Improper Payments:

Improvements Needed in CMS and IRS Controls over Health Insurance Premium Tax Credit

GAO-17-467: Published: Jul 13, 2017. Publicly Released: Jul 13, 2017.

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What GAO Found

In fiscal year 2016, the Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services (CMS) assessed its advance premium tax credit (PTC) program as susceptible to significant improper payments. CMS instituted a qualitative method for assessing the susceptibility of its program that was consistent with requirements, including assessing each of the nine required qualitative risk factors. However, CMS stated that it may not report improper payment estimates for the PTC program as required until at least fiscal year 2022 because of the complexity and timing of the process for developing such estimates. As a result, HHS's overall improper payments estimate will continue to be understated, and Congress and others will continue to lack key payment integrity information for monitoring HHS's improper payments. The fiscal year 2016 Internal Revenue Service (IRS) assessment for its PTC program was not consistent with requirements nor did it demonstrate whether the program met applicable thresholds for susceptibility to significant improper payments. Until IRS conducts an appropriate assessment, it will remain uncertain whether IRS should estimate the amount of improper payments for its PTC program.

Although CMS properly designed and implemented control activities related to the accuracy of advance PTC payments, it did not properly design control activities related to preventing and detecting improper payments of advance PTC, such as verifying individuals' eligibility. As a result, CMS is at increased risk of making improper payments of advance PTC to issuers on behalf of individuals.

CMS Key Control Activities Related to Preventing and Detecting Improper Payments of Advance PTC

CMS Key Control Activities Related to Preventing and Detecting Improper Payments of Advance PTC

aGAO did not evaluate whether control activities that were not properly designed were operating as designed.

IRS did not design and implement certain key control activities related to preventing and detecting PTC improper payments, including recovering excess advance PTC overpayments. For example, IRS did not properly design procedures to routinely check for duplicate employer- or government-sponsored coverage. In addition, in 2015 and 2016, IRS used an ad hoc process for notifying nonfilers of the requirement to file tax returns; however, IRS did not establish procedures for sending these notices regularly during each filing season to facilitate compliance. Without properly designed control activities related to PTC, IRS is at increased risk of making improper payments to individuals.

IRS faces challenges that affect its ability to design and implement procedures related to preventing and detecting PTC improper payments, including recovering advance PTC overpayments and reimbursing advance PTC underpayments. For example, IRS maintains that reduced resources have impaired its ability to implement needed controls. Further, statutory limitations contributed to IRS's inability to fully collect excess advance PTC overpayments and reimburse PTC underpayments and to automatically correct errors in tax returns. GAO previously suggested that IRS seek legislative authority to correct tax returns at filing based on marketplace data. The Department of the Treasury, on behalf of IRS, has submitted proposals for congressional consideration to permit IRS to correct such errors where individuals' information on tax returns does not match corresponding information provided in government databases. Congress has not yet granted this broad authority.

IRS Key Control Activities for Preventing and Detecting Improper Payments of PTC

U:\Work in Process\VCA_Graphics\FY 17\FMA\100574 - PTC\Fig_Sv5_5_100574.tif

aExcept for control activities related to IRS's review of tax returns that contain errors, GAO did not evaluate whether other control activities that were not properly designed were operating as designed.

Why GAO Did This Study 

The Patient Protection and Affordable Care Act (PPACA) aims to expand health insurance coverage and affordability. PPACA provides eligible individuals with PTC to help cover the cost of premiums for health plans purchased through a marketplace. CMS maintains the federally facilitated marketplace known as HealthCare.gov. IRS is responsible for processing PTC-related amounts on tax returns. The estimated fiscal year 2016 net outlay for PTC that was refunded to taxpayers was about $24 billion, while the estimated revenue effect from PTC that taxpayers used to reduce their tax liabilities was about $2 billion. 

GAO was asked to examine improper payments related to PTC. This report assesses the extent to which (1) CMS and IRS assessed the susceptibility of their PTC programs to significant improper payments; (2) CMS properly designed and implemented key control activities related to preventing and detecting improper payments of advance PTC; and (3) IRS properly designed and implemented key control activities related to preventing and detecting improper payments of PTC, including recovering overpayments and reimbursing underpayments of PTC. 

