OIG: Healthcare.gov still struggles with eligibility verification

Healthcare.gov site on computer
Healthcare.gov was unable to easily determine an accurate number of applicants with inconsistencies because its data cannot uniquely identify an individual seeking to enroll in a qualified health plan, according to the OIG.

The federal health insurance marketplace continues to have problems resolving inconsistencies between information reported by enrollees and other data used to verify their eligibility for coverage and financial assistance, according to a new report.

The report (PDF) from the Department of Health and Human Services’ Office of Inspector General found that the federal marketplace has resolved just 40% and expired 2% of inconsistencies from the first open enrollment period for applicants enrolled in qualified health plans.

Comparatively, in June 2014 the Centers for Medicare & Medicaid Services reported that the federal marketplace was unable to resolve most inconsistencies from the first open enrollment period because the eligibility system was not fully operational.

RELATED: OIG: Flawed Healthcare.gov controls unable to verify individuals' eligibility

While inconsistencies don’t necessarily mean that an applicant inappropriately enrolled in a QHP or insurance affordability program, Healthcare.gov “cannot ensure that the applicants meet the requirements unless it resolves their inconsistencies,” the report states.

The OIG also reports that even through the 2015-16 open enrollment period, Healthcare.gov was unable to easily determine an accurate number of applicants with inconsistencies because its data cannot uniquely identify an individual seeking to enroll in a QHP. For example, the OIG found “thousands of instances in which one member identification number was assigned to individuals with different Social Security numbers,” which means using that number would inaccurately count applicants.

The agency’s inability to identify unique applicants or link duplicate inconsistencies, meanwhile, created additional work for CMS and increased the burden on applicants. For instance, CMS’ system had required it to send multiple letters to one applicant—each requesting information to resolve a different inconsistency—rather than sending one letter per household, as it now does.

To fix the problems the OIG identified, it recommended that CMS improve how it manages the inconsistency resolution process to ensure that it can readily identify all applicants with inconsistencies. It also suggested that CMS refine its data management system so that it can track individuals and readily count the number of each type of inconsistency, as well as whether those inconsistencies are unresolved, resolved or expired.