Payment integrity: additional coordination is needed for assessing risks in the improper payment estimation process for advance premium tax credits : report to congressional requesters

Payment integrity: additional coordination is needed for assessing risks in the improper payment estimation process for advance premium tax credits : report to congressional requesters

Collection:
Health Policy and Services Research
Contributor(s):
United States. Government Accountability Office, issuing body.
Publication:
Washington, DC : United States Government Accountability Office, March 2023
Language(s):
English
Format:
Text
Subject(s):
Fraud -- legislation & jurisprudence
Government Regulation
Insurance, Health -- legislation & jurisprudence
Legislation, Medical
United States
Centers for Medicare & Medicaid Services (U.S.)
Genre(s):
Technical Report
Abstract:
Why GAO did this study. To help taxpayers cover the cost of health insurance premiums, PPACA provides advance premium tax credits for individuals who meet certain eligibility requirements. For fiscal year 2022, the Department of Health and Human Services (HHS) reported an estimated $256 million in improper payments for the federally facilitated marketplace. GAO was asked to review advance premium tax credit payment integrity efforts. This report examines (1) key control activities selected states and CMS implemented to prevent providing advance premium tax credits to ineligible individuals through the state-based marketplaces and (2) the extent to which CMS developed a reliable methodology to estimate improper payments in the program. GAO analyzed policies and procedures for determining eligibility in plan year 2022 from CMS, and selected states to include those with the highest average monthly payment amounts and those with new and more established marketplaces (California, Colorado, Nevada, New Jersey, and Pennsylvania). GAO also reviewed CMS’s improper payment estimation methodology for the advance premium tax credit for fiscal year 2022. What GAO recommends. GAO is making two recommendations to CMS to coordinate with the states to assess residual risks when estimating improper payments, and to determine if additional guidance or actions are needed. HHS disagreed with GAO’s recommendations. GAO continues to believe the recommendations are valid, as discussed in the report.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (ii, 36 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918627774806676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918627774806676