GAO reviewed the improper payment susceptibility assessments completed by CMS and IRS; interviewed agency officials; reviewed policies and procedures; and tested statistical samples of (1) CMS applications with advance PTC transactions during the 2016 open enrollment period and (2) income tax returns with PTC transactions processed during the first 9 months of fiscal year 2016. 

What GAO Recommends

GAO is making 10 recommendations to HHS. Of these, 2 recommendations are related to complying with annual reporting of advance PTC improper payments estimates, including assuring that CMS expedites the process for reporting such estimates. The 8 remaining recommendations address improving control activities related to eligibility determinations and calculations of advance PTC based on incomes and family sizes. HHS concurred with 7 of the recommendations and neither agreed nor disagreed with the remaining 3 recommendations, which related to improving control activities for verifying identities of individuals, preventing duplicate coverage of individuals receiving minimum essential coverage through their employers, and verifying household incomes and family sizes. GAO continues to believe that actions to implement these 3 recommendations are needed as discussed in the report.

GAO is also making 5 recommendations to IRS. Of these, 1 recommendation focuses on properly assessing the susceptibility of the PTC program to significant improper payments. The remaining 4 recommendations address improving control activities related to processing PTC information on tax returns, such as recovering advance PTC made for individuals who do not meet the eligibility requirements for citizenship or lawful presence. IRS agreed with 2 recommendations, partially agreed with 2 other recommendations, and disagreed with the remaining recommendation. For the 2 partial concurrences, GAO continues to believe that actions to fully implement these recommendations are needed as discussed in the report. Although IRS disagreed with the 1 recommendation related to reviewing tax returns to those who are not reporting shared responsibility payments, the actions IRS described in its comments, if implemented effectively, would address the recommendation.

For more information, contact Beryl H. Davis at (202) 512-2623 or davisbh@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Priority recommendation

    Comments: HHS concurred with this recommendation. On February 28, 2018, the Department of Health and Human Services's (HHS) Centers for Medicare and Medicaid Services (CMS) stated that it has updated improper payment measurement methodologies. Further, CMS stated that updates on the advance premium tax credit (PTC) program improper payment measurement development were provided in the fiscal year (FY) 2017 Agency Financial Report (AFR), which was published on November 15, 2017. We reviewed the FY 2017 AFR that HHS's CMS cited in support for closing this recommendation. Based on our review, the FY 2017 AFR does not address our recommendation as it does not report an improper payment estimate for the advance PTC program. Therefore, we still consider this recommendation open. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to annually report improper payment estimates and error rates for the advance PTC program.

    Agency Affected: Department of Health and Human Services

  2. Status: Open

    Comments: HHS concurred with this recommendation. On February 28, 2018, the Department of Health and Human Services's (HHS) Centers for Medicare and Medicaid Services (CMS) stated that updates on the advance premium tax credit (PTC) program improper payment measurement development were provided in the fiscal year (FY) 2017 Agency Financial Report (AFR), which was published on November 15, 2017. We reviewed the FY 2017 AFR that HHS's CMS cited in support for closing this recommendation. Based on our review, the FY 2017 AFR does not address our recommendation as it does not provide a timeline for reporting an improper payment estimate. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, and until annual reporting of improper payment estimates and error rates for the advance PTC program is performed, the Secretary of Health and Human Services should direct the Administrator of CMS to disclose significant matters relating to the Improper Payments Information Act (IPIA) estimation, compliance, and reporting objectives for the advance PTC program in the agency financial report, including CMS's progress and timeline for expediting the achievement of those objectives and the basis for any delays in meeting IPIA requirements.

    Agency Affected: Department of Health and Human Services

  3. Status: Open

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding verification of filer identity, HHS stated that for individuals starting a new application via phone, the call center representatives use verbal attestations for identity verifications from individuals. HHS stated that for paper applications, individuals must provide names and complete addresses as well as other information. In addition, HHS stated that individuals must attest that the information they provide on all applications is accurate by signing under penalty of perjury. However, these steps do not involve the verification of applicant's identity to a third party source. GAO continues to believe that because CMS does not validate the identities of individuals who apply by phone or mail, CMS is vulnerable to enrolling ineligible individuals in qualified health plans with advance PTC. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying the identities of phone and mail applicants to reasonably assure that ineligible individuals are not enrolled in qualified health plans in the marketplaces or provided advance PTC.

