Marketplace Data Matching Inconsistencies

DeLana Traugott

DeLana Traugott
VP, Regulatory Affairs

When Federally-Facilitated and State-Based Health Insurance Marketplaces were implemented in 2013, they were immediately faced with a multitude of challenges. While many of the technical obstacles were hurdled in the second enrollment period, data matching discrepancies are ongoing and have become a nuisance for consumers and Issuers alike.

In particular, consumer citizenship ineligibility and unsubstantiated income levels result in involuntary policy adjustments, which pose challenges to both Issuer and consumer.  At the time of enrollment, consumers attest to both citizenship and income, which is then transmitted for verification by the Federally-Facilitated Marketplace (FFM) system. While this verification process (Data Matching) is underway, the FFM and Issuer process the application under the assumption that all information provided by the consumer is true and accurate. However, the consumer-reported data often does not match federal verification sources, creating a Data Matching Inconsistency—and a new set of headaches for both the Issuer and the consumer.

In the case of the consumer, Data Matching Inconsistency can lead to policy termination or loss of federal support to pay for premiums and / or claims-related cost sharing. For the Issuer, it can mean reduction in revenue due to non-payment of premiums, as well as reduced subsidy reimbursements from the federal government.

Because the Data Matching process is still in early development phases, there are still kinks in the system process due to timing and process clarity by both the Issuer and consumer.  Adding to this already-trying scenario are other discrepancies between Marketplace and Issuer databases, such as addresses and enrollment status.

Prior to sending Issuers a policy termination or subsidy reduction, the FFM sends the impacted consumer several notices about the Data Matching Inconsistency and instructions on how to resolve the inconsistency to prevent a loss in coverage or federal financial support. There is generally a 90-95 day notification period during which the consumer can send documentation to resolve the inconsistencies. However, in cases where the FFM does not have the most current address, the consumer may not even be aware the coverage or subsidy is in jeopardy, or that coverage has been terminated.  For consumers losing federal support, their monthly bill showing a premium amount several hundred dollars higher than normal may be the first time they are made aware of the loss of subsidy.

Even consumers who do receive timely notice are experiencing challenges when attempting to resolve Data Matching Inconsistencies, particularly income inconsistencies.  Issuers are experiencing high call volumes and complaints from consumers who lost their despite having submitted supporting documentation. Although the FFM later sends the Issuer a data file to restore the consumer’s subsidy, the restoration is prospective. That leaves the consumer with one month of a full or significantly higher member responsibility of the total premium.

One solution to improve transparency with impacted members is improved proactive Issuer communication, using tools such as the Outreach File. The FFM provides an Outreach File to Issuers several weeks before sending the data transactions to term policies and remove federal financial support which  includes information on at-risk consumers. Issuers can use these files to attempt to contact  impacted consumers and educate them on the Data Matching resolution process and follow up on any communication attempts on behalf of the FFM. Issuers can also share the Outreach files with agents so they can also attempt contact with their clients.

Another solution is for the FFM to allow retroactive restoration of subsidy in the case of income inconsistencies.  This would minimize gaps in federal financial support and is similar to how the process works for eligibility restoration for citizenship inconsistencies.  The FFM could also enhance its current termination process to validate there are no supporting documents in the processing queue prior to transmitting the income inconsistency subsidy reduction transaction for a respective enrollee.

A medium for recommendations such as the above is the Centers for Medicare & Medicaid Services’ Alpha Advisory Group.  The Alpha Group is a group of Issuer and vendor partners, including HealthPlan Services, that have demonstrated industry leadership and credibility to CMS.  Alpha Issuer partners troubleshoot Issuer and consumer challenges and collaborate to create recommendations.  The overall goal is to align with CMS and ultimately streamline enrollment and shore up the infrastructure to improve the overall user interface and experience.

The FFM life-cycle has shown marked improvements as the system matures.  However, as has been demonstrated with the Data Matching verification process, there are still member education and data enhancements to be considered and addressed.