FEDERAL HEALTH 

INSURANCE 

EXCHANGE

CMS Needs to Ensure 

Complete, Accurate 

Data on Terminations 

of Coverage for 

Nonpayment of 

Premiums 

Report to Congressional Requesters

March 2018

GAO-18-269

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-269, a report to 

congressional requesters

March 2018

FEDERAL HEALTH INSURANCE EXCHANGE 

CMS Needs to Ensure Complete, Accurate Data on 

Terminations of Coverage for Nonpayment of 

Premiums 

What GAO Found

In 2015, 9.2 million individuals enrolled in the federal health insurance exchange 

in 37 states. Eligible individuals (e.g., U.S. citizens or those lawfully present in the 

United States) are able to enroll in health coverage during the annual open 

enrollment period. Outside of open enrollment, eligible individuals may enroll in 

coverage or change their coverage selection during special enrollment periods. 

Individuals may enroll under a special enrollment period if, for example, they lost 

their coverage from another source, such as Medicaid or an employer, or due to 

relocation. Under federal regulations, enrollees may not sign up for coverage 

under a special enrollment period citing loss of coverage if the coverage was lost 

due to nonpayment of premiums. 

About half (53 percent) of the 2015 federally facilitated exchange (FFE) enrollees 

maintained continuous health insurance coverage throughout the year—that is, 

they began coverage between January 1 and March 1, 2015, and maintained it 

through December 31, 2015. These individuals had an average of 11.6 months 

of coverage. The remaining 47 percent of FFE enrollees started their coverage 

later or ended it during the year; they averaged 5.0 months of coverage. 

Enrollees could have voluntarily ended coverage—due to gaining other 

coverage, for example—or have had it terminated by the Centers for Medicare & 

Medicaid Services (CMS) or the issuers of coverage for valid reasons, including 

losing eligibility for exchange coverage or for nonpayment of premiums.

CMS does not have reliable data on issuer-generated terminations of coverage 

for enrollees’ nonpayment of premiums. Although CMS and issuers share data 

on the terminations each generates and reconcile their data on a monthly basis 

to ensure data accuracy, the agency does not require issuers to consistently 

report data on the reasons for terminations. Officials told us they do not track 

these data because they are not critical to ensure the accuracy of the federal 

subsidy amounts—which is the main function of the monthly reconciliation 

process. Further, CMS lacks a transparent process to ensure the accuracy of 

these data, as the monthly reconciliation files transmitted between CMS and 

issuers do not include a place to capture data on termination reasons. Issuers 

said that they are therefore unable to ascertain whether data they provide on the 

reasons for termination match CMS’s data, and thus they cannot make 

corrections where necessary. 

The agency’s lack of reliable data on terminations for nonpayment limits its ability 

to effectively oversee certain federal regulations. For example, because CMS is 

not systematically tracking these data, it cannot tell whether enrollees applying 

for coverage under a special enrollment period had lost their coverage for 

nonpayment of premiums—in which case they would be ineligible for the special 

enrollment period per federal regulations. CMS could capitalize on its existing 

process, already familiar to issuers, by adding a variable that captures data on 

termination reasons to the monthly reconciliation file. By taking this step, in 

addition to requiring issuers to report these data, CMS could help ensure it has 

reliable and transparent data on terminations of enrollee coverage for 

nonpayment of premiums, and it could use these data to assess the effects of 

CMS policies and the overall stability of the exchange. 

View GAO-18-269. For more information, 

contact John E. Dicken at (202) 512-7114 or 

dickenj@gao.gov.

Why GAO Did This Study

CMS has noted that it is important for 

enrollees to maintain continuous health

insurance coverage to ensure the 

stability of the FFE. Certain rules allow 

for enrollment flexibilities—such as 

special enrollment periods and a 3-

month grace period that is allowed 

before coverage is terminated for 

recipients of federal income-based 

subsidies who default on their 

premiums. However, some issuers 

have stated that these rules could be 

misused, resulting in non-continuous 

coverage. There are little data on the 

extent to which enrollees maintain 

continuous coverage during a year 

and, more specifically, on the extent to 

which coverage is terminated for 

nonpayment of premiums. 

GAO examined (1) the extent to which 

FFE enrollees maintained coverage in 

2015 and (2) the extent to which CMS 

has reliable data on termination of 

enrollees’ coverage for nonpayment of 

premiums. GAO analyzed CMS’s 2015 

FFE enrollment data (the most recent 

year of available data); interviewed 

CMS officials and selected issuers; 

and reviewed applicable laws and 

guidance from CMS. 

