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Data inadequacies undermine CMS's oversight of the inconsistency resolution process for the federal marketplace

Series Title(s):
Report in brief
Contributor(s):
United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
Publication:
[Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, March 2017
Language(s):
English
Format:
Text
Subject(s):
Data Collection
Eligibility Determination
Health Insurance Exchanges
Cost Sharing
Federal Government
Government Regulation
Humans
United States
United States. Department of Health and Human Services.
United States.
Centers for Medicare & Medicaid Services (U.S.)
Genre(s):
Technical Report
Abstract:
Why OIG Did This Review. Ensuring that only eligible applicants can enroll in qualified health plans (QHPs) and insurance affordability programs depends on the integrity of the enrollment process. A key part of that process involves resolving inconsistencies between self-attested information submitted by applicants and data received through Federal and other data sources. In June 2014, the Centers for Medicare & Medicaid Services (CMS) reported to the Office of Inspector General (OIG) that the Federal Marketplace was unable to resolve most inconsistencies from the first open enrollment period because the eligibility system was not fully operational. This report follows up on our earlier work, focusing on CMS's data management and resolution of prior inconsistencies. How OIG Did This Review. We requested updated data related to inconsistencies that occurred in the first open enrollment season from CMS's Multidimensional Insurance Data Analytics System. We also interviewed CMS staff and contractors about the data management process for inconsistencies and the resolution process for inconsistencies and conducted a site visit at an office of the Federal Marketplace. What OIG Found. The Federal Marketplace is unable to calculate the total number of applicants with inconsistencies during the first open enrollment period because the data cannot uniquely identify an individual seeking to enroll in a QHP. These shortcomings in the data also created additional work for CMS because it had to resolve the same inconsistencies more than once and increased the burden to applicants with redundant requests for information. CMS experienced challenges using its inconsistency data and was unable to extract accurate data on inconsistencies or fully explain how it tracks inconsistencies in its data in a timely manner. Our analysis of the portion of inconsistencies for applicants enrolled in QHPs shows that the Federal Marketplace appears to have resolved or "expired" (i.e., terminated) 42 percent of inconsistencies that we tracked for the first open enrollment period. Inconsistencies do not necessarily indicate that an applicant inappropriately enrolled in a QHP or incorrectly enrolled in one or more insurance affordability programs. However, the Federal Marketplace cannot ensure that the applicants meet the requirement unless it resolves their inconsistencies.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (21 pages))
Illustrations:
Illustrations
NLM Unique ID:
101737746 (See catalog record)
Series Title(s):
Report in brief
Contributor(s):
United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
Publication:
[Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, March 2017
Language(s):
English
Format:
Text
Subject(s):
Data Collection
Eligibility Determination
Health Insurance Exchanges
Cost Sharing
Federal Government
Government Regulation
Humans
United States
United States. Department of Health and Human Services.
United States.
Centers for Medicare & Medicaid Services (U.S.)
Genre(s):
Technical Report
Abstract:
Why OIG Did This Review. Ensuring that only eligible applicants can enroll in qualified health plans (QHPs) and insurance affordability programs depends on the integrity of the enrollment process. A key part of that process involves resolving inconsistencies between self-attested information submitted by applicants and data received through Federal and other data sources. In June 2014, the Centers for Medicare & Medicaid Services (CMS) reported to the Office of Inspector General (OIG) that the Federal Marketplace was unable to resolve most inconsistencies from the first open enrollment period because the eligibility system was not fully operational. This report follows up on our earlier work, focusing on CMS's data management and resolution of prior inconsistencies. How OIG Did This Review. We requested updated data related to inconsistencies that occurred in the first open enrollment season from CMS's Multidimensional Insurance Data Analytics System. We also interviewed CMS staff and contractors about the data management process for inconsistencies and the resolution process for inconsistencies and conducted a site visit at an office of the Federal Marketplace. What OIG Found. The Federal Marketplace is unable to calculate the total number of applicants with inconsistencies during the first open enrollment period because the data cannot uniquely identify an individual seeking to enroll in a QHP. These shortcomings in the data also created additional work for CMS because it had to resolve the same inconsistencies more than once and increased the burden to applicants with redundant requests for information. CMS experienced challenges using its inconsistency data and was unable to extract accurate data on inconsistencies or fully explain how it tracks inconsistencies in its data in a timely manner. Our analysis of the portion of inconsistencies for applicants enrolled in QHPs shows that the Federal Marketplace appears to have resolved or "expired" (i.e., terminated) 42 percent of inconsistencies that we tracked for the first open enrollment period. Inconsistencies do not necessarily indicate that an applicant inappropriately enrolled in a QHP or incorrectly enrolled in one or more insurance affordability programs. However, the Federal Marketplace cannot ensure that the applicants meet the requirement unless it resolves their inconsistencies.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (21 pages))
Illustrations:
Illustrations
NLM Unique ID:
101737746 (See catalog record)