CMS operated a federally facilitated  marketplace or partnership marketplace for 34 states for plan years2014 and 2015. The Office of Information Services, headed by  the CMS Chief Information Officer (CIO), is responsible for oversight of  the development and implementation of federal systems supporting the  establishment and operation of the federally facilitated marketplace,  including review, selection, implementation, and continual evaluation of  these systems. Eligibility and enrollment module. CMS  concurred with most of the recommendations. Initial Development and Deployment of Healthcare.gov and Its Supporting Systems Faced Problems with System Capacity, Software Code Issues, and Limited Functionality, but CMS Has Taken Steps to Address Them

Several problems occurred in the development and deployment of  Healthcare.gov and its supporting systems, which affected their  performance. Since the initial launch of  Healthcare.gov and its supporting systems, CMS has taken a number of  steps to address these problems, to include increasing system capacity,  outlining a new approach for ensuring the quality of software code, and  further developing required system functionality. As a result, CMS  had not planned to provide a level of capacity that would ensure  uninterrupted service to users in a cost-effective manner. As with the capacity problems, these software code errors also  contributed to the problems applicants faced in attempting to enroll in  health care plans. CMS Inadequately Applied Best Practices in Developing Systems Supporting Healthcare.gov, and Needs to Build on Recent Progress

In developing Healthcare.gov and its supporting systems, CMS did not  adhere to best practices for managing IT development projects, which  contributed to problems with the launch of Healthcare.gov and its  supporting systems. Such best practices include managing requirements  to ensure that delivered functionality meets the needs of users,  conducting adequate system testing to validate that systems function as  intended, and providing oversight to ensure that a project is progressing  as planned and that corrective actions are taken as needed. In addition, CMS’s  oversight of the initiative was limited by an unreliable schedule, lack of  estimates of work needed to complete the project, unorganized and  outdated project documentation, and inconsistent reviews of project  progress. However, deficiencies in  requirements management, systems testing, and oversight remain. In addition, HHS has  not provided adequate oversight of the Healthcare.gov initiative through  its office of the CIO, while OMB’s oversight role was limited to facilitating  discussions with federal partners, providing federal policy guidance, and  overseeing the project’s budget. In addition, it was not always clear what requirements were being  approved. Systems Supporting Healthcare.gov Were Not Fully Tested, and Test Documentation Was Missing Key Elements

Testing an IT system is essential to validate that the system will satisfy  the requirements for its intended use and user needs. However, CMS did not always (1) ensure project schedules for  Healthcare.gov and its supporting systems were well-constructed;  (2) estimate level of effort for DSH and FFM functional requirements;  (3) implement data management and monitoring processes; and  (4) conduct all recommended and required project progress and  milestone reviews. However, CMS and its contractors did not effectively implement data  management processes. These reviews are important to  ensure that a project is progressing as planned and to identify corrective  actions needed. Consequently, individuals faced significant  challenges when attempting to enroll for health insurance coverage. Specifically, by not  managing requirements to ensure that they addressed all needed  functionality and not fully documenting and executing key testing  activities, CMS did not have reasonable assurance that Healthcare.gov  and its supporting systems would perform as intended. Appendix I: Objectives, Scope, and Methodology

The objectives of this study were to (1) describe the problems  encountered in developing and deploying Healthcare.gov and its  supporting systems, and determine the status in addressing these  deficiencies; and (2) determine the extent to which the Centers for  Medicare & Medicaid Services (CMS) oversaw the development effort  and applied disciplined systems development practices to manage  requirements and conduct systems testing, as well as the extent to which  the Department of Health and Human Services (HHS) and the Office of  Management and Budget (OMB) provided oversight of the effort.
Why GAO Did This Study

The Patient Protection and Affordable Care Act required the establishment of health insurance marketplaces to assist individuals in obtaining health insurance coverage. CMS, a component of HHS, was responsible for establishing a federally facilitated marketplace for states that elected not to establish their own. This marketplace is supported by an array of IT systems, which are to facilitate enrollment in qualifying health plans. These include Healthcare.gov, the website that serves as the consumer portal to the marketplace, as well as systems for establishing user accounts, verifying eligibility, and facilitating enrollment.
GAO was asked to review CMS's management of the development of IT systems supporting the federal marketplace. Its objectives were to (1) describe problems encountered in developing and deploying systems supporting Healthcare.gov and determine the status of efforts to address deficiencies and (2) determine the extent to which CMS applied disciplined practices for managing and overseeing the development effort, and the extent to which HHS and OMB provided oversight. To do this, GAO reviewed program documentation and interviewed relevant CMS and other officials.

What GAO Found

Several problems with the initial development and deployment of Healthcare.gov and its supporting systems led to consumers encountering widespread performance issues when trying to create accounts and enroll in health plans:
Inadequate capacity planning: The Centers for Medicare & Medicaid Services (CMS) did not plan for adequate capacity to support Healthcare.gov and its supporting systems.
Software coding errors: CMS and its contractors identified errors in the software code for Healthcare.gov and its supporting systems, but did not adequately correct them prior to launch.
Lack of functionality: CMS had not implemented all planned functionality prior to the initial launch of Healthcare.gov and its supporting systems.
Since the initial launch, CMS has taken steps to address these problems, including increasing capacity, requiring additional software quality reviews, and awarding a new contract to complete development and improve the functionality of key systems. After it took these actions, performance issues affecting Healthcare.gov and its supporting systems were significantly reduced.
In addition, CMS did not consistently apply recognized best practices for system development, which contributed to the problems with the initial launch of Healthcare.gov and its supporting systems.
Requirements were not effectively managed: Requirements management helps ensure that a project's plans and work products are aligned with the needs of users. However, CMS did not always ensure that requirements were approved and were linked to source and lower-level requirements. As a result, CMS was hindered in ensuring that expected functionality for the system was delivered.
System testing was inconsistent. Testing is essential for ensuring that a system operates as intended. However, Healthcare.gov and its supporting systems were not fully tested prior to launch, and test documentation was missing key elements such as criteria for determining whether a system passed a test. Thus, CMS's assurance that these systems would perform as intended was limited.
Project oversight was not effective. Oversight includes monitoring a project's progress and taking corrective actions when its performance deviates from what is planned. However, CMS's oversight was limited by an unreliable schedule, lack of estimates of work needed to complete the project, unorganized and outdated project documentation, and inconsistent reviews of project progress.
As it has undertaken further development, CMS has made improvements in some of these areas, by, for example, establishing new requirements management processes and improving test documentation. However, weaknesses remain in its application of requirements, testing, and oversight practices. In addition, the Department of Health and Human Services (HHS) has not provided adequate oversight of the Healthcare.gov initiative through its Office of the Chief Information Officer. The Office of Management and Budget's (OMB) oversight role was limited, and GAO has previously recommended that it improve oversight of IT projects' performance.

What GAO Recommends

GAO is recommending that CMS take seven actions to implement improvements in its requirements management, system testing, and project oversight, and that HHS improve its oversight of the Healthcare.gov effort. HHS concurred with all of the recommendations.