Recommendation: The Assistant Secretary of Labor for the Employee Benefits Security Administration should evaluate whether targeted oversight in response to information received is effective for ensuring compliance with MH/SU parity requirements. If this evaluation determines the current targeted oversight approach results in significant program risks, the Employee Benefits Security Administration should develop a plan to more effectively enforce MH/SU parity requirements and if necessary seek additional oversight authority, as warranted. (Recommendation 1)

Agency: Department of Labor: Employee Benefits Security Administration
Status: Open

Comments: DOL agreed with this recommendation. In February 2020, DOL reported that its Employee Benefits Security Administration plans to evaluate its targeted approach to MH/SU parity enforcement. When we confirm what actions DOL has taken in response to this recommendation, we will provide updated information.

Recommendation: The Administrator of CMS should evaluate whether targeted oversight in response to information received is effective for ensuring compliance with MH/SU parity requirements for non-federal governmental plans. If this evaluation determines the current targeted oversight approach results in significant program risks, CMS should develop a plan to more effectively enforce MH/SU parity requirements and if necessary seek additional oversight authority, as warranted. (Recommendation 2)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: HHS agreed with this recommendation. In August 2020, HHS reported that CMS has developed a two-part evaluation to determine whether targeted oversight of non-federal governmental plans is effective for enforcing MH/SU parity requirements. According to HHS, this evaluation will include (1) a review of non-federal governmental plan documents for compliance with MH/SU parity requirements and (2) a survey of state enforcement authority and regulatory best practices for ensuring MH/SU parity compliance. As of August 2020, HHS reported that the first part of the CMS evaluation is underway.

Recommendation: The Secretary of HHS should establish numeric enrollment targets for healthcare.gov, to ensure it can monitor its performance with respect to its objectives. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS does not concur with this recommendation. In October 2018, the agency noted that there are numerous external factors, such as the state of the economy and plan premiums, that may affect the number of people who decide to enroll in coverage. HHS also stated that it does not believe that numeric enrollment targets are relevant to assess the performance of objectives related to a successful open enrollment period. We continue to believe that the development of numeric enrollment targets is important for effective monitoring of the program and management of its resources. As of September 2019, HHS had not provided any additional information about steps to implement this recommendation. The status of this recommendation will be reconsidered once relevant action is taken.

Recommendation: Should the agency continue to focus on enhancing the consumer experience as a goal for the program, the Secretary of HHS should assess other aspects of the consumer experience, such as those it previously identified as key, to ensure it has quality information to achieve its goal. (Recommendation 3)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurs with this recommendation, and in October 2018, stated that as it is looking for ways to improve the consumer experience, it will consider focusing its assessment on other aspects of the consumer experience as needed. As of September 2019, HHS had not provided evidence of any additional steps it had taken to improve the consumer experience. The status of this recommendation will be reconsidered once relevant action is taken.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that state-based marketplace annual sustainability plans, to the extent possible, have complete 5-year budget forecasts. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not concur with our recommendation and stated that it had updated its requirement to request 2-year budget forecasts instead of 5-year budget forecasts. In its December 2017 statement of actions, HHS stated that it was working to streamline and simplify its data collection effort as part of the annual sustainability plan. In April 2018, HHS provided a revised 2-year budget forecast template as well as related state marketplace training documentation. As of April 2020, HHS had not provided further documented evidence of its streamlined process using the 2-year budget forecast template or justification that a 5-year budget is not necessary for assessing long-term financial sustainability and state marketplace sustainability risks.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that all state-based marketplaces provide required annual financial audit reports which are in accordance with generally accepted government auditing standards. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation and stated in its December 2017 update that it continued to provide technical assistance such as webinars and other trainings on independent financial and programmatic audit submission requirements. In April 2018, HHS provided evidence that it had taken some steps to ensure that state-based marketplaces provide required annual financial audit reports, including draft financial audit procedures, documentation of related training provided to states, and a revised HHS state officer annual review checklist emphasizing financial audit reporting. However as of April 2020, the department had not provided evidence of finalized procedures, examples of checklist usage, or of states providing annual financial audit reports. Further, HHS training documentation stated that state-based marketplaces could provide alternate financial audit reports, such as a state-wide financial audit report, in lieu of a marketplace specific report. It is not clear from the provided evidence that the department has ensured that state-based marketplaces are in compliance with financial audit reporting requirements. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes further action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that marketplace IT self-sustainability risk assessments are based on fully defined measurable terms, a clear categorization process, and a defined response to high risks. (Recommendation 3)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with our recommendation and stated in its December 2017 update that it would refine its marketplace self-sustainability risk assessment process to provide greater insight into the state marketplace sustainability efforts and to identify areas where states may need assistance. In April 2018, HHS provided evidence that it had taken some steps to base its risk assessments on fully defined processes. CMS provided documentation of clearly defined and measurable terms used for state marketplace budget analysis. However, HHS did not provide evidence that these defined terms were incorporated into analyses or risk assessments. As of April 2020, CMS has not provided evidence that it took steps to develop a clear categorization process or a defined response to high risks. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that states develop, update, and follow performance measurement plans that allow the states to continuously identify and assess the most important IT metrics for their state marketplaces. (Recommendation 4)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS partially concurred with our recommendation and stated in its December 2017 update that though each marketplace was accountable for managing and reporting its own IT metrics in accordance with federal and state law, HHS would work with states on the improvement of their management and operations through technical assistance and oversight and accountability measures. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to conduct operational analysis reviews and systematically monitor the performance of states' marketplace IT systems using key performance indicators. (Recommendation 5)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not concur with our recommendation and stated that it conducted Open Enrollment Readiness Reviews to assess marketplace key performance indicators, which according to CMS officials, are similar to operational analysis reviews. However, as of October 2018, HHS had not provided evidence that the Open Enrollment Readiness Reviewed systematically and comprehensively reported on the key performance indicators or include discussion of other key elements identified in best practices for operational analysis reviews, such as how objectives could be better met, or costs could be saved. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation.

Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to take steps to ensure that metrics collected from states to monitor marketplaces' operational performance link to performance goals and include baselines and targets to monitor progress. (Recommendation 6)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS partially concurred with our recommendation and stated in its December 2017 update that states were responsible for monitoring their own performance measures but HHS would continue to review IT metrics of state marketplaces in the implementation phase of their systems through technical assistance activities and oversight and accountability measures. As of April 2020, the agency had not yet provided sufficient evidence that it has implemented the recommendation. We will continue to monitor the department's progress in implementing the recommendation and provide updates when the agency takes action.

Recommendation: To make it more likely that HHS will achieve its goals to reduce quality measure misalignment and associated provider burden, the Secretary of HHS should direct CMS and the Office of the National Coordinator for Health Information Technology to prioritize their development of electronic quality measures and associated standardized data elements on the specific quality measures needed for the core measure sets that CMS and private payers have agreed to use.

Agency: Department of Health and Human Services
Status: Open

Comments: In January 2019, HHS told us that CMS completed an analysis to determine which measures-from the core measure sets that CMS and private payers have agreed to use-are feasible to develop as electronic clinical quality measures. Further, in April 2019, CMS officials told us they will consider developing new electronic clinical quality measures where appropriate and feasible to fill future measure needs or gaps identified by the Core Quality Measures Collaborative (CQMC). However, we determined that the actions did not fully address the recommendation because they do not include efforts to work with ONC to prioritize their development of electronic clinical quality measures for the CQMC core measure sets. We will update the status of this recommendation when we receive additional information.

Recommendation: To make it more likely that HHS will achieve its goals to reduce quality measure misalignment and associated provider burden, the Secretary of HHS should direct CMS to comprehensively plan, including setting timelines, for how to target its development of new, more meaningful quality measures on those that will promote greater alignment, especially measures to strengthen the core measure sets that CMS and private payers have agreed to use.

Agency: Department of Health and Human Services
Status: Open

Comments: In April 2019, HHS told us that CMS had conducted an assessment of the impact of selected measures used in its quality programs and has linked key component of that assessment to some meaningful measure areas that CMS has identified as priorities. However, this document did not include elements of a comprehensive plan--such as setting timelines-for how to target its development of new, more meaningful quality measures that will promote greater alignment. We will update the status of this recommendation when we receive additional information.

Recommendation: To improve the effectiveness of the MSP program and process for NGHPs, and to improve the agency's communication regarding the MSP process for situations involving NGHPs, the Acting Administrator of CMS should develop guidance regarding liability and no-fault set-aside arrangements.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: As of March 2019, CMS officials reported that the agency was still in the process of implementing this recommendation about developing guidance regarding liability and no-fault set-aside arrangements. Since April 2012, the month the recommendation was made, CMS officials have reported at various times that the agency was planning to issue either regulatory or sub-regulatory guidance on this topic. In March 2019, officials said that the agency now planned to issue regulatory guidance, and that a Notice of Proposed Rulemaking was expected to be posted in October 2019. We will continue to update the status of this recommendation as new information is available.