    Agency Affected: Department of Health and Human Services

  4. Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that its previous assessments of available electronic data sources did not identify any comprehensive national data source for verifying residency. HHS recently conducted a study to assess the feasibility of developing an employer-sponsored coverage database and determined that development would be costly and highly burdensome given available resources. Additionally, HHS stated that it would impose extra burden on employers to collect the information needed to build a comprehensive employer-sponsored coverage database. HHS will continue to assess and document whether any sufficiently reliable data sources exist and examine the feasibility of implementation. HHS stated that it will provide analysis and documentation on whether any sufficiently reliable data source exists and examine the feasibility of implementation by December 2018. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility and availability of obtaining sufficiently reliable data to verify individuals' residencies and lack of minimum essential coverage from nonfederal employers and, if appropriate, design and implement procedures for using such data in its verification processes.

    Agency Affected: Department of Health and Human Services

  5. Status: Open

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding sending notices to nonfederal employers, HHS stated that it is evaluating its 2016 employer notice program to determine the best approach for notifying employers in the future and that it will evaluate the employer notice program and report on its efficacy to us by December 2018. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for sending notices to nonfederal employers routinely and terminating advance PTC for individuals who have access to minimum essential coverage from their employers.

    Agency Affected: Department of Health and Human Services

  6. Status: Open

    Comments: HHS concurred with this recommendation. HHS stated that its preliminary analysis indicates that identifying government sponsored coverage for individuals receiving Medicaid and CHIP in Federally-facilitated Exchange states outside of the state where the applicant is enrolled in coverage would add several months to the time needed to execute the process of identifying duplicate enrollees and ending their advance PTC. Such additional time would significantly reduce the timeliness and effectiveness of the process and lead to an increase in burden on the state Medicaid systems used to verify duplicate coverage. HHS stated that it will continue this analysis and document the feasibility of approaches for identifying duplicate government sponsored coverage for individuals receiving Medicaid and CHIP coverage in Federally-facilitated Exchange states outside the application state of the consumer as well as periodically verifying individual's continued eligibility. In addition, HHS stated that it has implemented a Periodic Data Matching process to proactively identify consumers who may be receiving Minimum Essential Coverage through Medicare, and thus are no longer eligible for financial assistance to help pay for Exchange coverage. HHS is also exploring approaches to identifying Exchange enrollees who may be deceased and should thus be disenrolled from coverage. HHS stated that it will evaluate the feasibility of implementing its periodic Medicaid/Children's Health Insurance Program and death matching programs by December 2018. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility of approaches for (1) identifying duplicate government-sponsored coverage for individuals receiving Medicaid and Children's Health Insurance Program coverage in federally facilitated marketplace states outside of the states where they attest to residing and (2) periodically verifying individuals' continued eligibility by working with other government agencies to identify changes in life circumstances that affect advance PTC9 eligibility--such as commencement of duplicate coverage or deaths-- that may occur during the plan year and, if appropriate, design and implement these verification processes.

    Agency Affected: Department of Health and Human Services

  7. Status: Open

    Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. In June 2018, HHS's Centers for Medicare & Medicaid Services (CMS) prepared a document titled "Terminating Advance Payment of Premium Tax Credit on a More Timely Basis: Assess and Document". In this document, CMS stated that it appreciates GAO's recommendation and is working toward processing inconsistency expirations on a rolling basis instead of by cohort in order to realize operational efficiencies. CMS stated that it has included information technology (IT) functionality that will support this processing change in CMS's three year plan. Also, CMS indicated it will provide GAO an update when this change is scheduled for an IT release. CMS believes that it is neither financially nor operationally feasible to change the current processes around advance premium tax credit before the IT functionality is available. In its follow-up response to GAO on July 26, 2018, CMS stated that its three year plan has not been finalized. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to assess and document the feasibility of approaches for terminating advance PTC on a timelier basis and, as appropriate, design and implement procedures for improving the timeliness of terminations.

    Agency Affected: Department of Health and Human Services

  8. Status: Open

    Priority recommendation

    Comments: HHS concurred with this recommendation. HHS stated that the IRS provides information to Exchanges on consumers who received advance PTC in the prior coverage year but have not taken the necessary steps to file a tax return and reconcile advance PTC. Beginning in Open Enrollment for 2018, the Federally-facilitated Exchange will end advance PTC on behalf of the tax filers who have not filed or have not reconciled advance PTC when that information is reported to the Exchange by IRS. HHS stated that it will report to us on its procedures by December 2018. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying compliance with applicable tax filing requirements--including the filing of the federal tax return and the Form 8962, Premium Tax Credit--necessary for individuals to continue to be eligible for advance PTC.