What GAO Recommends

GAO recommends that CMS ensures it 

has (1) complete data on terminations 

of coverage for nonpayment of 

premiums; and (2) a transparent 

process to reconcile discrepancies and 

ensure the accuracy of these data. The 

Department of Health and Human 

Services concurred with both 

recommendations. 
Page i GAO-18-269 Federal Health Insurance Exchange Enrollment

Letter 1

Background 6

Just over Half of FFE Enrollees Maintained Continuous Coverage 

throughout 2015; Length of Coverage Varied by Enrollee 

Characteristics 11

CMS Lacks Complete and Transparent Data on Terminations of 

Enrollee Coverage for Nonpayment of Premiums 16

Conclusions 19

Recommendations 19

Agency Comments and Our Evaluation 19

Appendix I Demographic and Coverage Characteristics of Federally Facilitated 

Exchange Enrollees, 2015 21

Appendix II Average Length of Coverage for Federally Facilitated Exchange 

Enrollees, 2015 26

Appendix III Comments from the Department of Health and Human Services 30

Appendix IV GAO Contact and Staff Acknowledgments 33

Tables

Table 1: Demographic Characteristics of Continuously Covered, 

and All Other, Federally Facilitated Exchange Enrollees, 

2015 21

Table 2: Coverage Characteristics for Continuously Covered, and 

All Other, Federally Facilitated Exchange Enrollees, 2015 22

Table 3: Proportion of Federally Facilitated Exchange Enrollees 

Who Maintained Continuous Coverage throughout 2015, 

by State 24

Table 4: Average Length of Coverage for Federally Facilitated 

Exchange Enrollees by Demographic Characteristics, 

2015 26

Table 5: Average Length of Coverage for Federally Facilitated 

Exchange Enrollees by Coverage Characteristics, 2015 27

Contents
Page ii GAO-18-269 Federal Health Insurance Exchange Enrollment

Table 6: Average Length of Coverage for Federally Facilitated 

Exchange Enrollees by State, 2015 28

Figures

Figure 1: Data Transfer between CMS and Issuers for Initial 

Enrollment, Subsequent Updating, and Reconciliation 

Processes in the Federally Facilitated Exchange 9

Figure 2: Length of Coverage for Federally Facilitated Exchange 

Enrollees, 2015 12

Figure 3: Length of Coverage for Federally Facilitated Exchange 

Enrollees by Initial Enrollment Period, 2015 14

Abbreviations 

APTC Advance Premium Tax Credit

CMS Centers for Medicare & Medicaid Services 

FFE federally facilitated exchange 

HHS Department of Health and Human Services 

OEP open enrollment period 

PPACA Patient Protection and Affordable Care Act

SEP special enrollment period

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-18-269 Federal Health Insurance Exchange Enrollment

441 G St. N.W.

Washington, DC 20548

March 9, 2018

The Honorable Orrin Hatch

Chairman

Committee on Finance

United States Senate

The Honorable Greg Walden

Chairman

Committee on Energy and Commerce

House of Representatives

The Honorable Fred Upton

House of Representatives

The Patient Protection and Affordable Care Act (PPACA) required, 

beginning in 2014, the establishment of exchanges (or marketplaces) in 

each state where eligible consumers can directly compare and select 

among a variety of qualified health plans offered by participating private 

issuers.1 The Centers for Medicare & Medicaid Services (CMS)—the 

agency within the Department of Health and Human Services (HHS) that 

oversees the federally facilitated exchange (FFE) in 39 states that elected 

to use the FFE in 2017—has noted that, while consumers enrolled in 

health insurance need to maintain continuous coverage for the entire year 

to ensure a stable and affordable marketplace, exchange rules should 

also allow individuals the flexibility to make changes to their enrollment in 

response to life circumstances.2 However, some issuers offering health 

 1

Pub. L. No. 111-148, §§ 1501, 10106, 124 Stat. 119, 244, 909 (2010), as amended by 

the Health Care and Education Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 

§§ 1002, 1004, 124 Stat. 1029, 1032, 1034 (2010) (codified at 26 U.S.C. § 5000A). In this 

report, references to PPACA include any amendments made by HCERA. To be eligible to 

enroll in the exchanges, an individual must be a U.S. citizen or national or otherwise be 

lawfully present in the U.S.; not be incarcerated (unless pending disposition of the 

charges); and reside in the state in which the exchange operates. 

2

Each state may operate its own exchange or elect to use the FFE. (For purposes of this 

report we are treating the District of Columbia as a state.) States that operate their own 

exchanges may also use the FFE for certain functions. In 2017, the 12 states that 

operated their own exchanges and did not use the FFE were: California, Colorado, 

Connecticut, the District of Columbia, Idaho, Maryland, Massachusetts, Minnesota, New 

York, Rhode Island, Vermont, and Washington. 

Letter
Page 2 GAO-18-269 Federal Health Insurance Exchange Enrollment

insurance plans in the FFE have noted that certain of these rules could 

also undermine enrollees’ incentives to maintain continuous coverage.

