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Not All of the Minnesota Marketplace's Internal Controls Were Effective in Ensuring That Individuals Were Enrolled in Qualified Health Plans According to Federal Requirements

Not all of the Minnesota marketplace's internal controls were effective in ensuring that individuals were enrolled in qualified health plans (QHPs) according to Federal requirements.

On the basis of our review of 45 sample applicants from the enrollment period for insurance coverage effective in 2014 and performing other audit procedures, such as interviewing marketplace officials and reviewing supporting documentation, we determined that certain controls were effective, such as the controls for verifying applicants' identities. However, certain controls were not effective. Specifically, the marketplace had deficiencies related to determining eligibility of applicants, resolving inconsistencies in eligibility data, and maintaining and updating eligibility and enrollment data.

The presence of an internal control deficiency does not necessarily mean that the Minnesota marketplace improperly enrolled an applicant in a QHP or improperly determined eligibility for insurance affordability programs. Other mechanisms exist that may remedy the internal control deficiency, such as the resolution process during the inconsistency period. For example, if a marketplace did not have a control in place to verify an applicant's citizenship through the Social Security Administration, as required, the marketplace may still have been able to verify citizenship with satisfactory documentation provided by the applicant during the inconsistency period. The deficiencies that we identified occurred because of enrollment system design limitations and defects.

To address the specific deficiencies that we identified, we recommended that action be taken to improve the Minnesota marketplace's internal controls related to verifying applicants' eligibility and maintaining and updating eligibility and enrollment data.

We also recommended that the Minnesota marketplace redetermine, if necessary, the eligibility of the sample applicants for whom we determined that verifications were not performed according to Federal requirements. The Minnesota marketplace generally agreed with our findings and all but our second recommendation. The Minnesota marketplace described actions it had taken or planned to take to address our recommendations.

Filed under: Centers for Medicare and Medicaid Services