GAO: Errors plague Affordable Care Act eligibility decisions

Eligibility decisions under the Affordable Care Act are plagued by errors, leading to duplicate coverage and likely overpayments by the government, according to new reports from the Government Accountability Office (GAO).

For its first study, GAO created 18 fictitious healthcare applicants. Ten were used to test the application and enrollment controls for signing up for subsidized health plans through the federal marketplace in New Jersey and North Dakota and through state marketplaces in California and Kentucky. The additional eight false accounts were used to test specific enrollment in state Medicaid programs in the same four states.

Of the first 10 fake applicants, eight failed the initial identity-checking process, but all 10 were eventually approved by the marketplace. Four originally failed because they used Social Security numbers that had never been used, and others had duplicate enrollment or claimed that their employer did not provide minimum coverage. From this information, GAO concluded that the Centers for Medicare & Medicaid Services (CMS) "cannot identify erroneous expenditures due to incorrect eligibility determinations, which also limits its ability to ensure that state expenditures are appropriately matched with federal funds."

For the additional eight false applicants, seven were able to obtain Medicaid or an alternative subsidized coverage plan, and GAO found that some individuals had duplicate coverage. Some amount of duplicate coverage is allowed, but the report revealed that it was happening under other circumstances, such as when applicants would not cancel their subsidized coverage after being made Medicaid eligible.

In its other study, GAO found the underlying problem is that there are gaps in oversight of Medicaid enrollment and a lack of coordination between the ACA exchanges. Kentucky, in particular, has recently come under some scrutiny because it has failed to ensure that all customers who signed up for insurance on the state's health exchange were actually eligible for coverage.

GAO recommends that states review federal determinations of Medicaid eligibility for accuracy and use that information to ensure that expenditures are reported correctly and appropriately matched. The report also recommends that CMS establish a schedule for regular checks for duplicate coverage and develop a strategy to monitor the effectiveness of the checks.

To learn more:
- read the full GAO report on the undercover study (.pdf)
- read the full GAO report on the need for Medicaid controls (.pdf)

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