GAO Issues Report on Patient Protection, Affordable Care Act
The report was sent to Sen.
Why GAO Did This Study: "Under PPACA, consumers can enroll in health insurance coverage, or change from one qualified health plan to another, through the federal and state marketplaces either (1) during the annual open enrollment period or (2) outside of the open enrollment period, if they qualify for an SEP. A consumer may qualify for an SEP due to specific triggering events, such as a nonvoluntary loss of health-care coverage. CMS reported that 1.6 million individuals made a plan selection through an SEP in 2015.
GAO was asked to test marketplace enrollment and verification controls for applicants attempting to obtain coverage during an SEP.
This report describes the results of GAO attempts to obtain subsidized qualified health-plan coverage during the 2016 SEP in the federal marketplace and two selected state-based marketplaces--
To perform the undercover testing of enrollment verification, GAO submitted 12 new fictitious applications for subsidized health-insurance coverage outside of the open enrollment period in 2016. GAO's applications tested verifications related to a variety of SEP triggering events. The results cannot be generalized to all enrollees.
GAO provided a draft of this report to CMS and the selected state agencies. In their written comments, CMS and the states reiterated that they are not required to verify an SEP event and instead rely on self-attestation. However, prudent stewardship and good management practices suggest that fraud risks be understood and managed to protect public funds."
What GAO Found: "The Patient Protection and Affordable Care Act (PPACA) requires that federal and state-based marketplaces verify application information--such as citizenship or immigration status--to determine eligibility for enrollment in a health plan, potentially including a subsidy. However, there is no specific legal requirement to verify the events that trigger a Special Enrollment Period (SEP), which is an opportunity period to allow an individual to apply for health coverage after events such as losing minimum essential coverage or getting married. Prior to the start of GAO's enrollment tests, the
The federal and selected state-based marketplaces approved health-insurance coverage and subsidies for 9 of 12 of GAO's fictitious applications made during a 2016 SEP. The remaining 3 fictitious applicants were denied. The marketplaces instructed 6 of 12 applicants to provide supporting documentation, such as a copy of a recent marriage certificate, related to the SEP triggering event; the remaining 6 of 12 were not instructed to do so. For 5 applicants, GAO provided no documents to support the SEP triggering event, but coverage was approved anyway. Officials from the marketplaces explained that they do not require applicants to submit documentation to support certain SEP triggering events. For other SEP triggering events, CMS officials explained that the standard operating procedure in the federal Marketplace is to enroll applicants first, and verify documentation to support the SEP triggering event after enrollment. The officials also noted that all applicants must attest to their eligibility for enrollment.
GAO is not making any recommendations to the
The full-text of the GAO report is available at http://www.gao.gov/products/GAO-17-78?utm_medium=email&utm_source=govdelivery.
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