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Data Inadequacies Undermine CMS's Oversight of the Inconsistency Resolution Process for the Federal Marketplace

03-16-2017 | Report (OEI-01-14-00620) | Complete Report

WHY WE DID THIS STUDY

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 this process involves resolving inconsistencies between self-attested information submitted by applicants and data received through Federal and other data sources. In June 2014, CMS reported to OIG that the Federal Marketplace is 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 WE DID THIS STUDY

We requested updated data related to inconsistencies that occurred in the first open enrollment season from CMS's Multidimensional Insurance Data Analytics System. We interviewed CMS staff and contractors about the data management and the resolution processes for inconsistencies and conducted a site visit at the office of the Federal Marketplace.

WHAT WE FOUND

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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 duplicate inconsistencies and increased the burden to applicants with redundant requests for information. CMS officials stated that the improvements to Healthcare.gov and the use of a data manipulation process would help eliminate duplicate inconsistencies.

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 a QHP 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 requirements unless it resolves their inconsistencies.

WHAT WE RECOMMEND

CMS should improve its management of the inconsistency resolution process to ensure that it can readily identify all applicants with inconsistencies. CMS should refine its data management system so that it can track individuals and readily count the number of each type of inconsistency and whether those inconsistencies are unresolved, resolved, or expired. CMS concurred with our recommendation.