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Accuracy of Financial Assistance Payments for Individual Enrollees

Under the Patient Protection and Affordable Care Act an enrollee may be eligible for a premium tax credit. The tax credit lowers an individual's premiums for insurance purchased on a marketplace. An enrollee can choose to have the marketplace compute an estimated credit that is paid to the insurance company to lower the amount the enrollee pays in monthly premiums (advance payments of the premium tax credit, or APTC). For enrollees who receive APTCs but do not pay their portion of the premium for 3 consecutive months, qualified health plan issuers are responsible for terminating coverage, returning a portion of APTC payments, and reporting this information to Centers for Medicare & Medicaid Services. In addition, cost-sharing reductions (CSRs) assist certain low-income enrollees with their out-of-pocket costs. The Federal Government makes monthly payments to qualified health plan issuers to cover their estimated CSR costs, and these payments are then periodically reconciled to actual CSR amounts that should have been paid to all plans for confirmed enrollees. We will determine whether Centers for Medicare & Medicaid Services's internal controls were effective in ensuring the accuracy of financial assistance payments - APTC and CSRs - for individual enrollees. We will also conduct work on Centers for Medicare & Medicaid Services's automated policy-based payments system at the Federal Marketplace by potentially looking at the accuracy of the determination of financial assistance payments and the use of enrollment and payment data.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
October 2017 Centers for Medicare & Medicaid Services Accuracy of Financial Assistance Payments for Individual Enrollees Office of Audit Services W-00-15-59018 2018

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