Report Requested by E&C Republicans to Better Understand Obamacare Program Integrity

Washington, D.C. — A new report issued by the Government Accountability Office (GAO) has found that the Centers for Medicare and Medicaid Services (CMS) does not adequately enforce Obamacare’s requirement that states fund the cost of state-mandated health insurance benefits.

The report, requested by Energy and Commerce Committee Republicans, raises issues about CMS’s controls to ensure federal taxpayer dollars are not illegally subsidizing state mandates.

BACKGROUND:

Obamacare mandates a certain set of essential health benefits (EHBs) be covered by insurance plans within the individual health insurance market. States may choose to mandate additional benefits but are then required to cover the cost of such benefits. States are not permitted to use federal tax dollars, in the form of Advance Premium Tax Credits (APTCs), to do so.

In its report, GAO found that CMS delegates oversight of this policy to the States instead of enforcing it on its own. As outlined in the report, “CMS has limited assurance that APTCs accurately exclude the costs of non-EHB mandated benefits” and that “CMS has expressed concerns about states’ compliance with this requirement,” highlighting critical concerns about the potential for improper federal spending.

“This report, coupled with the immense Obamacare fraud this administration has overseen, highlights the need for Congress and the incoming administration to work swiftly to safeguard taxpayer funds at every corner of the agency. CMS should prioritize rigorous enforcement of all requirements intended to prevent improper spending,” said Committee Chair Cathy McMorris Rodgers (R-WA). “I commend GAO for its investigative efforts, which will help Congress protect taxpayer dollars by correcting government waste, fraud, and abuse.”

REPORT HIGHLIGHTS:

• CMS is supposed to enforce this requirement on States, but defers to states to enforce this federal requirement on themselves: 
• “States may require marketplace plans to cover items and services in addition to EHB; we refer to such benefits as non-EHB mandated benefits. However, APTCs cannot be used to offset the costs of these additional benefits. Specifically, the Centers for Medicare & Medicaid Services (CMS)—the federal agency responsible for determining the APTC amounts—must exclude the costs of non-EHB mandated benefits from the APTC calculation. CMS delegates responsibility for identifying non-EHB mandated benefits to the states.” 
• Even CMS has concerns with State compliance with the Obamacare requirement that States fund the cost of their coverage mandates. 
• “However, CMS has expressed concerns about states’ compliance with this requirement. For example, in the 2021 Payment Notice, CMS noted state confusion regarding the identification of non-EHB mandated benefits and concerns that the premium data it uses to calculate the APTCs did not exclude their costs, resulting in improper federal payments. CMS reiterated these concerns in its 2022 and 2023 Payment Notices.” 
• GAO found one state that did not believe it had the responsibility to identify benefits that it must fund, contrary to CMS’s position of deference to states. 
• “Further, we identified one state that inappropriately placed the onus on CMS to determine whether a mandated benefit was non-EHB, rather than identify these benefits itself.” 
• CMS does not know if premium data appropriately excludes state-mandated benefits: 
• “In addition, CMS does not know whether the premium data submitted by marketplace plans and used to calculate APTCs exclude the costs of non-EHB mandated benefits.” 
• GAO concludes that CMS does not have assurances that federal taxpayer dollars are not improperly funding state-mandated benefits. 
• “CMS has limited assurance that APTCs accurately exclude the costs of non-EHB mandated benefits. This poses a risk to its oversight objective and is inconsistent with federal internal control standards. These standards state that agencies should identify, analyze, and respond to risks related to achieving agency objectives. Assessing whether its current oversight approach is sufficient to respond to identified risks and making changes as appropriate would be consistent with these standards. Such an assessment would also provide greater assurance that the APTCs accurately exclude the costs of non-EHB mandated benefits.” 

CLICK HERE to read the GAO report.