Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to track the value of advance premium tax credit and cost-sharing reduction (CSR) subsidies that are terminated or adjusted for failure to resolve application inconsistencies, and use this information to inform assessments of program risk and performance. (See related recommendation 7.)

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, HHS reported it considers this recommendation closed because it expanded the use of analytics to analyze the value of premium tax credit and CSR subsidies that are eliminated or adjusted for 2015 actions at the policy level, and that CMS continues to analyze the data to develop future operations changes. In May 2016, we requested documentation of these actions, including (1) information produced using the capability described; (2) ways in which this information is being used for analysis for purposes such as program operations, monitoring, risk assessment, or fraud cleaning; and (3) a description of the future operational changes contemplated based on the analyses done. However, as of December 2018, HHS officials had not provided GAO with evidence that the agency had implemented this recommendation. GAO said it would continue to monitor the agency's progress in this area. In March 2019, CMS reversed its initial concurrence with the recommendation, citing inability to obtain necessary data from another agency and a legal opinion on CSR subsidies. GAO kept the recommendation open, saying the developments HHS cited were irrelevant. In December 2019, after HHS reiterated its non-concurrence, GAO continued to maintain the recommendation as open.

Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to, in the case of CSR subsidies that are terminated or adjusted for failure to resolve application inconsistencies, consider and document, in conjunction with other agencies as relevant, whether it would be feasible to create a mechanism to recapture those costs, including whether additional statutory authority would be required to do so; and for actions determined to be feasible and reasonable, create a written plan and schedule for implementing them.

Agency: Department of Health and Human Services
Status: Open

Comments: As of December 2018, CMS officials said the Department of Health and Human Services (HHS) had received a legal opinion from the U.S. Attorney General regarding validity of CSR payments, which prompted the agency to halt the payments as of October 2017. CMS officials said that if the recommendation were to be implemented, it would amount to creating new rules and a process for a program feature that no longer exists. However, in January 2019, HHS indicated that the administration supports a legislative solution that would appropriate CSR payments, and GAO continues to monitor for relevant legislative action. If funding becomes available to restore CSR payments, then implementing this recommendation would aid CMS in reducing improper payments. In December 2019, CMS reversed its initial concurrence with the recommendation, citing the legal opinion. GAO, however, continued to maintain the recommendation as open.

Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to identify and implement procedures to resolve Social Security number inconsistencies where the Marketplace is unable to verify Social Security numbers or applicants do not provide them.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, HHS reported that it considered this recommendation open and was working on implementing functionality for updating consumers' Social Security numbers (SSN) and their eligibility based on the correct SSN. HHS reported that is it targeting deployment of the SSN update functionality in 2017. However, as of December 2018, HHS officials had not provided GAO with evidence that the agency had implemented this recommendation. In December 2019, HHS told GAO it continues to evaluate steps necessary to implement the recommendation, and expects close-out by October 2020. We will continue to monitor the agency's progress in this area.

Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to reevaluate CMS's use of Prisoner Update Processing System (PUPS) incarceration data and make a determination to either (a) use the PUPS data, among other things, as an indicator of further research required in individual cases, and to develop an effective process to clear incarceration inconsistencies or terminate coverage, or (b) if no suitable process can be identified to verify incarceration status, accept applicant attestation on status in all cases, unless the attestation is not reasonably compatible with other information that may indicate incarceration, and forego the inconsistency process.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, HHS reported it considers this recommendation closed because in 2015, it made the determination to no longer require application filers to submit documentation regarding incarceration status. We were aware of that determination, but the recommendation was to reevaluate use of PUPS from the specific standpoint of using the data as it was intended to be used as in indicator of further research and then draw a conclusion on the use of the data. In May 2016, we requested documentation demonstrating that in the period since we made this recommendation, CMS has undertaken the reevaluation in the fashion that we indicated. As of December 2018, HHS officials had not provided GAO with evidence that the agency had implemented this recommendation. In December 2019, HHS told GAO it continues to evaluate steps necessary to implement the recommendation, and expects close-out by October 2021. We will continue to monitor the agency's progress in this area.

Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to create a written plan and schedule for providing Marketplace call center representatives with access to information on the current status of eligibility documents submitted to CMS's documents processing contractor.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, HHS reported that since May 2015, call center representatives have received daily updates on the status of eligibility documentation. HHS reported that it is working to provide call center representatives with real-time data. HHS reported it considers this February 2016 recommendation to be closed. In May 2016, GAO noted that its February 2016 recommendation was focused on providing such real-time capability and requested (1) confirmation that call center representatives currently have on-demand, real-time access to up-to-date, application-level document status; and documentation showing development and implementation of this capability; or (2) a written plan and schedule for providing this capability as recommended. However, as of December 2018, HHS officials had not provided GAO with evidence that the agency has implemented this recommendation. In December 2019, the agency provided new evidence in support of closure, for which GAO requested supporting information. We will continue to monitor the agency's progress in this area.

Recommendation: To better oversee the efficacy of PPACA's enrollment control process; to better monitor costs, risk, and program performance; to assist with tax compliance; to strengthen the eligibility determination process; to provide applicants with improved customer service and up-to-date information about submission of eligibility documentation; and to better document agency activities, the Secretary of Health and Human Services should direct the Acting Administrator of CMS to fully document prior to implementation, and have readily available for inspection thereafter, any significant decision on qualified health plan enrollment and eligibility matters, with such documentation to include details such as policy objectives, supporting analysis, scope, and expected costs and effects.

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: In April 2016, HHS reported it considers this recommendation closed because CMS prepares an annual Marketplace and Related Programs Cycle Memo to fulfill reporting requirements for internal control. The Memo describes all significant eligibility and enrollment policy and process changes, including new internal key controls associated with these changes, and the 2015 Memo was released in September 2015. In May 2016, we notified HHS that its actions do not close the recommendation. Information contained in the Memos is after-the-fact and while useful, does not meet the full range of documentation contemplated by our recommendation, especially development and analysis of changes prior to implementation. As of December 2018, HHS officials had not provided GAO with evidence that the agency has implemented this recommendation. In December 2019, HHS reversed its initial concurrence with the recommendation and said it would provide additional information on that decision. We will continue to monitor the agency's progress in this area.