Specifically, issuers have raised concerns about enrollment that occurs 

outside of the open enrollment period (OEP), which generally runs near 

the start of the coverage year, and about enrollees ending their coverage 

before the end of the year. Individuals may use special enrollment periods 

(SEP) to sign up for coverage outside of open enrollment if they 

experience a triggering event, such as losing coverage from another 

source including Medicaid or an employer.3 However, issuers have noted 

that an SEP could be misused if individuals, instead of signing up during 

OEP, delayed enrollment until they were sick and had imminent health 

care costs to be covered. Some issuers also noted that CMS could be 

allowing individuals whose coverage was terminated due to nonpayment 

of premiums to re-enroll under an SEP due to loss of coverage although, 

under federal regulations, this is not allowed.4 Finally, some issuers have 

stated that enrollees receiving Advance Premium Tax Credits (APTC), 

which reduce the cost of coverage for eligible individuals, may 

intentionally stop paying their premiums before the end of the year to take 

 3

45 C.F.R. §§ 155.410,155.420 (2016). The triggering events for SEPs have changed 

over time; according to CMS, as of 2017, there are six broad categories: 1) loss of 

qualifying coverage from other sources (e.g., employer, Medicare, Medicaid); 2) change in 

household size (e.g., through marriage, birth or adoption of a child); 3) change in primary 

place of living (e.g., relocation to a new zip code); 4) change in eligibility for exchange 

coverage or in help paying for coverage (e.g., becoming newly eligible for FFE coverage 

or changes in household income); 5) enrollment or plan error on the part of the exchange; 

and 6) other situations (e.g., becoming incapacitated).

The open enrollment period generally ran from November 1 of the prior year to January 31 

of the coverage year, but the end date has changed in recent years. Specifically, for 

coverage year 2015, it ended on February 15 of the coverage year; in 2016 and 2017, it 

ended on January 31 of the coverage year; and for coverage years 2018 and beyond, it 

will end on December 15 of the prior year.

4

45 C.F.R. § 155.420(e) (2016). 
Page 3 GAO-18-269 Federal Health Insurance Exchange Enrollment

advantage of the 3-month coverage grace period allowed by law while still 

meeting requirements for PPACA’s individual mandate.5

There is, however, little data about the extent to which these specific 

problems have occurred.6 Further, enrollees may stop paying premiums 

and terminate their coverage for valid reasons including unexpected 

reductions in household income or gaining other government or 

employer-sponsored coverage, and other research has found that short 

periods of coverage were common in the individual market even prior to 

PPACA.7 Officials from both CMS and issuers indicated that individuals 

often do not provide notification that they are ending their coverage due to 

a change of circumstance. Instead, they stop paying premiums and let 

their exchange policies “passively” terminate.

You asked us to examine the extent to which exchange enrollees 

maintained coverage and paid their premiums during the plan year. This 

report:

 5

PPACA provides premium tax credits for individuals purchasing coverage through the 

exchanges if they meet applicable income requirements and are not eligible for coverage 

from another source. In this report, we refer to advance payments of these federal 

subsidies to issuers—rather than directly to enrollees—as APTCs. APTC recipients are 

entitled to receive a 3-month grace period if they default on their premium payments. For 

non-APTC recipients, grace periods are governed by state law and are typically 1 month. 

If APTC recipients do not pay their outstanding premiums during the grace period, the 

individuals are responsible for any medical costs incurred during the last 2 months of the 

grace period.

PPACA required that, with some exceptions, individuals maintain qualifying health 

insurance during the year or pay a tax penalty. This requirement is referred to as the 

individual mandate. In December 2017, a law repealing the tax penalty imposed for failure 

to comply with the individual mandate was enacted. As a result, beginning January 1, 

2019, individuals who fail to comply with the individual mandate will no longer face a tax 

penalty. See Pub. L. No. 115-97, § 11081 (Dec. 22, 2017). 

6

Some research has reported more general enrollment trends. For example, one industry 

study estimated that for a group of 13 issuers, 17 percent of enrollment through June 2015 

was through an SEP. The study also indicated that SEP enrollees were more likely to drop 

coverage—5 percent per month, compared to 3.5 percent for other enrollees. See Oliver 

Wyman, “Special Enrollment Periods and the Non-Group, ACA-Compliant Market,” New 

York, NY, Feb. 2016. According to a survey of 2,763 consumers eligible for individual 

coverage, approximately 21 percent reported stopping paying their premiums in 2015. 

Approximately 87 percent of individuals who reported stopping paying their premiums also 

reported repurchasing a plan in 2016, and about half of these purchased the same plan. 

The survey did not report on why the individuals dropped coverage. See McKinsey & 

Company, “2016 OEP: Reflection on Enrollment,” (Washington, DC; May 2016). 

