Legislative leaders highlighted the need to clamp down on fraud following the release of a report that found gaps in verifying eligibility for consumers using Special Enrollment Periods (SEPs) under the health care law.
SEPs were designed for consumers to purchase health coverage outside of open enrollment periods because of specific life events like moving, having or adopting a child, or getting married.
Federal and state-based marketplaces are required to verify application information, such as citizenship or immigration status, to determine eligibility for enrollment in a health plan that may include a subsidy under the Patient Protection and Affordable Care Act.
However, according to a recent Government Accountability Office (GAO) report, significant shortcomings exist in verifying consumer eligibility for SEPs. Historically, consumers have been granted presumptive eligibility rather than verified eligibility, which could lead to the potential misuse of public funds.
U.S. Sen. Orrin Hatch (R-UT), the chairman of the Senate Finance Committee, and U.S. Reps. Fred Upton (R-MI), the House Energy and Commerce Committee chairman, and Kevin Brady (R-TX), chairman of the House Ways and Means Committee, requested the GAO report.
“This report confirms what we’ve known all along: bad actors are taking advantage of loose enforcement mechanisms to access highly subsidized health care plans,” Upton, Brady and Hatch said in a joint statement. “We’re encouraged that the administration has acknowledged the verification gaps, but their actions don’t go far enough to protect taxpayers and stabilize markets. It’s time to close the floodgates on fraud.”
The GAO said it had performed undercover testing of enrollment and verification procedures for applicants attempting to obtain coverage during a SEP earlier this year.
“The federal and selected state-based marketplaces approved health insurance coverage and subsidies for nine of 12 of GAO’s fictitious applications made during a 2016 SEP,” the report states.
Hatch, Upton and Brady previously urged the administration to require pre-enrollment verification for all SEP consumers after committee hearings on the matter.
The Obama administration recently announced steps to enhance SEP safeguards through a pre-enrollment verification pilot program that would launch next summer.