    Agency Affected: Department of Health and Human Services

  9. Status: Closed - Implemented

    Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. On July 23, 2018, we received a correspondence from HHS stating that its Centers for Medicare & Medicaid Services (CMS) implemented the Special Enrollment Period Verification program and has documented this verification program in its standard operating procedure (SOP). We verified that CMS's SOP (last updated March 23, 2018) has procedures for verifying major life changes using documentation submitted by applicants enrolling during special enrollment periods. Specifically, the SOP outlines in detail the process for verifying an applicant's eligibility based on documentation submitted to support his or her qualifying event, which includes loss of minimal essential coverage, permanent move, gaining a dependent, marriage, and Medicaid/Children's Health Insurance Program. We believe CMS's corrective actions address our recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying major life changes using documentation submitted by applicants enrolling during special enrollment periods.

    Agency Affected: Department of Health and Human Services

  10. Status: Open

    Priority recommendation

    Comments: HHS neither agreed nor disagreed with this recommendation. However, regarding verification of household income and family sizes, HHS stated that as part of its eligibility verification requirements, it verifies consumer-reported income with data from IRS. However, HHS stated that because household incomes may fluctuate year to year, it is difficult for consumers to project income for the year in advance. According to HHS, in instances where applicant-reported income is higher than the IRS data, HHS accepts the consumer attestation. However, HHS stated that it will assess the feasibility and burden on individuals of setting a reasonable threshold for the generation of annual household income inconsistencies that would require additional verification for consumer-attested income that significantly exceeds income amounts reported by IRS or other third party sources. We believe that such an evaluation is a reasonable step to address our recommendation to enhance the effectiveness and efficiency of the program related to verification of household income. In addition, HHS stated that it currently accepts attestation when the family size provided by the individual does not match IRS's records. HHS stated that establishing a process to verify family size with IRS would require significant operational and privacy complexity. While we recognize that there may be certain complexities in the verification of family sizes, it is important that CMS develop policies and procedures to reasonably assure that such verifications are made on a regular basis. HHS did state that it will report to us on its analysis of potentially verifying income and family sizes by December 2018. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying with IRS (1) household incomes, when attested income amounts significantly exceed income amounts reported by IRS or other third-party sources, and (2) family sizes.

    Agency Affected: Department of Health and Human Services

  11. Status: Open

    Priority recommendation

    Comments: The Internal Revenue Service (IRS) partially agreed with this recommendation. On July 10, 2018, IRS informed us that it is in the process of conducting quantitative analysis of the premium tax credit (PTC) using National Research Program (NRP) data for tax year 2014 and aggregating and assessing the data to determine the reliability of this data for determining the extent of improper payments related to PTC. IRS believes it will complete its assessment sometime during the 4th quarter of fiscal year 2018. IRS also stated that they plan to do a qualitative risk assessment for the PTC program using Department of Treasury's template. Until IRS conducts an appropriate risk assessment consistent with the Improper Payments Information Act of 2002, as amended, it will continue to be uncertain about whether it should estimate the amount of improper PTC payments. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess the program against applicable IPIA-defined thresholds and conclude on its susceptibility to significant improper payments, and revise the scope of its improper payments susceptibility assessment for the PTC program to include instances in which advance PTC is greater than or equal to the amount of PTC claimed on the tax return. If the program meets the IPIA definition for being susceptible to significant improper payments based on this assessment, estimate and report improper payments associated with the PTC program consistent with IPIA requirements.

    Agency Affected: Department of the Treasury: Internal Revenue Service

  12. Status: Open

    Comments: The IRS agreed with this recommendation. On July 11, 2018, IRS informed us that it conducted a detailed review which has resulted in an alternative recommendation consistent with the objectives of the GAO recommendation and will allow IRS to prevent premium tax credit (PTC) at filing for non-citizens.The July 2018 e-mail did not indicate a timeframe of when IRS expects this recommendation to be implemented. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess and document the feasibility of approaches for incorporating information from the marketplaces on individuals who did not demonstrate that they met the eligibility requirements for citizenship or lawful presence in the tax compliance process. If determined feasible, IRS should work with Treasury to require marketplaces to periodically provide such information on individuals and use such information to recover advance PTC made for those individuals.