7

See, for example, Henry J. Kaiser Family Foundation, “How Many People Have 

Nongroup Health Insurance?” Menlo Park, Calif (2013). 
Page 4 GAO-18-269 Federal Health Insurance Exchange Enrollment

1. describes the extent to which enrollees who purchased health 

insurance coverage through the FFE in 2015 maintained their 

coverage during the plan year; and

2. evaluates the extent to which CMS has reliable data on the rate at 

which enrollees in the FFE are terminated from coverage due to 

nonpayment of premiums.

To describe the extent to which enrollees who purchased health 

insurance coverage through the FFE in 2015 maintained their coverage 

during the plan year, we obtained and analyzed enrollment and 

demographic data from CMS.8 According to CMS officials, 2015 was the 

most recent full year of data available at the time of our review. 

Specifically, CMS provided us with data from its centralized enrollment 

system, the Multidimensional Insurance Data Analytics System, for each 

enrollee who obtained health insurance coverage—that is, selected a 

plan and paid their first premium—through the FFE for coverage year 

2015.9 These data included, among other information, the enrollees’ 

coverage start and end dates; type of plan, premium, and any APTC 

amounts; and demographic information reported by enrollees, including 

gender, state of residence, and household income.10 We used these to 

analyze the extent to which enrollees maintained continuous FFE 

coverage throughout 2015—which we defined as coverage that began 

from January 1, 2015, to March 1, 2015, and ended on December 31, 

 8

We focused our review on the 37 states that used the FFE in 2015 because enrollment 

data from state-based exchanges that did not use the FFE were not readily available. In 

2015, the 14 states that operated their own exchanges and did not use the FFE were: 

California, Colorado, Connecticut, the District of Columbia, Hawaii, Idaho, Kentucky, 

Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, and 

Washington. 

9

CMS provided data on all individuals who were ever enrolled in 2015 coverage through 

the FFE, including any enrollees whose coverage was ultimately terminated by the agency 

because citizenship status or other key information could not be verified.

According to the Social Security Administration’s May 2017 Death Master File, 25,599 of 

the enrollees who obtained 2015 health insurance coverage through the FFE died during 

2015. We excluded these enrollees from our analysis. We also excluded dental coverage 

for the purposes of our analysis.

10We did not examine potential differences in health costs or the health status of 

individuals in the two groups because these data were not available from CMS’s 

centralized enrollment system. 
Page 5 GAO-18-269 Federal Health Insurance Exchange Enrollment

2015.11 We compared the demographic and coverage characteristics of 

enrollees who maintained continuous coverage throughout 2015 with 

those of all other enrollees. We also examined the demographic and 

coverage characteristics of all FFE enrollees in 2015. Further, CMS 

provided us with FFE enrollment data for the time period of January 1, 

2016, through June 30, 2016, which we used to analyze the extent to 

which the 2015 FFE enrollees re-enrolled for coverage year 2016.12 We 

assessed the reliability of the data provided by CMS in several ways, 

including discussing the reliability of the data with CMS officials, reviewing 

relevant CMS data manuals and other documentation, performing manual 

and electronic tests of the data to identify any outliers or anomalies, and 

comparing the data with data from published sources. We also 

interviewed representatives from a small selection of issuers to discuss 

the reliability of relevant issuer-reported data maintained in CMS’s 

centralized enrollment system.13 We determined that the data were 

sufficiently reliable for the purposes of our reporting objectives.

To evaluate the extent to which CMS has reliable data on the rate at 

which FFE enrollees are terminated from coverage due to nonpayment of 

premiums, we examined data from CMS’s enrollment system on the 

reported reasons for termination of enrollee coverage in 2015. For a small 

selection of enrollees identified by CMS as having their coverage 

terminated for nonpayment, we examined the termination reasons listed 

in issuer data.14 We also interviewed officials from CMS, industry 

 11We picked a start date of no later than March 1, 2015, because open enrollment ended 

on February 15, 2015, so individuals enrolling during the open enrollment time frame 

would generally have had coverage start dates on or before March 1. In addition, 

individuals who began coverage by March 1, 2015, and remained enrolled through the 

end of the year would have had at least 10 months of continuous coverage, which fulfilled 

PPACA’s individual mandate for health coverage. Individuals could have held multiple 

exchange policies purchased through the FFE during this time frame; we considered them 

to have maintained coverage as long as they did not have any uncovered days in between 

policies. To examine the average number of months enrollees held coverage, we 

assumed that months are 30.4 days long, as this was the average month length in 2015.

12According to CMS officials, data for the remainder of 2016 were not available at the time 

of our request because it takes at least 6 months for enrollment data to stabilize.

13For example, we interviewed issuer representatives about the reliability of coverage end 

dates, which are revised and transmitted to CMS by issuers when issuers terminate 

policies. We interviewed representatives from Aetna, Anthem, