Healthcare

Some Americans Kicked Off Obamacare Health Plans Weren’t Actually Fraudulently Enrolled: REPORT

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Some Americans recently removed from Obamacare health plans amid the Trump administration’s fraud crackdown were not fraudulently enrolled, KFF Health News reported Thursday.

The administration in September terminated 760,000 individuals from the Affordable Care Act (ACA) exchanges, citing alleged fraud. However, anonymous insurance industry sources told KFF Health News that the Centers for Medicare & Medicaid Services (CMS) has now restored a small share of individuals whose ACA health coverage should not have been scrapped.

“It may be true that some of those enrollments were not authorized, but it can be equally true that people got lost in the shuffle and have a valid enrollment. Without more information, it’s almost impossible to tell,” Katie Keith, a director of the Center for Health Policy and the Law at Georgetown Law, told the outlet.

“That they [the Trump administration] are not being very transparent is telling too,” Keith added.

“CMS identified 1.18 million potentially unauthorized enrollments that were all agent or broker assisted and lacked a Social Security Number (SSN) or immigration document number,” a CMS spokesperson told the Daily Caller News Foundation. “They were then reviewed for the following longstanding criteria: The individual’s premium had to be covered 100% by advance payments of the premium tax credit (APTC); No claims could have been filed for any enrollee on the policy; and The issuer could have no record of the enrollee contacting the company about the policy or benefits. After applying these criteria, CMS determined 760,000 of those enrollments were unauthorized.”

“Once an enrollment was found to have met ALL of the above criteria, issuers were required to use multiple methods to conduct outreach and provided 30 days for the consumer to respond,” the spokesperson added. “Enrollments that met the criteria, and for which the issuer was unable to contact a consumer following outreach, were canceled. For additional background, the criteria used are operational processes that have been in the FFE enrollment manual since June 2019.”

The CMS spokesperson went on to say that the agency “also maintains safeguards for consumers whose coverage may have been canceled in error. If a legitimate consumer was affected, that consumer can contact the Marketplace Call Center, provide a verified SSN [social security number] or immigration document number, and be reinstated,” adding that “currently, there is no additional data to share.”

Per information CMS supplied to KFF Health News, the agency in June selected almost 1.2 million ACA enrollments for further review that exhibited four indicators of potential fraud.

Subsequently, CMS issued lists of those Obamacare accounts to certain health insurers, instructing them to review the accounts and use at least two contact methods to attempt to touch base with the enrollees, KFF Health News first reported on Aug. 3. Policyholders were granted 30 days to reply to the health insurance companies and supply the missing information, and CMS kicked off those who didn’t respond.

“To the extent there is a reaction depends on whether the government got it wrong, whether people try to get care and then find out their coverage is no longer active,” Adrianna McIntyre, assistant professor of health policy and politics at the Harvard T.H. Chan School of Public Health, told the outlet.

Still, widespread fraud across the ACA’s exchanges is expected to cost U.S. taxpayers billions of dollars this year, per a Paragon Health Institute analysis released in early June.

CMS vowed in a Sept. 22 news release that the agency “will continue working with health insurance companies to identify and investigate potentially unauthorized enrollments, cancel those confirmed to be unauthorized, and recoup and end associated taxpayer-funded subsidies.”