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


This brief highlights strategies that State Medicaid agencies and State-based Marketplace—collectively, "States"—described as beneficial for their enrollment processes 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.


The Office of Inspector General (OIG) collected survey information between November 2021 and February 2022 from 49 of 51 State Medicaid agencies including the District of Columbia and all 18 State-based Marketplaces (hereafter "Marketplaces") that used their own enrollment platform at some point during the PHE. In these surveys, we asked Medicaid and Marketplace officials about their experiences with enrollment processes during the PHE, from January 2020 to the time of their survey response.


States faced challenges in maintaining key Medicaid and Marketplace enrollment functions as a result of a rapidly changing landscape during the COVID-19 public health emergency (PHE). States could no longer rely on existing outreach and application practices because patterns of work and life shifted. Further, gaps in demographic data about applicants and enrollees limited States' ability to identify disparities and to support equitable access to enhanced coverage. At the same time, States faced a surge in demand for coverage and had to align their enrollment and program operations with new Medicaid and Marketplace requirements and eligibility options promulgated in response to COVID-19.

States used several strategies for addressing Medicaid and Marketplace enrollment challenges:

Expanded outreach efforts. States leveraged information from a variety of sources to identify potential enrollment disparities and target their outreach. They took actions to address barriers to applicants being able to access information about enrollment through outreach efforts and found different ways to connect with existing enrollees and groups of people newly eligible to enroll.

Improved applications and support. States expanded options for receiving application assistance; simplified their application processes; and updated their online application features and tools to support their applicants and enrollees.

Simplified eligibility determination processes. States streamlined their Medicaid and Marketplace eligibility determination processes while also being mindful of program integrity vulnerabilities.

Adapted program operations. States introduced new ways of managing enrollment and modified their hiring and onboarding processes. States also reflected on their experiences to help them reconsider program operations in preparation for another emergency.


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 Medicaid and Marketplace enrollment processes and help them prepare for future local, State, or Federal emergencies.