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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-09-18-01000
Report Description

Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) operates the federally facilitated marketplace (Federal marketplace) in States that chose not to operate their own marketplaces. Prior OIG audits of the Federal marketplace covering the 2014 coverage year determined that not all of the marketplace's internal controls were effective in ensuring that individuals were properly determined eligible for qualified health plans (QHPs) and insurance affordability programs. Further, since 2014, additional eligibility verification requirements have become effective. The results of our prior audits and these additional requirements led us to review the marketplace's eligibility determinations for the 2018 coverage year.

Report Type
Audit
Agency Wide
Yes
Number of Recommendations
9
Questioned Costs
$0
Funds for Better Use
$0
Additional Details
https://oig.hhs.gov/oas/reports/region9/91801000.asp

Open Recommendations

This report has 9 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
268206 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace corrects an error in its eligibility and enrollment system so that information on whether an individual met the 5 year bar does not automatically carry over from a previous coverage year.

268209 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace establishes guidance to exclude income from other gains on a Federal tax return submitted by an individual when resolving an income inconsistency.

268204 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace revises its written guidance so that it does not extend an individual’s inconsistency period when the marketplace receives returned mail.

268211 No $0 $0

To improve procedures related to verifying whether individuals complied with the requirement to file a Federal tax return and reconcile APTC payments, we recommend that the Centers for Medicare & Medicaid Services ensure that the Federal marketplace’s eligibility and enrollment system performs subsequent FTR verifications for an individual who received an FTR indicator for a tax-filing extension.

268210 No $0 $0

To improve procedures related to verifying whether individuals complied with the requirement to file a Federal tax return and reconcile APTC payments, we recommend that the Centers for Medicare & Medicaid Services require an individual to submit supporting documentation (e.g., a Federal tax return with IRS Form 8962) when he or she attests to having filed a tax return to reconcile a previous year’s APTC payments.

268205 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace corrects an error in its eligibility and enrollment system so that the system does not incorrectly show that an individual is no longer enrolled in a QHP.

268203 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services redetermine, if necessary, the eligibility of the eight sampled individuals for whom eligibility for insurance affordability programs was not or may not have been determined in accordance with Federal requirements.

268207 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace implements a change in its eligibility and enrollment system so that the system maintains data showing that verifications of minimum essential coverage through non-ESI were performed, even if responses were not received from some of the electronic data sources.

268208 No $0 $0

Although the Federal marketplace properly determined most individuals’ eligibility for insurance affordability programs, to address the specific deficiencies that we identified, we recommend that the Centers for Medicare & Medicaid Services take steps to ensure that the Federal marketplace corrects an error in its eligibility and enrollment system so that the marketplace generates an inconsistency when an individual’s attested information related to eligibility for minimum essential coverage through ESI is not completed.

Department of Health & Human Services OIG

United States