPERIENCE

User needs
THEMES FROM THE JOURNEY TO ENROLLMENTAPPLICANTS // USER NEEDSAs an applicant, I need…

Information that is clear,easy to find, and easy to understand.
WE HEARD:
Applicants don’t know where to start - often relying
on word-of-mouth to determine where to go for info
or what to apply for.
Applicants often get the run-around: the website isdown, the office is closed, the help number is busy or
not accepting calls.

Without easy access to reliable information,
applicants can be deterred by misinformation (eg,that applying for benefits could affect yourcitizenship status; that the wait time to receive abenefit is too long to be worth applying for, etc.).
Application forms are long and written in confusing
terms. Many applications find they need the help of
an assistor to complete their enrollment.

APPLICANTS // USER NEEDSAs an applicant, I need…

Interactions with staff and officesthat are accessible and encouraging.
WE HEARD:
Applicants often feel disrespected and unsupported
by workers at government offices, and report having
the impression that staff don’t want to help them orare sometimes not sufficiently trained or are lacking
up-to-date information.

Wait times at government offices and on phone lines
are prohibitively long and often feel understaffed.
Getting to government offices can be very difficult inrural areas, in cities with limited public transit, or for
elderly, disabled, or pregnant applicants.

APPLICANTS // USER NEEDSAs an applicant, I need…

A faster process with lesswaiting and uncertainty.
WE HEARD:
Many applicants experience inexplicable waits
between when they submit an application and when
they are deemed eligible, or when they are deemed
eligible and when they begin actually receiving theirbenefits. Those long stretches without benefits canbe devastating to an applicant’s life circumstances.

Applicants have to take off work to visit offices or
wait on hold to talk to someone - for many, this is abarrier to enrollment.
Applicants often feel like they are submitting their
documents or questions into a black hole, waiting
for long periods of time with no response.

APPLICANTS // USER NEEDSAs an applicant, I need…

A variety of options for how
I interact with benefits programs.
WE HEARD:
Preferences for how to engage with programs varies
from person to person, and those are usually strong.
Applicants who prefer online interactions are often
more comfortable with technology, and/or theywant to avoid the sense of discrimination, stigma or
embarrassment that many feel with visiting a local
office or having to reveal private information toanother person.

Applicants who prefer in-person interactions
appreciate being walked through the process andhaving their experience tailored to their needs; thepersonal connection helps them avoid feelingoverwhelmed or nervous.
Many applicants who prefer phone interactions
appreciate the personal, human contact, but use thephone since visiting offices can be prohibitively
difficult.

APPLICANTS // USER NEEDSAs an applicant, I need…

Notifications and feedback loops
that are reliable and timely.
WE HEARD:
Reliance on letter mail as the only form ofcorrespondence is problematic, since many applicants
do not have stable addresses, and it is easy for mail to
get lost or delayed.
Even when notices do reach applicants, informationand instructions are often hard to understand (not at
the right reading/comprehension level, not in theapplicant’s native language, etc.).

If notices aren’t received, applicants often discover
there have been changes to their benefits once it’salready too late (e.g. at the doctor’s office or grocery
store checkout when they’re trying to use them).

APPLICANTS // WORKS WELL

As an applicant, it’s helpful when I can…

Learn about and apply for assistancethough an independent organization.
WE HEARD:
The personal connections fostered at CBOs helps
reassure applicants and makes the process lessintimidating.
Staff at CBOs tend to find meaning in helping
others, and therefore treat applicants withmore respect.

Wait times at CBOs are almost always much
shorter than at government offices.

APPLICANTS // WORKS WELL

As an applicant, it’s helpful when I can…

The option to determine my eligibility andapply for one or more programs all in one place.
WE HEARD:
Screening for eligibility across multiple programsin one place often exposes applicants toprograms that they wouldn’t have otherwise
known to seek out.

While some applicants will choose to apply for
only one program, the option to apply for
multiple programs altogether in one sitting
greatly improves experience (less time spent
shuttling between many offices, less exposure totreatment at government offices).

