Health Reform WK-EDGE Three state marketplaces get an A for verifying applicant eligibility
Wednesday, September 20, 2017

Three state marketplaces get an A for verifying applicant eligibility

By Sheila Lynch-Afryl, J.D., M.A.

Three state-based marketplaces used varied data sources to verify applicant eligibility for subsidized coverage and had few indications of potentially improper or fraudulent enrollments for plan year 2015, according to the Government Accountability Office (GAO). The GAO did, however, identify data-quality issues, such as data-entry errors or name changes (GAO Report, No. GAO-17-694, September 7, 2017).

Sec. 1411 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) requires state-based marketplaces to verify applicant information to determine eligibility for enrollment and income-based subsidies, if applicable. For the three states—Idaho, Maryland, and Rhode Island—the GAO analyzed approximately 210,000 individual applicants associated with about $428 million in advance premium tax credit amounts.

Social security numbers. The GAO identified about 2,000 applicants of the approximately 210,000 applicants for whom a social security number (SSN), first name, last name, or date of birth did not match the Social Security Administration’s (SSA) records. Marketplace officials cited inherent challenges with verifying SSN information, such as applicants with name changes or incorrect dates of birth.

Deceased applicants. It also identified 21 applicants (.01 percent) who were deceased before starting coverage in plan year 2015, the majority of whom died after their applications were submitted but before starting coverage. An additional 30 applicants had SSNs that matched an identity that was deceased before the start of coverage, but whose names or birthday did not match. In addition, 324 applicants (.15 percent) died during plan year 2015. The marketplaces ended coverage for about 73 percent of these applicants within two months, and for the remainder coverage continued for three to 12 months after the date of death.

Immigration-related inconsistencies. In Rhode Island and Maryland, almost 3,000 applicants did not resolve their immigration-related data-matching inconsistencies, and more than half of these applicants received coverage for more than six months. State officials reported that since plan year 2015 they have implemented automated or semi-automated processes to automatically close inconsistencies and terminate coverage after 90 days.

Potentially incarcerated applicants. The GAO identified 245 potentially incarcerated applicants. State officials reported challenges with receiving inaccurate or outdated information from incarceration databases—for example, some databases contain information on when an individual was incarcerated but do not always accurately record when an individual was released.

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