    Agency Affected: Department of the Treasury: Internal Revenue Service

  13. Status: Open

    Priority recommendation

    Comments: The Internal Revenue Service (IRS) agreed with this recommendation. On July 10, 2018, IRS informed us that it plans to perform analysis to determine the magnitude of the noncompliance related to duplicate health insurance coverage. IRS will use the results from this analysis to determine whether it makes sense to update its Internal Revenue Manual (IRM) to require examiners to use the checklist. IRS believes it will complete this analysis sometime in fiscal year 2019. Until such policies and procedures are incorporated in the IRM, IRS is vulnerable to improperly providing premium tax credit (PTC) to ineligible recipients. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess whether IRS should require its examiners to verify health care coverage of individuals to determine eligibility for PTC. To do this, IRS should complete its evaluation of the level of noncompliance related to duplicate health insurance coverage. Based on this evaluation and if cost effective, IRS should design and implement formal policies and procedures to routinely identify individuals inappropriately receiving PTC because of their eligibility for or enrollment in health care programs outside of the marketplaces and notify such individuals of their ineligibility for PTC.

    Agency Affected: Department of the Treasury: Internal Revenue Service

  14. Status: Closed - Implemented

    Comments: IRS disagreed with this recommendation. Nevertheless, in a September 2017 letter, IRS stated that they drafted a new Internal Revenue Manual (IRM) that would identify and assess individuals that did not appropriately report the shared responsibility payments (SRPs). The IRS stated that this IRM section will be placed in clearance before publication in September 2018. However, in December 2017, about five months after our report issuance, the individual mandate was repealed (Pub. Law No. 115-97, ? 11081). IRS analyzed the law and its impact on its IRM. Based its analysis, IRS found that no change was necessary to the IRM for incorporating SRPs since the requirement no longer exists. Because IRS was taking appropriate steps regarding the implementation of our recommendation for assuring taxpayer compliance of the SRP and appropriately terminated those steps after its repeal, we are closing the recommendation as implemented.

    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to design and implement procedures in the Internal Revenue Manual (IRM) for examiners in the post-filing compliance units to review tax returns for health insurance coverage for the entire year, and to identify and assess individual shared responsibility payments (SRP) from those who are not appropriately reporting SRPs on their tax returns.

    Agency Affected: Department of the Treasury: Internal Revenue Service

  15. Status: Open

    Priority recommendation

    Comments: The Internal Revenue Service (IRS) partially agreed with this recommendation. On March 23, 2018, IRS stated that it developed a process for sending notices to individuals who received advance premium tax credit (PTC) paid on their behalf in the previous calendar year and who failed to file a tax return or requested an extension to file. At that time, IRS stated that it will determine whether this information should be included in an existing Internal Revenue Manual (IRM). On July 10, 2018, IRS informed us that after further consideration, it does not plan to update the IRM to include procedures for notifying nonfilers of the requirement to file tax returns in order to receive advance PTC in the future. IRS stated it has noticed a steady decline in nonfilers in tax year 2016 and expects to see a continuation of declines in nonfilers in tax year 2017. Because of this expected decline, IRS is uncertain if it will send notices to individuals for the current tax year. IRS considers these notices discretionary, post-filing season activity that is focused primarily on educating taxpayers of their requirement to file the appropriate tax return data and to alert them of the potential loss of future advance PTC subsidies. We continue to believe that IRS needs to design and implement procedures to regularly notify non-filers of the need to file to continue receiving advance PTC. The lack of these procedures increases the risk of individuals losing their subsidized health care coverage from the marketplaces in the future. This can occur because the individuals may not be aware of the requirement to file their tax returns and reconcile the advance PTC since there is a year's interval between when individuals first apply for advance PTC and when they are supposed to reconcile it on their tax returns. In addition, unless individuals make an assessment or claim through tax return filing, the federal government may not be aware of or fully collecting on excess advance PTC that it may be owed or paying any additional PTC that is due to individuals. We will continue to monitor the agency's actions to address this recommendation.

    Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to design and implement procedures in the IRM to regularly notify nonfilers of the requirement to file tax returns in order to continue to receive advance PTC in the future.

    Agency Affected: Department of the Treasury: Internal Revenue Service

 

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