ENROLLMENT EXPERIENCE

The journey to public assistance
STEPS, PAIN POINTS + BEST PRACTICES FOR PEOPLE SEEKING TO ENROLLAPPLICANT JOURNEYAPPLICANT JOURNEY // PHASE 1

PAIN POINTS: FINDING SUPPORT

Finding the rightplace to start is hard.

Information about programs andqualifications is confusing.

Lots of calling, googling, leaving messages, etc. to findthe right oﬀice -- o#en hard to reach and a sense ofbeing given “the run around.”Searching online can help for some, but leads tooverwhelming amounts of information in language thatcan be hard to understand.

People looking for support are sometimes completely
disconnected from the groups available to help andwithout contacts who’ve already been through anenrollment process, may not know how to find thesegroups. Many find it hard to know which sources to trust.

Information that is presented in technical and formal
legal/policy language that are confusing and opaque toapplicants.

“I don’t want to become and expert on
this stuﬀ but I have learned I have to be.”“The bureaucratic language on human services
websites works for policy makers, but it doesn't workfor people. Language ...walls oﬀ people.”“If you don’t know somebody who’s been throughthe process, then you just don’t know what to do.”Understanding the diﬀerencesand qualifications for multiple
programs can be complex.
Many people worry that participating
in one program will disqualify themfor others.
Immigrant applicants o#en have concerns about
how citizenship will impact eligibility, or program
participation will put them at risk.

APPLICANT JOURNEY // PHASE 1

WHAT WORKS WELL: FINDING SUPPORTInformal social networks
help people get connected
to support.

The support, comfort and info
provided by CBOs oﬀers a leg
up in preparing to apply forservices.

Learning about programs
while using/enrolling in otherprograms is helpful.

Screening for multiple
benefits helps applicants get
setup quickly and moreeasily.

When an event triggers someone toseek out assistance, they almost
always start by asking friends, family,
religious or community institutions foradvice.

Because the process feels daunting,human contact with someone who
understands the process eases anxiety.

Applicants reported positive responses
when they were informed about
specific services available to themfrom programs they were alreadyconnected to. For example: utility
support resources listed on heatingbills.

The application process feels muchless daunting and much clearer whenapplicants understand what isavailable to them all together at thesame time.

“I looked to this communityof single mothers + Mormon friends
for support, people who’ve been
through this. They had such good
recommendations.”

Applicants are less likely to makemistakes or lose hours to long wait
times when they connect with a
Community Based Organization (CBO).
“When I started coming here and it
was way easier. This place is just ahuge stress relief. I don't have to use
all my time that I could be using to finda job standing in line.”“I got my Medicaid when I went torenew my childcare support; they letme know I was eligible which I didn’tknow about.”APPLICANT JOURNEY // PHASE 2

PAIN POINTS: DOCUMENTS

Gathering documents required toprove eligibility can be challenging
and stressful.
Many people in poverty have limited accessto old paper documents such as pay stubs orleases. Locating this evidence can slow down
the applicant’s timeline.
There is general confusion around the needto provide the same information multiple
times for diﬀerent applications.
People are o#en unclear on whichdocuments they need for which programs
and at which step of the process.

PAIN POINTS: SUBMITTING AN APPLICATION

Applicants experience anxiety andadditional burden if they apply inperson without the correct documents
in-hand.
When applicants arrive at enrollment oﬀices
without all of the documents required, it’s aburden to return home and resubmit. People try tofigure it out up front, but are easily confused by
the diﬀerent requirements of diﬀerent programs.
“I actually came way over prepared and they
didn't need half of it. But it's so annoying to go
through these processes where if you forget one
thing, you get sent home and then you have tocome back again. In New York that's a lot oftransit and it feels terrible.”

APPLYING WITHOUT SUPPORT

Those with limited language or tech literacy
really need a helper to apply.
Many people -- especially older people -- felt a strong desire
for a human hand to help them through. Some feel unable tounderstand the apps/process on their own.

