http://online.wsj.com/news/articles/SB10001424052702304202204579256680760860664Errors Continue to Plague Government Health Site
Flaws Include Missing Customers and Inaccurate Eligibility Determinations
By
Christopher Weaver
Updated Dec. 13, 2013 7:42 p.m. ET
Thousands of web applicants above have received inaccurate assignments.
Insurers and federal officials sifting through insurance applications under the health-care law have identified a raft of errors, including missing customers and inaccurate eligibility determinations that mean people may be enrolled in the wrong coverage.
Thousands of insurance applicants from HealthCare.gov—at least one in five at the height of the problems by one estimate—have received inaccurate assignments to Medicaid or to the marketplace for private plans, or have received incorrect denials, people familiar with the matter said. Eligibility determinations are an early step in the application process, before consumers choose plans.
In some cases described by a state official with knowledge of the matter, legal immigrants who aren't yet eligible for Medicaid in Illinois—it takes five years of residence to join the state-run programs for low-income people—were nevertheless told they would be enrolled.
The risk that consumers could remain in limbo as the health law's coverage expansion begins in January has been a continual political threat to the Obama administration, which has addressed flaws—ranging from a malfunctioning website to the cancellation of health policies that don't meet the law's requirements—with a patchwork of last-minute fixes.
The Department of Health and Human Services on Thursday urged insurers to help avoid Jan. 1 mix-ups by loosening coverage rules. Officials asked companies to cover people retroactively who miss the Jan. 1 deadline to pay premiums and pay for drugs next month, even for customers who haven't yet fully enrolled.
But insurance-industry executives warn that some of these data problems will only emerge once customers begin seeking care in January at physicians' offices, pharmacies and hospitals. The result could be bureaucratic chaos as doctors and patients storm insurers' phone banks and federal officials work to clean up the inaccuracies.
There will be "eligibles lost in the ether," said Mark Bertolini, chief executive of Aetna Inc., AET -0.18% in an interview. In some cases, children who are meant to be enrolled in their parents plans aren't listed there, he said.
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"The big moment of truth is 12 a.m. Jan. 1, when a mother is standing at a pharmacy with a baby in her arms trying to get a script filled," Mr. Bertolini told investors Thursday.
HHS spokeswoman Joanne Peters said, "HealthCare.gov is making accurate determinations for nearly all users," though she acknowledged that applicants with "complicated family and tax situations" have faced problems.
"As part of the technical enhancements to HealthCare.gov, we have fixed several issues related to eligibility determinations, and we are working to implement additional fixes soon for bugs that are impacting a limited number of people," she said.
Administration officials urged customers to contact the companies they believe will cover them to verify their enrollment, or call state Medicaid agencies to confirm that they are in fact eligible for those programs. People who believe they have received inaccurate eligibility determinations can appeal the decisions, HHS officials have said.
To correct inaccuracies, some people may have to delete accounts and start over now that some glitches have been repaired, people familiar with the matter said.
Insurers have been working for months to clean up other data problems, such as missing data fields and children reported as spouses, in enrollment files they receive from the federal exchange. The Obama administration has said about one-quarter of enrollment files—known in the industry as 834s—were flawed initially, but repair efforts have reduced the error rates to one in 10.
"We certainly want to make sure that [for] anyone who thinks that they've enrolled with us, actually the information has gone to the plan…so that when the person shows up in January to get health care, you all will know who they are," Gary Cohen, a top official in the HHS agency overseeing the law, told a health-plan industry conference on Thursday.
As insurers start to match up federal data files against the roster of enrollees known to them, some companies say they are finding discrepancies they must still sort out with three weeks to go before policies must go into effect.
But the flawed eligibility determinations raise the prospect that insurers could face a scramble that stretches deeper into January.
"We are able to resolve the errors that we do find in our data," said Merit Smith, chief strategy officer of FirstCare Health Plans, based in Austin, Texas. "We can't look back up the pipeline and see what's up there" that hasn't yet emerged, he said.
The eligibility determination errors are the result of software malfunctions in a system meant to assign people to Medicaid or the insurance marketplaces, the two main arms of the law's coverage expansion. The software filters people based on things like immigration status and income based on about 200 rules.
Errors can lead to people who earn too much being enrolled in state Medicaid programs for which they aren't actually eligible, or citizens being incorrectly barred from the marketplaces.
Federal officials and the contractor that developed HealthCare.gov, CGI Group Inc., GIB.A.T -0.25% have identified dozens of scenarios in which the eligibility software produces inaccurate determinations. Many were fixed amid a broader push in November to cure the site's faults.
One glitch separates applicants who are members of the same family into separate households when some or all members of the family—such as children—don't file taxes in some cases. That can result in some members being inaccurately assigned to Medicaid or denied coverage when they should be steered toward private plans.
The glitches mostly afflict the most complicated family arrangements. For instance, a record of tests performed on the system reviewed by The Wall Street Journal shows fourteen separate scenarios in which a couple, a child, and a former spouse all file as members of the same household.
CGI said it couldn't comment on client matters.
Few applicants appeared to be aware of the miscalculations. Only about 1,400 have appealed determinations, a person familiar with the matter said. HHS decline to comment on the number of appeals.
In Idaho, some single adults with incomes above the Medicaid threshold have told state officials that HealthCare.gov said they were likely eligible for Medicaid. State officials think some determinations are wrong, but "we don't have the data to verify," said Tom Shanahan, a spokesman for the state's health agency.
The 36 states that participate in the federally run exchange are only just beginning to receive Medicaid enrollment data from HHS, and some officials said they expect to identify more eligibility problems soon.
The problems with inaccurate eligibility problems reach back to before the launch of the troubled federal marketplace, The Wall Street Journal reported in September.
—Louise Radnofsky and Spencer Ante contributed to this article.
