In plan year 2015, 37 states relied on the FFM. We discuss these 8.04 million  applicants later in this report. If the information the applicant provided on the application does not  match the information contained in the data source, or if a data source is  not available to verify the information, the FFM generates an  inconsistency. HHS concurred with our recommendations. Analyses Identified about 1 Percent of Enrollments during Plan Year 2015 as Potentially Improper or Fraudulent, with Challenges Remaining in the Identification and Reenrollment of Reportedly Deceased Individuals

		About 1 Percent of Enrollments for Plan Year 2015 Were Identified as Potentially Improper or Fraudulent

Our analysis of plan year 2015 FFM enrollment and eligibility data  identified a small percentage—about 1 percent—of enrollments that were  potentially improper or fraudulent because they had an unresolved issue  related to citizenship, status as a national, or lawful presence, or to SSN,  or were reportedly deceased. Such cases required the FFM to request supporting  documentation from the applicant. Although the  FFM was not actively resolving SSN inconsistencies in plan year 2015,  according to CMS officials, most applicants with an SSN inconsistency  also had an inconsistency related to citizenship, status as a national, or  lawful presence, and documentation submitted to resolve those  inconsistencies may also resolve SSN inconsistencies. We could not  associate APTC subsidies with individual applicants because applications  may include more than one person. According to additional information provided by CMS officials, the  federal government paid APTC to issuers on behalf of all five of these  individuals in plan year 2015 after their reported date of death. Further, according to CMS officials, the FFM does not recheck the  full death file before automatically reenrolling applicants for subsequent  plan years or reverify information, but rather only rechecks income, to  help encourage individuals to maintain enrollment in coverage from one  year to the next and align with the process for individuals with employer- sponsored health insurance. CMS does not always identify deaths of enrollees in time to terminate  enrollment through the exchange as of the date of death or to prevent  automatic reenrollment, because CMS relies on third parties, such as  family members, to report the death of an enrollee to the FFM. According to CMS officials, in  plan year 2015, the FFM received notification of policy termination and  policy end dates from plan issuers but did not always receive information  on the reason coverage was terminated. The agency agreed with the  recommendation and stated that it was exploring approaches to identify  enrollees who may be deceased and should therefore be unenrolled from  coverage. However, in some instances, applicant-submitted documentation used to  verify applicant information did not match CMS data. Without processes to identify the deaths of enrollees in a timely manner,  including prior to reenrollment for the following plan year, CMS is at risk of  providing additional months of subsidized coverage improperly with  related costs to the federal government. In 2017, we recommended that  CMS assess the feasibility of approaches for periodically verifying  changes, such as death, that affect eligibility for subsidies. Appendix I: Objectives, Scope, and Methodology

The objective of this review was to examine the extent to which  indications of potentially improper or fraudulent enrollments exist in the  federally facilitated marketplace’s (FFM) application, enrollment, and  eligibility-verification process for the 2015 enrollment period. To identify indications of potentially improper or fraudulent enrollments in  the FFM’s application, enrollment, and eligibility-verification process, we  reviewed relevant federal statutes, Department of Health and Human  Services (HHS) regulations, and Centers for Medicare & Medicaid  Services (CMS) policies for plan year 2015. Specifically, we  identified and analyzed data for applicants receiving coverage with an  associated subsidy (1) with inconsistencies related to citizenship, status  as a national, or lawful presence; (2) whose information, including Social  Security number (SSN), did not match the Social Security  Administration’s (SSA) records, and (3) who were reportedly deceased. Applicants who were reportedly deceased. Patient Protection and Affordable Care Act: Status of CMS Efforts to  Establish Federally Facilitated Health Insurance Exchanges.
Why GAO Did This Study

The Patient Protection and Affordable Care Act (PPACA) offers subsidized health-care coverage for qualifying applicants. States may operate their own health-care marketplaces or rely on the FFM, maintained by CMS. In PY 2015, 37 states relied on the FFM and over 8 million plan selections were made through the FFM. PPACA represents a significant fiscal commitment for the federal government, which pays subsidies to issuers on participants' behalf.
GAO was asked to examine enrollment into the FFM for PY 2015, the most current data available at the time of GAO's review. This report examines the extent to which indications of potentially improper or fraudulent enrollments existed in the FFM's application, enrollment, and eligibility-verification process for the 2015 enrollment period.
GAO reviewed relevant federal statutes, regulations, and policies for PY 2015 and interviewed CMS officials. GAO analyzed eligibility and enrollment data for about 8.04 million applicants in PY 2015 to identify applicants (1) who had a citizenship, status as a national, or lawful presence inconsistency; (2) whose information did not match SSA records; or (3) who were reportedly deceased. GAO also reviewed a nongeneralizable sample of 45 applicants to more fully understand verification processes.

What GAO Found

A small percentage—about 1 percent—of plan year (PY) 2015 enrollments were potentially improper or fraudulent. These applicants had unresolved inconsistencies related to citizenship, status as a national, lawful presence, or Social Security number (SSN), or received coverage while reportedly deceased, according to GAO's analysis of federally facilitated marketplace (FFM) eligibility and enrollment data. To verify applicant information, such as citizenship, status as a national, or lawful presence, and SSNs, the FFM uses data from the Department of Homeland Security (DHS) and Social Security Administration (SSA), among other sources. When an applicant's information does not match the available data sources, the FFM generates an inconsistency, and the FFM should take steps, such as requesting applicant documentation, to resolve it. Having an SSN is not a condition of eligibility; however, unresolved inconsistencies could indicate that an enrollment is potentially improper or fraudulent. The FFM did not actively resolve SSN inconsistencies for PY 2015, but the Centers for Medicare & Medicaid Services (CMS) has since completed system upgrades and established procedures for verifying SSNs with applicant-provided documentation, according to CMS officials.
Note: Some applicants may be included in more than one category.
GAO found that applicants or enrollees may have received or maintained coverage with an associated subsidy after their reported death because the FFM did not always identify individuals as deceased in a timely manner, such as prior to automatic reenrollment. CMS relied on third parties, such as family members, to report the death of an enrollee to the FFM, but did not always receive adequate notification to verify the death. According to CMS officials, CMS is exploring approaches to identify enrollees who may be deceased and should therefore be unenrolled from coverage. The FFM checks applicants' information against death information from SSA before initial enrollment but does not recheck death information prior to reenrollment. According to CMS officials, the FFM does not reverify information, other than income, when automatically reenrolling applicants to help encourage individuals to maintain enrollment in coverage from one year to the next. Without rechecking SSA death information prior to automatic reenrollment, the FFM remains at risk of providing subsidized coverage to deceased individuals with related costs to the federal government.

What GAO Recommends

GAO recommends that CMS assess and document the feasibility of approaches to identify the deaths of individuals prior to automatic reenrollment. HHS concurred with GAO's recommendation.