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Recent Industry News

Department of HHS OIG

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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently reported on the Federal Marketplace’s inability to calculate the total number of applicants with data inconsistencies in their program eligibility information. The data inconsistencies arise from differing information provided in applicants’ self-attested information and that received from federal and other data sources. These inconsistencies must be resolved to uphold the integrity of the enrollment process for qualified health plans and other federal affordable insurance programs. To conduct the review, the OIG requested timely data from the Centers for Medicare and Medicaid Services’ (CMS) Multidimensional Insurance Data Analytics System regarding inconsistencies that occurred in the first open enrollment season. The OIG also reviewed inconsistencies in the data management and data resolution processes through interviews with CMS staff and contractors. Additionally, the OIG conducted a site visit at an office of the Federal Marketplace.

The OIG reported the following findings:

  • The data from the first enrollment period did not specifically identify whether an individual sought to enroll in a qualified health plan (QHP). As a result, CMS was required to resolve the same inconsistencies more than once.
  • CMS was also unable to use its inconsistency data to extract accurate information or fully explain how data inconsistencies were tracked.
  • The OIG analysis of data inconsistencies for applicants enrolled in QHPs indicated that the Federal Marketplace resolved or terminated 42 percent of inconsistencies from the first open enrollment period. The inconsistencies failed to indicate whether an applicant inappropriately enrolled in a QHP or incorrectly enrolled in one or more insurance affordability program.
  • The Federal Marketplace cannot ensure that the applicants meet the enrollment requirements unless it resolves their inconsistencies.

The OIG requested that CMS:

  • Improve its management of the inconsistency resolution process to ensure that all applicants with inconsistencies could be readily identified.
  • Refine its data management system to identify whether inconsistencies were unresolved, resolved, or expired.

The OIG report is available at:

https://oig.hhs.gov/oei/reports/oei-01-14-00620.pdf.

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