Testifying Wednesday before the House Ways and Means hearing on the Health and Human Services (HHS) budget, Kathleen Sebelius was bombarded with questions about implementation of the Affordable Care Act. She was asked to provide details on the administration’s claims about current enrollment levels.
Rep. Tom Price asked Sebelius how many of the 4.2 million individuals that HHS has reported as signing up via the Marketplaces have actually made a premium payment (via Politico):
While Sebelius claims that HHS only receives information about “those who have paid premiums and are eligible for tax credits,” guidance issued for insurers by the Centers for Medicare and Medicaid Services (CMS) shortly after the launch of Healthcare.gov contradicts that assertion. According to the guidance, part of the confirmation that issuers are required to report back to HHS (via Healthcare.gov) must include premium payments, and indeed is necessary to validate an “effectuated enrollment.”
The document is entitled Federally Facilitated Marketplace Enrollment Operational Policy & Guidance was issued on October 3, 2013. In Section 2.4 – Relationship between Premium Payments and the Confirmation/Effectuation 834 Transaction, the guidance states [emphasis added]:
The document includes a number of examples throughout the text regarding confirmations, and nowhere does the required confirmation hinge on eligibility for tax credits.
Further, in Section 2.3 – Premium Payments, the guidance indicates that users at Healthcare.gov who have selected a plan with an insurer will be shown a “payment redirect” link to their insurers to make a payment online, or in the absence of online payment capability by the insurer, the user will be shown “standard language… that the issuer will bill them for premium payment.” The link, however, will only be shown to the user as long as the premium remains unpaid or a cancellation is received by the FFM (Healthcare.gov):
This requirement is further documented in another CMS document, the Standard Companion Guide Transaction Information. This document includes very detailed instructions on the type of information that must be communicated in both directions between the Qualified Health Plan (QHP) issuers (the insurance companies) and the Federal Facilitated Exchange (FFE, or Healthcare.gov.) Under Section 10.2 – Enrollment Confirmation/Effectuation Instructions – QHP Issuer to FFE, the document states [emphasis added]:
The above documents make clear that the intention of HHS from the start was that insurers would confirm enrollment only when premiums were actually received. As to the timing of such confirmations, Section 2.4 of the guidance document issued on October 3 states that “the FFM expects QHP and QDP issuers to send all confirmation transactions by the fifth calendar day of the effective month of coverage.” While HHS has implemented various exceptions, delays and clarifications, there is no indication that insurers have been relieved of the responsibility to confirm premium payments, although the timing has been stretched, as an Interim Final Rule published in the Federal Register on December 17, 2013 spells out:
HHS has granted flexibility about due dates, effective dates, and the timing of confirmation of enrollments, but not the substance of those confirmations. If insurers are following the guidance issued by HHS, then the agency has accumulated data on paid enrollments at least relative to the Federal Marketplace. Some states running their own Marketplaces, such as Maryland, report weekly on the number of paid enrollments.
But as Kathleen Sebelius’s testimony demonstrates, HHS is not yet ready to make the federal data on paid enrollments available to the public or even acknowledge its existence.
