Tuesday, August 11, 2015

qotd: IG report on problems with eligibility determinations in exchange plans

Department of Health and Human Services
Office of the Inspector General
August 2015
Not All of the Federally Facilitated Marketplace's Internal Controls
Were Effective in Ensuring That Individuals Were Properly Determined
Eligible for Qualified Health Plans and Insurance Affordability Programs

Our objective was to determine whether the Federal marketplace's
internal controls were effective in ensuring that individuals were
determined eligible for enrollment in QHPs (qualified health plans) and
eligible for insurance affordability programs according to Federal


Social Security Numbers Were Not Always Validated Through the Social
Security Administration

Citizenship Was Not Always Verified Properly

Annual Household Income Was Not Always Verified Properly

Family Size Was Not Always Determined Correctly


Inconsistencies Related to Certain Eligibility Requirements Were Not
Always Resolved Properly

Inconsistencies Related to Certain Eligibility Requirements Were Not
Always Expired Properly

Applicant Data and Documentation Related to Resolving Inconsistencies
Were Not Always Maintained Properly



Comment by Don McCanne

Considering the administrative complexities of the Federally Facilitated
Marketplace (insurance exchanges) established by the Affordable Care
Act, these deficiencies in determining eligibility for the exchange
health plans and for the premium tax credits and cost-sharing reductions
do not really demonstrate bureaucratic incompetence but rather would be
expected based on the complex program design authorized by the legislation.

This was totally unnecessary. By design, in a single payer system
everyone is eligible and automatically enrolled. There is no need for
premium tax credits since there are no premiums. The program is funded
through equitable taxes instead. There also is no need for cost-sharing
reductions since there are no deductibles or coinsurance. It is a
prepaid program.

Instead of reading the news reports and merely tisk-tisking the
incompetence of the administration, we need to give more thought as to
why the administrative boondoggles exist and redirect the blame to the
fact that we are implementing a highly flawed model of health care
financing. That should then lead us to advocating for a model that
really does work well - a single payer national health program.

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