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 Reflecting on the challenges that States faced, and the eligibility and enrollment strategies they employed, may be useful as State Medicaid and to identify what is 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 2 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 Marketplaces-collectively, "States"-faced 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 landscape during the COVID-19 PHE. States existing enrollees and groups of people newly eligible to enroll. • State Medicaid agencies 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 3 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 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. Key Strategies for Managing Enrollment 4 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 Key Strategies for Managing Enrollment 5 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 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. Key Strategies for Managing Enrollment 6 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, ethnicity, and language data Used a statewide pulse survey to collect information to learn more about health disparities and among enrollees [is a how people in different demographic groups, such as the uninsured, understand the Marketplace. challenge] –since the Used focus groups to 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 assistance through 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 -Marketplace official, MA eligibility policies and practices. Key Strategies for Managing Enrollment 7 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 was a challenge, particularly Partnered with trusted community-based groups with a history of working in local communities, residents in underserved to connect with people who may not have been reached by other outreach efforts. communities. Where Focused outreach on 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 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. Key Strategies for Managing Enrollment 8 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 closely with the hospitals, Leveraged other government agencies, such as employment offices, to target outreach, for FQHCS, rural health clinics, example, to people who may have recently lost their jobs and health insurance coverage. advocates and community "The ability to have more Conducted outreach in community settings to connect directly with potential applicants. partners. We trained their interactions virtually... staff on how to assist folks to Modified media strategy as 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 contacts with 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 emergency." Hosted virtual outreach events to connect with potential applicants, even when offices and other 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 9 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 10 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 avenues for clients to apply person support: for and enroll in Medicaid. Expanded the availability of telephone and other remote appointments with 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 brokers-entities 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 appointments to help staff plan for the number of people arriving for in- to assist clients…We operate person assistance. a toll free call center for Medicaid questions. We Hosted webinars and other virtual events to share general information about coverage options to have kiosks in every county compensate for the reduction of in-person events. for clients who would like Expanded or established call centers to 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 Key Strategies for Managing Enrollment 11 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 "We are more focused than enroll by reducing procedural barriers: before on member experience and reducing Shifted in-person interviews to audio or video calls for applicants who required or requested a administrative burdens, meeting as part of their application process. 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 have on their time and Provided kiosks at community locations, making online access to applications available to people eliminating normal energies, and how important who lacked personal computers or Internet access. 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 or don't have or can't get to seeking a policy change within their State, but helped to simplify the process of applying. administrative reasons." a place with Internet access." -Marketplace official, MA -Medicaid official, GA Key Strategies for Managing Enrollment 12 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 navigation throughout the Updated online applications and enrollment portals to provide more information and make them application, we have made it more user-friendly. 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 applicants and those assisting them to use when communicating questions and changes with enrollment staff. Key Strategies for Managing Enrollment 13 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 additional qualifying life Used available flexibility to create a new Medicaid eligibility group. For example, the Families First events in order to grant Coronavirus Response Act and the American Rescue Act allowed Medicaid agencies to enroll people into a consumers access to designated eligibility group- the COVID-19 Uninsured Group- to provide access to coverage for medically [qualified] health plans necessary COVID-19-related services to uninsured individuals in their State. 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 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. Key Strategies for Managing Enrollment 14 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 employers, which would typically provide documentation in States exercised flexibilities that were allowed during the PHE support of eligibility, experienced office closures and disrupted to temporarily pause some of their pre-enrollment and renewal operations during the PHE. Applicants and enrollees faced verification activities. 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 15 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 procedures/policies allowed Expanded use of presumptive eligibility through which applicants can become enrolled for faster enrollment of temporarily after being screened by qualified entities, such as hospitals. Presumptive eligibility can beneficiaries during a time provide timely access to care for applicants while a final determination is made and offer additional where health coverage and channels through which individuals can apply. 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 algorithms to account for policy changes-such as increased renewal volumes allowed us financial assistance for Marketplace plans and exclusion of certain unemployment income from to ensure that there was eligibility calculations-so that applicants and enrollees could benefit from these changes sufficient staff to rapidly "Streamlining the eligibility 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 significant change in Relied more heavily on available electronic records and data to verify information included in applicants/recipients and operational approach." reduced administrative 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 16 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 matching to 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 redetermination at 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. Key Strategies for Managing Enrollment 17 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. Key Strategies for Managing Enrollment 18 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 efforts by preparing a Increased employee compensation and incentives to help limit turnover and make enrollment- staffing request for the related positions more attractive. upcoming legislative session, Leveraged remote work as 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 in case 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, and condensed 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 Key Strategies for Managing Enrollment 19 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, [the Marketplace] went fully caseloads: virtual and prioritized Prioritized investments in technology that 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 meetings for 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, and is 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 divisions to manage increasing demands -Medicaid official, SD for assistance. Key Strategies for Managing Enrollment 20 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 emergencies-it has to be 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 operations allowed 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 agencies was needed to ensure that States' actions during the and they have to be 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 applicants was 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 changes was important to ensure that emergency response decisions did not worsen disparities in access to coverage or assistance. Key Strategies for Managing Enrollment 21 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. Key Strategies for Managing Enrollment 22 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. Key Strategies for Managing Enrollment 23 OEI-09-20-00590