State Health Insurance Marketplaces: CMS Should Improve Oversight of State Information Technology Projects
Highlights
What GAO Found
States reported to the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) that they spent about $1.45 billion in federal marketplace grant funding on information technology (IT) projects supporting health insurance marketplaces, as of March 2015. The majority of this spending was for state-based marketplaces (i.e., marketplaces established and operated by the states). These marketplaces reported spending nearly 89 percent of the funds on IT contracts, and CMS has ongoing efforts to track states' IT spending in more detailed categories. States also reported spending, as of December 2014, $2.78 billion in combined federal and state funds designated for Medicaid eligibility and enrollment systems—a portion of which was used for marketplace IT projects. However, the specific amount spent on marketplace-related projects was uncertain, as only a selected number of states reported to GAO that they tracked or estimated this information. Regarding the status of states' marketplace IT projects, 14 states with state-based marketplaces had developed and were operating IT systems to support their marketplaces, but, as of February 2015, not all system functions were complete. In addition, as of November 2014, 7 of 37 states using the federal marketplace system could not transfer health insurance applications between their state Medicaid systems and a key component of the federal marketplace or had not completed testing or certification of these functions. According to CMS officials, states operating their own IT systems and states using the federal marketplace system were continuing to improve the development and operation of their marketplaces in the enrollment period that began in November 2014.
CMS tasked various offices with responsibilities for overseeing states' marketplace IT projects. However, the agency did not always clearly document, define, or communicate its oversight roles and responsibilities to states as called for by best practices for project management. According to some states, this resulted in instances of poor communication with CMS, which adversely affected states' deadlines, increased uncertainty, and required additional work. CMS also did not involve all relevant senior executives in decisions to approve federal funding for states' IT marketplace projects; such involvement, according to leading practices for investment management, can increase accountability for decision making. Further, while CMS established a process that required the testing of state marketplace systems to determine whether they were ready to be made operational, these systems were not always fully tested, increasing the risk that they would not operate as intended. For their part, states oversaw their IT projects through state agencies or quasi-governmental entities, depending on marketplace type, as well as using other oversight mechanisms.
States reported a number of challenges in establishing the systems supporting their marketplaces. These fell into several categories, including project management and oversight, system design and development, resource allocation and distribution, and marketplace implementation and operation. States also identified lessons learned from dealing with such challenges, including the need for strong project management and clear requirements development. CMS has taken various actions to respond to state challenges, identify lessons learned, and share best practices with states; continuing these efforts will be important as states work to complete their marketplace systems.
Why GAO Did This Study
The Patient Protection and Affordable Care Act required the establishment of health insurance exchanges—or marketplaces—to allow consumers and small employers to compare, select, and purchase health insurance plans. States can elect to establish a state-based marketplace, or cede this authority to CMS to establish a federally facilitated marketplace. To assist states in establishing their marketplaces and supporting IT systems, federal funding was made available, including grants and Medicaid matching funds. CMS has responsibilities for overseeing states' use of these funds and the establishment of their marketplaces.
The objectives of this study were to (1) determine how states have used federal funds for IT projects to support their marketplaces and the status of the marketplaces, (2) determine CMS's and states' roles in overseeing these projects, and (3) describe IT challenges states have encountered and lessons learned. To do this, GAO surveyed the 50 states and the District of Columbia, reviewed relevant documentation from the states and CMS, and interviewed CMS officials.
Recommendations
GAO is recommending that CMS define and communicate its oversight roles and responsibilities, ensure senior executives are involved in funding decisions for state IT projects, and ensure that states complete testing of their systems before they are put into operation. HHS concurred with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | To improve the oversight of states' marketplace IT projects, the Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to clearly document, define, and communicate to all state marketplace officials and stakeholders the roles and responsibilities of those CMS officials involved in overseeing state marketplaces in a comprehensive communication management plan. |
Closed – Implemented
In 2015, Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) concurred with the recommendation. In April 2017, we verified that CMS, in response to our recommendation, completed a comprehensive communications plan which outlined the roles and responsibilities of key organizations and officials within the agency that are involved in overseeing state marketplace IT projects as well as those that support states in effectively establishing and operating marketplace systems. Further, the plan was made available to state marketplaces to establish a common understanding of roles and responsibilities. Further, the agency developed an engagement roadmap which provided a high level summary of annual CMS reporting and oversight activities for state marketplaces. CMS noted that the engagement roadmap was shared with state marketplace officials in July 2016. As a result, CMS has established a consistent and comprehensive communication of roles and responsibilities that is necessary to support the states in effectively establishing and operating their marketplace systems. Having a comprehensive communication management plan that now identifies and conveys the roles and responsibilities of key organizations and officials will be a valuable resource for clearly understanding the communication expected between CMS officials and states on any further marketplace IT efforts.
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| Department of Health and Human Services | To improve the oversight of states' marketplace IT projects, the Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to ensure that all CMS senior executives from IT and business units who are involved in the establishment of state marketplace IT projects review and approve funding decisions for these projects. |
Closed – Not Implemented
In 2015, Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) concurred with the recommendation. The department, in agency comments on the report, stated that it already included senior executives in its funding decisions for these projects. However, as noted in our report, CMS did not provide evidence that key senior executives from CCIIO, CMCS, and OTS were involved in various funding decisions associated with the states' IT projects. For example, CMS did not demonstrate that senior-level executives from all relevant business and IT units were involved in the initial approval of grant awards or the release of restricted IT funds from marketplace grants as states progressed with their projects. In addition, CMS did not provide evidence of senior executive involvement in the approval of Medicaid funds for marketplace IT projects. As of March 10, 2017, CMS still had not provided evidence that it had taken such actions to support the implementation of this recommendation. Furthermore, in July 2018, CMS submitted documentation that the marketplace grant funding was closing at the end of 2017 and that no cost extensions would be offered. Since the grant funding has come to an end, CMS has no further plans to enhance its oversight of marketplace project grants.
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| Department of Health and Human Services | To improve the oversight of states' marketplace IT projects, the Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to ensure that states have completed all testing of marketplace system functions prior to releasing them into operation. |
Closed – Implemented
In 2015, Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) concurred with the recommendation. In fiscal year 2018, we verified that CMS, in response to our recommendation, had taken steps to ensure that states have completed testing of marketplace system functions prior to releasing them into operation.
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