From: HHS Office of Inspector General <donotreply@subscriptions.hhs.gov>
Date: Tue, Jul 1, 2014 at 7:10 AM
Subject: OIG posts 2 reports, letters to Congress, related podcast and news about enforcement actions - 7/1
To: iammejtm@gmail.com
Good morning from Washington, DC. Today OIG posts 2 reports, related letters to Congress, a related podcast and news about enforcement actions. As always, you can use the links provided to go directly to the new material.
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Marketplaces Faced Early Challenges Resolving Inconsistencies with Applicant Data (OEI-01-14-00180) http://go.usa.gov/9Sjh WHY WE DID THIS STUDY
This evaluation examines how the Federal and State health insurance marketplaces ensured the accuracy of information submitted by applicants for enrollment in qualified health plans and for advance payment of premium tax credits and cost sharing reductions. This evaluation complements a separate Office of Inspector General report (A-09-14-01000) issued in response to the mandate in the Continuing Appropriations Act, 2014, by providing an analysis of how and the extent to which marketplaces resolved inconsistencies between applicants' self-attested information and the data received through the Federal Data Hub or from other data sources.
HOW WE DID THIS STUDY
We requested data on inconsistencies for October through December 2013 from all marketplaces although four did not provide any. We conducted interviews or site visits with the staffs at the Federal marketplace and all 15 State marketplaces between January and March 2014. We reviewed each marketplace's policies and procedures for resolving inconsistencies.
WHAT WE FOUND
During the period of our review, marketplaces were unable to resolve most inconsistencies, which they reported most commonly as citizenship and income. Each applicant can have multiple inconsistencies. Inconsistencies do not necessarily indicate that an applicant provided inaccurate information or is enrolled in a qualified health plan or is receiving financial assistance through insurance affordability programs inappropriately. Specifically, the Federal marketplace was unable to resolve 2.6 million of 2.9 million inconsistencies because the CMS eligibility system was not fully operational. The abilities of State marketplaces to resolve inconsistencies varied. Four State marketplaces reported that they were unable to resolve inconsistencies, seven reported that they resolved inconsistencies without delay, one reported that it resolved only some inconsistencies, and three reported that their State Medicaid offices resolved inconsistencies. We also found that data on inconsistencies are limited. For example, the Federal marketplace could not determine the number of applicants who had at least one inconsistency. Finally, marketplaces faced challenges resolving inconsistencies despite having policies and procedures in place.
WHAT WE RECOMMEND
CMS should develop and make public a plan on how and by what date the Federal marketplace will resolve inconsistencies. CMS should conduct additional oversight of State marketplaces to ensure that they are resolving inconsistencies according to Federal requirements. CMS concurred with both of our recommendations.
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Not All Internal Controls Implemented by the Federal, California, and Connecticut Marketplaces Were Effective in Ensuring That Individuals Were Enrolled in Qualified Health Plans According to Federal Requirements (A-09-14-01000) http://go.usa.gov/9Sjj
Not all internal controls implemented by the Federal, California, and Connecticut health insurance exchanges (marketplaces) were effective in ensuring that individuals were enrolled in qualified health plans (QHPs) according to Federal requirements. The deficiencies in internal controls that we identified may have limited the marketplaces' ability to prevent the use of inaccurate or fraudulent information when determining eligibility of applicants for enrollment in QHPs.
On the basis of our review of 45 sample applicants at each marketplace, we determined that certain controls were effective, e.g., verification of applicants' incarceration status at all 3 marketplaces. However, the internal controls were not effective for validating Social Security numbers at the Federal marketplace, verifying citizenship and lawful presence at the California marketplace, and performing identity proofing of phone applicants and verifying minimum essential coverage through non-employer-sponsored insurance at the Connecticut marketplace.
On the basis of performing other audit procedures, such as interviews with marketplace officials and reviews of supporting documentation, we determined that other controls were not effective. For example, the Federal and California marketplaces did not always resolve inconsistencies in eligibility data, and the Connecticut marketplace did not always properly determine eligibility for insurance affordability programs.
These deficiencies occurred because:
(1) The marketplaces did not have procedures or did not follow existing procedures to ensure that applicants were enrolled in QHPs according to Federal requirements or
(2) The marketplaces' eligibility or enrollment systems had defects or lacked functionality. For example, the Federal marketplace's system functionality to resolve inconsistencies in eligibility data had not been fully developed.
In addition, we noted other issues that may be of interest to stakeholders.
The presence of an internal control deficiency does not necessarily mean that a marketplace improperly enrolled an applicant in a QHP or improperly determined eligibility for insurance affordability programs. Other mechanisms exist that may remedy the deficiency.
To address the specific deficiencies that we identified, we recommended that CMS (which operates the Federal marketplace), Covered California (the California marketplace), and Access Health CT (the Connecticut marketplace) take action to improve internal controls related to:
(1) Verifying identity of applicants and entering application information,
(2) Determining applicants' eligibility for enrollment in QHPs and eligibility for insurance affordability programs, and
(3) Maintaining and updating eligibility and enrollment data.
We also recommended that CMS work with Covered California and Access Health CT to implement our recommendations addressing deficiencies identified at the California and Connecticut marketplaces.
CMS concurred with all of our recommendations and provided information on actions that it had taken or planned to take to address our recommendations. However, CMS stated that it did not believe that two of our recommendations, one of which we removed, should be included in the report. Covered California agreed with one of our recommendations and provided information on actions that it had taken or planned to take to address our remaining recommendations. However, Covered California disagreed with some of our findings. Access Health CT concurred with three of our recommendations but did not concur with one recommendation. In addition, Access Health CT did not concur with one of our findings; we removed the finding and the related recommendation. ------------------------------------------------------------------------------
Letter to Congress http://go.usa.gov/9SbY The President of the Senate and the Speaker of the House are sent copies of today's two reports with additional explanatory information.
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Podcast: Early Enrollment Challenges in Health Insurance Marketplaces http://go.usa.gov/9STA
Marc DeGuzman, a senior auditor in Los Angeles, interviews Maria Silvestre, a senior auditor in San Diego, about internal controls to safeguard enrollment in health insurance marketplaces. In the second half of the podcast, Russ Hereford, a Deputy Regional Inspector General interviews Danielle Fletcher, a program analyst in Boston, about marketplaces resolving inconsistencies with applicant enrollment information.
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June 30, 2014; U.S. Attorney; Western District of Missouri Former KC Man Sentenced For Fleeing U.S. To Avoid Paying Child Support http://go.usa.gov/9SrT
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June 30, 2014; U.S. Attorney; District of Maryland Baltimore Man Sentenced to over 5 Years in Prison for Dozens of Commercial Burglaries http://go.usa.gov/9SrT
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State Enforcement Actions Updated http://go.usa.gov/9Srm
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That's all we have for today. If we can be of any further assistance, please send an Email to public.affairs@oig.hhs.gov
Welcome to July – make it a great month!
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Jeremy Tobias Matthews
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