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Report (OEI-01-14-00180)

07-02-2014
Marketplaces Faced Early Challenges Resolving Inconsistencies With Applicant Data

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Summary

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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