NO CONFIRMATIONS

No tactile feedback when applying online or in
the mail. Incites the ‘sending into a black hole’
feeling.
"If you do fax things in you might be faxing into a void...
You can’t see if it’s received and you get no confirmation...”APPLICANT JOURNEY // PHASE 2

PAIN POINTS: SUBMITTING AN APPLICATION continued…
ONLINE APPLICATIONSONLINE APPLICATIONS

While digital is preferred by some, many applicants
do not feel comfortable using computers and are
unsettled when required to apply online.

“You can’t go online and put in all your info,
and everything you’re eligible for pops up. No,
it’s a one-by-one process; a diﬀerent site for thisand that.”

Many people have diﬀiculty accessing
or using online applications.

Most online applications are not mobile-friendly.
Some online systems aren’t reliable/available all
the time.
Not all applicants have easy or reliable internet
access.
“What if I press the wrong button? What if I misssomething? Am I disqualified?”

Applying for multiple programs with
diﬀerent applications is confusing.

PAPER APPLICATIONSAPPLYING IN PERSON

Oﬀice locations can be hard to get to,require long wait times and feelunwelcoming.
For those working, it can be very diﬀicult to get togovernment oﬀices during open hours. Limited public
transit or long distances create barriers for getting tophysical oﬀices.

Good for those with low technology
access but can feel burdensome
to others.

Many feel unwelcomed and unsupported by the staﬀ atlocal oﬀices. There is sometimes a sense of shame orembarrassment in going to a government ‘welfare’
oﬀice.

Some people find paper forms take longer andare hard to complete. Others feel heightened
concerned about paper forms getting lost in the
mail or at program oﬀices.

"It feels like nobody cares, they just want you to go
away. It’s heartbreaking to have to deal with that inevery interaction. I’m just preparing for stress.”

APPLICANT JOURNEY // PHASE 2

WHAT WORKS WELL: DOCUMENT MANAGEMENT

Applicants and CBOs have little tricks
for trying to keep track of all
paperwork needed/submitted.
With so many opportunities to lose track ofphysical documents or important steps, both
applicants and CBOs create copies of everything
in a variety of ways such as phone screenshots,texting or emailing things as a backup, or making
paper copies.
“I always take pictures of my client’s cards andpapers in case she loses it or it doesn’t make itinto the application.”

CBOs keep backups and copies forapplicants in case of processing
problems.
Applicants feel grateful and relieved when CBOs
are able to help keep track of all their physicalmaterials on file.
“They made the application process reallysimple. They took all my documents, submitted
all the paperwork, and I just did the phone callinterview. It was so much easier than I everanticipated.”

Digital document uploading helps
applicants, CBOs and government oﬀices.
When applicants can take and scan pictures of
documents this greatly eases the challenge of keeping
track of all required paperwork.
For governments, this improves quality of image over
faxed documents, and reduces churn as it oﬀers lesspaper to process.

APPLICANT JOURNEY // PHASE 2

WHAT WORKS WELL: DIGITAL TOOLS FOR STREAMLINED PROCESSESAUTOMATIC DETERMINATIONAPPLYING ONLINE

There are so many opportunities forpeople to drop out of the enrollment
process with every additional step andinteraction required. Verifying andenrolling at a single touchpoint
improves the experience and speeds up
the process for them and the agency.

While not all applicants will be
comfortable with digital tools, many
expressed a preference for being able
to submit applications online, using
mobile devices. It is crucial that all
digital tools be designing withfeedback from users and meet thehighest standards of web accessibility.

Same-day determination andenrollment eliminates the mostpainful parts of the application
process.

“I went to Planned Parenthood andwalked out with Medicaid the sameday. This was one of the happiest daysof my life. I was worried about
everything turning upside down andlosing it all.”Easy to understand, mobileresponsive and accessible
websites improve usability of
online applications.

“I did everything online. It was soeasy and basic. It was kinda likeusing TurboTax. I never even had tostep into the oﬀice.”

