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

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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: The Department of Health and Human Services (HHS) concurred with this recommendation. On May 23, 2018, HHS's Centers for Medicare and Medicaid Services (CMS) stated that it is currently in the process of developing an improper payment measurement for the advance premium tax credit (PTC). The development of the measurement methodologies will be a multi-year process which consists of the development of measurement policies, procedures, and tools. It also includes extensive pilot testing to ensure an accurate and efficient improper payment estimate, as well as, acquisition activities for procurement of improper payment measurement contractors. 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 in November 2017. In FY 2018, 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. In FY 2019, we reviewed HHS's FY 2018 AFR published in November 2018, which includes a statement that HHS will continue to update its annual AFRs on the status of the measurement program development until the improper payment estimate is reported. However, this latest AFR also does not provide a timeline for reporting an improper payment estimate for HHS's PTC program. 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: The Department of Health and Human Services (HHS) neither agreed nor disagreed with this recommendation. Regarding verification of filer identity, HHS stated, in response to the draft report, that for individuals starting an application via phone, the call center representatives use verbal attestations for 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 an applicant's identity to a third-party source. In August 2018, HHS officials stated that they are exploring alternatives for assessing risk and ensuring integrity of applicant information that is provided to the program and ways to ensure personal information provided by an individual is accurate through a variety of means. After this analysis phase, they will assess resource requirements, cost, and operational implications for potential implementation approaches with a target date for completion of 2019. As of December 2018, HHS had not designed and implemented procedures for verifying the identities of phone and mail applicants, as GAO recommended. 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: The Department of Health and Human Services (HHS) concurred with this recommendation. HHS provided documentation to demonstrate that the verification of individuals' residences is not feasible. However, as of November 2018, HHS had not assessed and documented the feasibility of obtaining sufficiently reliable data to verify individuals' lack of minimum essential coverage from nonfederal employers. Also, HHS did not provide GAO with a timeline for this analysis. 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: Closed - Implemented

    Comments: The Department of Health and Human Services (HHS) neither agreed nor disagreed with this recommendation. However, as of November 2018, HHS had assessed and documented the feasibility of routinely sending notices to nonfederal employers and terminating advance premium tax credit (PTC) for individuals who have access to minimum essential coverage from their employers. In its analysis, HHS found that the employer notices were of limited utility. Specifically, only the Internal Revenue Service (IRS) can independently determine any liability for an employer shared responsibility payment because only IRS has information on employees' final eligibility for PTC and employers' offers of coverage; this information is not held by HHS's Centers for Medicare and Medicaid Services (CMS). Because of this and the high cost of sending the notices and adjudicating subsequent appeals, HHS decided not to send employer notices. Because CMS appropriately reviewed the effectiveness of employer notices in regard to the recommendation, GAO is closing the recommendation as implemented.

