GAO Reports Inadequate CMS Federal Exchange Coverage Control
“CMS had no specific plan for monitoring the effectiveness of the checks and other planned procedures..."
By - Insufficient and inadequate policies and procedures from the Centers for Medicare & Medicaid Services (CMS) require greater levels of federal control to maintain effectiveness, says a report from the United States Government Accountability Office (GAO).
Coverage gaps and issues of duplicate coverage are being highlighted as areas that are posing especially problematic regarding liability repayment issues. Although a fairly small number of Medicaid and exchange enrollees may be making an upcoming transition across various types of coverage, the GAO maintains the overall improvement of CMS controls is still imperative.
Resultantly, individuals may end up paying more when they should only really be enrolled in Medicaid, says the GAO. Duplicate coverage may mean the federal government is sometimes collectively paying for both Medicaid and subsidized exchange coverage, the GAO adds.
The GAO identifies two specific weaknesses in CMS’s controls.
“GAO found that CMS's controls do not provide reasonable assurance that accounts — that is, records — for individuals transitioning from Medicaid to exchange coverage in FFE states are transferred in near real time,” GAO says.
“CMS regulations require that such transfers occur promptly to facilitate eligibility determinations and enrollment. However, as of July 2015, CMS was not monitoring the timeliness of transfers,” the organization adds.
Additionally, GAO says there are no procedures being implemented to detect instances of duplicate coverage. CMS has yet to establish an “acceptable” duplicate coverage baseline, the GAO adds.
CMS officials say the agency is considering various metrics to quantify the effectiveness of periodic checks. Such includes figuring out how many individuals were notified they have duplicate coverage before terminating their subsidized exchange coverage.
“According to CMS officials, CMS planned to implement periodic checks for duplicate coverage beginning later that month. However, CMS had not yet determined the frequency of the checks, a key to their effectiveness,” the GAO states.
“CMS had no specific plan for monitoring the effectiveness of the checks and other planned procedures, making it difficult for the agency to provide reasonable assurance that its procedures are sufficient or whether additional steps are needed to protect the federal government and individuals from duplicative and unnecessary expenditures,” adds the GAO.
GAO recommends CMS take three specific actions, which the Department of Health and Human Services (HHS) has concurred with:
- Routinely monitor the timeliness of account transfers from state Medicaid programs to CMS and identify alternative procedures if near real time transfers are not feasible in a state.
- Establish a schedule for regular checks for duplicate coverage and ensure that the checks are carried out according to schedule.
- Develop a plan, including thresholds for the level of duplicate coverage it deems acceptable, to routinely monitor the effectiveness of the checks and other planned procedures to prevent and detect duplicate coverage, and take additional actions as appropriate.