MULTI-CHANNEL OPTIONSAllow applicants to apply
over the channel that works
the best for their needs.
Given the range of familiarity with andaccess to online tools combined withpersonal preferences, applicants
appreciate the option to choose how
to apply.
“Some people are embarrassed to goin person; applying online makes theuncomfortable feeling go away. No
one knew I was even there.”“My friends all apply online, but I
prefer to go in person because I liketalking to a human.”

INTEGRATING APPLICATIONSApplying for more than one
program at a time significantly
reduces anxiety and burden for
applicants.
We observed great burden to applicantsin managing and keep track of multiple
applications, on diﬀerent timelines.
When applicants are able to apply to asuite of services up front, they feel asense of ease and enrollment processes
see reduced process churn when all
information is gathered and verified at
one time.

APPLICANT JOURNEY // PHASE 2

WHAT WORKS WELL: 3rd PARTIES AS A PROXYCOMFORT AND WARMTH

EXPERTISESUPPORT FOR MULTIPLE PROGRAMSINTEGRATING APPLICATIONS

CBOs try hard to meet people where
they are, to provide clarity and structure
to an overwhelming and opaque
process. Applicants time and again
spoke of how much this improved theirwell being.

CBOs invest in staying up to date on
rules and process so that their clients
don’t need to. Applicants are relieved
when they do not need to try tounderstand the complexities.

Applicants who work with CBOs
expressed great appreciation for the
support in managing processes,
documents and timelines which canfeel intimidating on their own.

We observed great burden to applicantsin managing and keeping track ofmultiple applications, on diﬀerent
timelines. When applicants are able toapply to a suite of services up front, they
feel a sense of ease.

“The application process for SNAP iseasy here. With her help, I feel like I
don't have to do anything. She keeps
it all together for me.”

“They made the application processreally simple. They took all mydocuments, submitted all thepaperwork, and I just did the phone
call interview. It was so much easierthan I ever anticipated.”

CBOs treat applicants as whole
people, creating a sense ofease and support o#en not felt
in government oﬀices.

“This place makes me feel so
comfortable and I don't feel shameful.
They are very respectful and helpful.
It's so welcoming. They are goodpeople.”

3rd parties can oﬀer advice
and understanding of thesystem, taking the burden oﬀ
of applicants to become‘experts.’

Because managing multiple
benefits can “feel like a fulltime job” the support of CBOs
on this front help people keep
track of everything.

Applying for more than one
program at a time significantly
reduces anxiety and burden for
applicants.

APPLICANT JOURNEY // PHASE 3

PAIN POINTS: NOTIFICATIONSPAIN POINTS: TROUBLESHOOTING

MAIL IS NOT A RELIABLE CHANNEL

WHERE DO I GO FOR HELP?

Mail-based notifications
regularly are not received.
Much of the applicant demographic has
unstable living situations; many people
do not regularly receive/have access tomail or do not have a consistent mailingaddress. When notices are only delivered
via mail, many applicants missimportant info.
NOTICES ARE CONFUSING

Written language in notices
is o#en diﬀicult for people
to understand.
Many applicants expressed diﬀiculty inmaking sense of the written documents
they receive, thus missing steps or losing
their benefits.

People have a hard time
figuring out which number
to call or oﬀice to visit.
Applicants aren’t always entirely clear
on who to contact in the even thatsomething goes wrong.

UNDERSTAFFED

Demand for support seems
to exceed size of workforce,
resulting in long wait times.
“There just aren’t enough people tofield all of the calls. You’ll get
transferred and have to wait 20, 30
minutes to talk to someone else.”

SPEAKING MY LANGUAGE“SHOUTING INTO THE VOID”

Applicants aren’t always familiar withthe policy or organizational terms theycome in contact with, and this proves
particularly troublesome when they aretrying to understand what has gonewrong with an application.

When applicants can’t reachsomeone directly, many will leave
voicemails, send emails or letters.
If their messages are not returned,
this adds discomfort and anxiety –particularly when applicants are
unsure of the status of an
application.

