John E. Dicken(202) 512-7114
dickenj@gao.gov
Office of Public Affairs
(202)
512-4800
youngc1@gao.gov
What GAO Found
The Centers for Medicare & Medicaid Services (CMS) will operate a health
insurance exchange in the 34 states that will not operate a state-based exchange
for 2014. Of these 34 federally facilitated exchanges (FFE), 15 are in states
expected to assist CMS in carrying out certain FFE functions. However, the
activities that CMS plans to carry out in these 15 exchanges, as well as in the
state-based exchanges, have evolved and may continue to change. For example, CMS
approved states' exchange arrangements on the condition that they ultimately
complete activities necessary for exchange implementation. CMS indicated that it
would carry out more exchange functions if any state did not adequately progress
towards implementation of all required activities.
CMS completed many activities necessary to establish FFEs by October 1, 2013,
although many remain to be completed and some were behind schedule. CMS issued
numerous regulations and guidance and took steps to establish processes and data
systems necessary to operate the exchanges. The activities remaining cross the
core exchange functional areas of eligibility and enrollment, plan management,
and consumer assistance. To support consumer-eligibility determinations, for
example, CMS is developing a data hub that will provide electronic, near
real-time access to federal data, as well as provide access to state and third
party data sources needed to verify consumer-eligibility information. While CMS
has met project schedules, several critical tasks, such as final testing with
federal and state partners, remain to be completed. For plan management, CMS
must review and certify the qualified health plans (QHP) that will be offered in
the FFEs. Though the system used to submit applications for QHP certification
was operational during the anticipated time frame, several key tasks regarding
plan management, including certification of QHPs and inclusion of QHP
information on the exchange websites, remain to be completed. In the case of
consumer assistance, for example, funding awards for Navigators--a key consumer
assistance program--have been delayed by about 2 months, which has delayed
training and other activities. CMS is also depending on the states to implement
specific FFE exchange functions, and CMS data show that many state activities
remained to be completed and some were behind schedule.
Much progress has been made, but much remains to be accomplished within a
relatively short amount of time. CMS's timelines provide a roadmap to
completion; however, factors such as the still-evolving scope of CMS's required
activities in each state and the many activities yet to be performed--some close
to the start of enrollment--suggest a potential for challenges going forward.
And while the missed interim deadlines may not affect implementation, additional
missed deadlines closer to the start of enrollment could do so. CMS recently
completed risk assessments and plans for mitigating risks associated with the
data hub, and is also working on strategies to address state preparedness
contingencies. Whether these efforts will assure the timely and smooth
implementation of the exchanges by October 2013 cannot yet be determined.
In commenting on a draft of this report, the Department of Health and Human
Services emphasized the progress it has made in establishing exchanges, and
expressed its confidence that exchanges will be open and functioning in every
state by October 1, 2013.
Why GAO Did This Study
The Patient Protection and Affordable Care Act required the establishment in
all states of exchanges—marketplaces where eligible individuals can compare and
select health insurance plans. CMS must oversee the establishment of exchanges,
including approving states to operate one or establishing and operating one
itself in states that will not do so. CMS will approve states to assist it in
carrying out certain FFE functions. CMS will also operate an electronic data hub
to provide eligibility information to the exchanges and state agencies.
Enrollment begins on October 1, 2013, with coverage effective January 1, 2014.
GAO was asked to examine CMSfs role and preparedness to establish FFEs and the
data hub. In this report, GAO describes (1) the federal governmentfs role in
establishing FFEs for operation in 2014 and state participation in that effort;
and (2) the status of federal and state actions taken and planned for FFEs and
the data hub.
GAO reviewed regulations and guidance issued by CMS and documents indicating
the activities that the federal government and states are expected to carry out
for these exchanges. GAO also reviewed planning documents CMS used to track the
implementation of federal and state activities, including documents describing
the development and implementation of the data hub. GAO also interviewed CMS
officials responsible for establishment of the exchanges. GAO relied largely on
documentation provided by CMS—including information CMS developed based on its
contacts with the states—regarding the status of the exchanges and did not
interview or collect information directly from states.
For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov.