CMS May Lack Data to Properly Oversee ACA's Special Enrollment Periods

Screenshot from Government Accountability Office video.

The Centers for Medicare and Medicaid Services (CMS) gathers and generates a lot of healthcare data, but when it comes to enforcing some of the regulations tasked to it, it may be lacking.

A new report from the Government Accountability Office (GAO) found that the agency currently doesn’t have reliable data about insurance coverage terminations, which makes it tricky to determine who is and isn’t actually eligible for Affordable Care Act (ACA) special enrollment periods.

GAO cites insurer concern as a reason why the report was conducted: Participating payers don’t have a clear picture of whether enrollees buying their coverage through special enrollment will actually pay their fees and remain enrolled for the year.

Special enrollments occur outside of the regular open enrollment periods, and extend to patients who have lost coverage for a reason the law deems valid—if they voluntarily ended it, relocated, or had it ended by their insurer or CMS for a number of other reason. If an enrollee has been terminated for non-payment of premiums, however, they technically aren’t eligible under the ACA for those special enrollment exceptions. But CMS doesn’t track data about that.

The new GAO report looked at 2015. Over 9 million people were enrolled in the federally facilitated exchanges (FFE), and just over 50% maintained continuous coverage throughout the year. The remaining 47% did not, for any number of the aforementioned reasons, and averaged 5 months of coverage that year.

Although CMS and ACA payers do share data monthly, the agency does not require the insurers to report reasons why enrollees were terminated.

“Officials told us they do not track these data because they are not critical to ensure the accuracy of the federal subsidy amounts—which is the main function of the monthly reconciliation process,” the report states. It recommends adding a variable to that existing process that would require cause for termination be reported.

“The agency's lack of reliable data on terminations for nonpayment limits its ability to effectively oversee certain federal regulations,” the new report concludes.

Shoring up that uncertainty likely wouldn’t assuage all of insurers’ concerns—and there are many—about whether they can actually make money in the federal exchanges. The GAO’s report is prefaced by a letter from Sen. Orrin Hatch (R-UT), Rep. Fred Upton (R-MI), and Rep. Greg Walden (R-OR). All 3 are staunch, vocal opponents of the ACA.

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