If they do reach someone,
applicants do not always havefull understanding of what
they are being told.

“They ask ‘Do you want to speakwith an agent or a counselor?’
What do those words mean?
I can't tell the diﬀerence!”

Lack of response whenlooking for answers makes
people lose confidence inthe process.

“It’s so frustrating. If you leavea voicemail it feels like you’re
shouting into the darkness. You
never know if you’ll hear back sojust keep trying.

APPLICANT JOURNEY // PHASE 3

PAIN POINTS: INTERVIEWSPRESCHEDULED INTERVIEWS

IN-PERSON INTERVIEWS

Repeatedly we heard about people not receiving,understanding or entirely missing prescheduled
appointments. Prescheduled interviews don’t accountfor applicant’s work schedules, transit accessibility etc. –and applicants are o#en unsure of what step to take ifthey miss or cannot make the predetermined time. This
step in particular keeps many applicants from completing
their application, and many site frustrating at needing torestart the application process as a result of missing aprescheduled interview.

Many people who work are required to take time oﬀ
to attend in person interviews, and limited public
transpit options can make a short interview become
an all day aﬀair.

Application completion suﬀers whenapplicants are sent prescheduledinterview times.

“They send you a notice for a specific time and date you
have to be available to take the interview call and if you
don't see the notice or can't get to your phone in time,then too bad, you don't get the benefits and you have tostart over.”Many applicants have a diﬀicult time
getting to oﬀices, which can cause
financial and physical burden.

Applicants prefer to choose between a phone and inperson interview, and to have the option to schedulethe interview for a time that fits into their schedule.

A SENSE OF DISRESPECT

Many applicants find the experienceof meeting with government staﬀ
unpleasant. This feels disrespectful
and hurtful.
While the in-person oﬀice experience varies widely
between localities, we heard and witnessed thehardship caused when applicants feel mistreatedby front-line staﬀ.
"It feels like nobody cares, they just want you
to go away."“They make me feel like I’m not human.”“It’s always heart-wrenching to send people
into the SNAP oﬀice -- it’s a whole day of being
treated badly.”APPLICANT JOURNEY // PHASE 3

WHAT WORKS WELL: TROUBLESHOOTING AND IMPROVING COMMUNICATIONSPLAIN LANGUAGE

Write all applicant communicationin plain language, designed and tested
with applicants to ensure people
with limited and low literacy clearly
understand all information.
Process churn, customer support demand andapplicant anxiety is improved upon when written
communication follows plain language guidance,
and is regularly tested with applicants so as toensure comprehension. Ensure this applies
consistently to all channels of written
communication – letters, website content, email
notices, etc.
When relevant, provide support and written
communication in non-English languages as well.

MULTI-CHANNEL REMINDERS

Provide multiple channels forcommunicating with applicants –email, written mail, text, phone calls –and oﬀer applicants the option tochoose their preferred channel toincrease speed and reliability of
applicant response time.
Given the instability of permanent mailingaddresses and the range of comfort withtechnology, enrollment programs which oﬀer
applicants the option to receive notices andupdates via the channel of their choosing see
swi#er, more reliable response rates. For
applicants, this gives them the option to engage inthe way that fits most seemlessly into their lives.

PROXIES

Send notices to 3rd party representatives(CBOs, family members, etc.) so thatapplicants more reliably receive notices.
When applicants have the option to list a family
member of 3rd party organization as their primarypoint of contact, challenges with changing addresses
or unreliable phone service are curbed.

Provide oﬀicial representative accessthe applicant’s full case materials.
Applicants and 3rd party representatives articulated astrong desire for designated reps to be able to seecase status, applicant history and other related
documents retained by enrollment programs. This
aids in troubleshooting and ensuring all parties arereferencing the same materials.

