Wednesday, September 17, 2014
Inquirer Daily News

Health exchanges fall short on verifying applicants' eligibility, probe finds

With the 2014 enrollment for individual marketplace coverage under the health care law now in the books, consumers, stakeholders and insurers have turned their attention to the cost of coverage in 2015.
With the 2014 enrollment for individual marketplace coverage under the health care law now in the books, consumers, stakeholders and insurers have turned their attention to the cost of coverage in 2015. Healthcare.gov

WASHINGTON - The new health insurance marketplaces run by the federal government and some states are not checking carefully enough that Americans who apply for health plans qualify for the coverage and federal subsidies to help pay for it, according to federal investigators.

A pair of reports, issued Tuesday by the Health and Human Services Office of Inspector General, conclude that "internal controls" for evaluating applications were not always effective at verifying people's Social Security numbers, their citizenship, and whether they are eligible to buy health plans through the marketplaces because they cannot find affordable insurance elsewhere.

Such deficiencies "may have limited the marketplaces' ability to prevent the use of inaccurate or fraudulent information" by consumers drawn to the insurance exchanges created under the 2010 Affordable Care Act, one of the reports said.

In the other report, the inspector general evaluated the marketplaces' ability to verify the accuracy of information that consumers submit when they apply for the insurance and for financial help. By the end of last year, the report said, the federal marketplace alone had 2.9 million "inconsistencies" - gaps between the information applicants provided and various federal records. And 2.6 million of them could not be resolved because the computer system needed to do so "was not fully operational."

As the Post has previously reported, the most common inconsistencies involve applicants' income and their citizenship.

 

Series of reviews

The reports are the first to emerge from a series of reviews undertaken by HHS' investigative arm to evaluate aspects of the new federal health insurance marketplace and 14 separate state-run marketplaces. The inspector general's mission is to ferret out fraud and waste in the department's programs.

Tuesday's reports, from independent investigators within the executive branch, lend credence to the contention of the health-care law's Republican detractors that the administration has not employed sufficient safeguards to prevent improper payments of the new insurance tax credits and other financial help to consumers under the law.

The broader of the two reports was required by Congress last year at the insistence of House Republicans, who made it a condition of the budget agreement that ended a partial government shutdown.

Both reports were based on the marketplaces' experiences from October through December. Those three months were part of half of the first six-month sign-up period for insurance under the health-care law for new plans that became available at the start of this year.

 

Most got financial aid

By the end of the sign-up period in early spring, eight million Americans had chosen a health plan, 5.4 million of them in the federal insurance exchange, and 85 percent had received financial help.

The finding in the broader report was based on a random sample of 45 applications from the federal exchange and separate exchanges in California and Connecticut - states whose marketplaces have worked more smoothly than most.

Investigators looked at documents used by the marketplaces to determine eligibility for insurance and subsidies, interviewed the marketplaces' staff and outside contractors, and watched the staff at work.

 

Not the same defects

The report found different defects in the three marketplaces it evaluated. Connecticut's exchange did not always adequately verify that applicants were who they said they were. California's sometimes failed to compare applicants' reported citizenship status with government immigrations records.

The federal marketplace sometimes failed to validate people's Social Security numbers and, overall, did not always iron out inconsistencies between the applicants' information and various federal records.

The separate inquiry into inconsistencies was based on information from the federal marketplace and 10 of the 14 state-run marketplaces.

 


BY THE NUMBERS

2.9M

Inconsistencies, or gaps between the information applicants provided and various federal records.

2.6M

Number of inconsistencies that could not be resolved.

8M

Number of Americans who had signed up for health-care coverage by spring.

Amy Goldstein Washington Post
Also on Philly.com
Stay Connected