    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: The Department of Health and Human Services (HHS) concurred with this recommendation. In November 2018, HHS provided documentation which shows that HHS's Centers for Medicare and Medicaid Services (CMS) assessed the feasibility of approaches for identifying individuals that have Medicare coverage or individuals that are deceased (i.e., bullet 2 of the recommendation). Based on this analysis, CMS is developing a data match process to periodically identify individuals with Medicare coverage or who are deceased. CMS anticipates full implementation of this process to be completed within the next 3 years. In April 2019, HHS stated that CMS has evaluated the feasibility of implementing its periodic data match (PDM) process to identify duplicate coverage for individuals receiving Medicaid and Children's Health Insurance Program (CHIP) benefits outside of the states where the individuals attested to residing (i.e., bullet 1 of the recommendation). CMS has determined such an expansion of the PDM is not feasible due to (1) time needed to conduct such a cross-state match and (2) CMS's belief that the Medicaid and CHIP enrollment match rate for consumers in states where they did not apply would be no higher - and, more likely, much lower- than the current low match rate for within-state data matching. As indicated above, CMS conducted a feasibility analysis related to bullet 1 of the recommendation and concluded it would not be feasible to design and implement a process that identifies duplicate government-sponsored coverage for individuals receiving Medicaid and CHIP coverage in federally facilitated marketplace states outside of the states where they attest to residing. Therefore, we believe that HHS has addressed bullet 1 of the recommendation since CMS assessed and documented a feasibility analysis, which meets the intent of the recommendation. We will continue to monitor the agency's actions to address bullet 2 of the 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. As of November 2018, HHS's Centers for Medicare & Medicaid Services (CMS) had taken steps to assess and document the feasibility of approaches for terminating advance premium tax credit (PTC) on a timelier basis and, as appropriate, to design and implement procedures for improving the timeliness of terminations, as GAO recommended. In June 2018, HHS provided documentation that showed that CMS assessed the feasibility of approaches for terminating advance PTC on a timelier basis. In this documentation, CMS stated that it 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 functionality that will support this processing change in CMS's 3-year plan. In its follow-up response to GAO in November 2018, HHS stated that it will implement this process within the next 3 years. 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: The Department of Health and Human Services (HHS) concurred with this recommendation. HHS stated that the Internal Revenue Service (IRS) provides information to marketplaces on consumers who received advance premium tax credit (PTC) in the prior coverage year but have not taken the necessary steps to file a tax return and reconcile advance PTC. Also, as of December 2018, HHS stated that it has established a process for verifying compliance with applicable tax filing requirements and provided documentation dated July 2018 of its procedures for verifying whether filers complied with these requirements. However, HHS has not provided documentation enabling GAO to validate that the verification process had taken place. 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: The Department of Health and Human Services (HHS) neither agreed nor disagreed with this recommendation. As of November 2018, HHS's Centers for Medicare & Medicaid Services (CMS) had taken steps to partially address the recommendation. HHS officials stated that they plan to implement a process to verify household income but do not have an exact date for implementation. HHS also provided documentation that demonstrated that it was not feasible to verify family size. Based on this analysis, GAO agreed with HHS's decision to not develop procedures to verify family sizes. 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 October 19, 2018, IRS stated that its Research, Applied Analytics and Statistics (RAAS) division completed an analysis of net premium tax credit (PTC) using National Research Program (NRP) data from tax year 2014. However, IRS determined that the data sample size was too small to provide an estimate that meets the requirements established in the Office of Management and Budget Circular A-123 Appendix C. Consequently, IRS stated that the sample and analysis will be updated and refined as more data from subsequent filing seasons become available. In the meantime, the IRS has completed a qualitative risk assessment of the PTC program, the results of which will be reported in the FY 2018 Treasury Agency Financial Report. 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 Internal Revenue Service (IRS) agreed with this recommendation. In December 2018, an IRS official indicated that IRS conducted a detailed review of the recommendation. IRS informed GAO that it is internally discussing an alternative way to address the recommendation to prevent premium tax credit to noncitizens. The IRS official indicated that IRS is reviewing this alternative with the Department of the Treasury and the Centers for Medicare & Medicaid Services. IRS did not provide GAO with a time frame for its implementation. 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. In November 2018, IRS informed GAO that it plans to perform analysis to determine the magnitude of the noncompliance related to duplicate health insurance coverage. IRS plans to use the results from this analysis to determine whether it makes sense to update its Internal Revenue Manual. However, IRS did not provide a specific time frame for completion of this determination. 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. As of November 2018, IRS had not designed and implemented procedures to regularly notify nonfilers of the requirement to file tax returns. In July 2018, IRS informed GAO that it does not plan to update the Internal Revenue Manual (IRM) to include procedures for notifying nonfilers of the requirement to file tax returns in order to receive advance premium tax credit (PTC) in the future. IRS indicated it had noticed a decline in nonfilers in tax year 2016 and expected to see a continuation of decline in nonfilers in tax year 2017. IRS considers these notices discretionary and 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. As a result, IRS decided to not make this a permanent process but to leave it as a discretionary activity without a formal IRM requirement. GAO continues to believe that IRS needs to design and implement procedures to regularly notify nonfilers of the need to file to continue receiving advance PTC. 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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