APPLICANT JOURNEY // PHASE 3

PAIN POINTS: USING BENEFITSHOW TO USE BENEFITSApplicants don’t always know where to start or how
to make use of programs once they’ve been approved.
In some instances, when applicants areapproved, they do not always
understand or receive notice of whatsteps they need to take. Many programs
take eﬀect right away while others may
take weeks or months to begin, leaving
applicants confused and unsupported
while they have already been enrolled.
Applicants do not always know where
their benefits are accepted. SNAP and
WIC users, for example, site initial
struggle in determining which kinds offoods are covered.

“I didn’t get my Medicaid card forquite a while. I was sick but didn’t
think I could get care until my card
came. When I finally went to thedoctor a#er the card showed up,
they told me I didn’t even need it.”

STIGMA OF USE

Perceived or real, many applicants feel stigma
in the day-to-day experience of using their benefits.
While health assistance programs are
more integrated into the ecosystem ofcare delivery, the lived experience ofusing programs like WIC and SNAP waso#en described by applicants as
humiliating.
People expressed a desire for the useof EBT and food stamps to be more
integrated into regular forms of
payment, and for it to cover a healthierand broader range of foods.

“The first time I tried to use WIC
at a grocery store, I was horrified.
They were shouting over the loudspeaker to find out if each food in
my basket qualified – and half
didn’t because it only covers
sugary stuﬀ, no fruits andveggies. I’m there, holding up thewhole line with people staring me
up and down. It was very
humiliating.”"When people find out you’re
on Medicaid, they treat you
like dirt."

APPLICANT JOURNEY // PHASE 3

PAIN POINTS: MISSING RECERTIFICATION WINDOWSPAIN POINTS: MULTI-PROGRAM RENEWAL

Much like other events which
require notification, renewal
notices sent only through mailo#en do not get received and/or are misunderstood.

Limited renewal periods makeit easy for people to missopportunities to renew,
and thus are sent throughre-enrollment all over.

Applicants drop out of
programs unknowingly
if requirements change
without their knowledge/
understanding.

People who need to maintain
enrollment in multiple
programs cite confusion
in managing multiple
recertification processes.

Many applicants discovered they’dmissed the renewal window as a resultof undelivered mail or lack ofcomprehension of the notice language.
This is particularly challenging as it
sends people back to the beginning of
the application process, which adds
burden to both applicants andenrollment processes.

Applicants aren’t always familiar withthe policy or organizational terms theycome in contact with, and this proves
particularly troublesome when they aretrying to understand what has gonewrong with an application.

When applicants have been enrolled in
one or more programs for multiple
years, they o#en skip over the fine print
or miss details about changes torecertification processes. This o#en
results in applicants suddenly losing
their benefits.

Recertification requirements andtimelines for vary between programs,
and people enrolled in more than one
program o#en find themselves struggling
to keep track of and keep up with thesemany overlapping processes.

“Cases close very quickly, but open
very slowly.”“I had been on food stamps, but when I
got a job they cut me oﬀ without
letting me know why.”“Many of our clients think they’ve
recertified for all their benefits, whenthey’ve only just handled one of them.
It’s genuinely confusing.”

APPLICANT JOURNEY // PHASE 3

WHAT WORKS WELL: TROUBLESHOOTING AND IMPROVING COMMUNICATIONSCONSISTENT ROUTINE

3rd PARTY REMINDERS

For applicants who have been through renewal in the past or
who are able to very clearly keep track of what’s being askedof them and when, they will plan ahead and makeaccommodations to ensure they submit materials on time.

When applicants look to assistors to support their enrollment
from the start, these 3rd parties will o#en take on the role oftracking program requirements, processes changes andrenewal timelines.

This proactive approach leaves applicants relying less on
short notice letters and notifications, which reduces their riskof missing enrollment windows.

This creates a helpful barrier between applicants and program
oﬀices, as 3rd parties are able to regularly communicate morereliably with their clients and help prepare them well inadvance to keep them enrolled.

When applicants have a clear understandingof steps and know what to expect, they canplan and prepare for renewal periods.

“Every 2 months, I know that I’ll need to walk 15 min to my
WIC oﬀice and refill my vouchers. I know it’s about 15 to 40
minute wait. I wish it were less, but since it’s always thesame, I pretty much know what to expect.”

Assistors will o#en remind their clients ofupcoming renewal periods and requirements,
reducing likelihood of missing renewal windows.

Design principles
PILLARS OF USER-CENTERED ENROLLMENT SERVICESDESIGN PRINCIPLES

Applicants have more success when government enrollment services...

Take on the role of verifying applicant eligibility,
reducing burden for applicants and churn in theprocess of eligibility determination.
WHAT THIS MEANS FOR SERVICE OPERATIONS:
When data is available to provide instant verificationor program staff take on the responsibility to manually
verify applicant eligibility, the amount of back-and-forth
between applicant and agency drops significantly,
improving timeliness in response to applicants andinternal efficiency.

ENROLLMENT OPERATIONS // DESIGN PRINCIPLES

Applicants have more success when government enrollment services...

Continuously invest
in increasing efficiency.
WHAT THIS MEANS FOR SERVICE OPERATIONS:●●

Evaluate the effectiveness of current
practices at regular intervals which helps
program staff identify ways they could
improve.
Invest in training and supporting workforce
culture change that allows for familycentered and efficiency-based operationalmodels.

●Reducing the number of hands on eachapplication minimizes clerical errors andsteps in the process.

●Web-based case management systems help
reduce reliance on cumbersome paper
forms and files, and decentralizes
information so that data can be accessed
anywhere.

ENROLLMENT OPERATIONS // DESIGN PRINCIPLES

Applicants have more success when government enrollment services...

Are integrated, to help serve individuals
and families more holistically.
WHAT THIS MEANS FOR SERVICE OPERATIONS:●

Taking a holistic view of the applicant andtheir family, program staff can suggest
additional programs that an applicant may
be eligible for beyond the programs they
are actively seeking out.

●

Ask applicants for up-front consent fordata-sharing across programs helps
program staff assess an applicant’s
eligibility must faster and more accurately.

●

Provide ways to apply for multiple benefits
in one stop greatly improves applicant’s
experience and increases their likelihood of
successfully enrolling in all the programs
they are eligible for.

ENROLLMENT OPERATIONS // DESIGN PRINCIPLES

Applicants have more success when government enrollment services...

Use technology and multi-channel touchpoints to ensure
people do not drop out during enrollment or renewal.
WHAT THIS MEANS FOR SERVICE OPERATIONS:●

Measure and track user engagement anddrop off at each stage of the process.

●Auto-generate notifications helps ensure
applicants don’t miss critical changes totheir benefits, and helps inform them ofother programs they may be eligible for.

●Enable the option for people to verbally
sign via telephonic signature for phone
applications and renewals.

●

Ensure information resources have good
multi-language support and use clear, plain
language to help lower barriers for applicantsseeking assistance.

ENROLLMENT OPERATIONS // DESIGN PRINCIPLES

Applicants have more success when government enrollment services...

Empower staff to use their judgment and discretion,
moving from a ‘line worker’ model and increasing
effectiveness and satisfaction for both staff and applicants.
WHAT THIS MEANS FOR SERVICE OPERATIONS:••

When program staff take the few extra
minutes to double-check information with anapplicant or follow-up directly, they greatly
increase the applicant’s chance of successfulenrollment.
Ensure staff are equipped with accurate andup-to-date info to empower them to truly
assist applicants throughout the process.

“We hire people to solve problems, not read scripts.”"We're not about titles. We all do whatever it takes.”"I always try to call before I reject because sometimes
I'm just missing a small piece of info. This isn'ta policy, I just like to do this.”Thank you to the partners and members of the public
who shared their stories, expertise and time for this project.
All stories used in this report have been anonymized.
Stories and photographs of participants are used with
their written consent.

For more information, visit https://usds.github.io/benefits-enrollment-prototype/or contact Nicole Comeaux at nicole.comeaux1@cms.hhs.gov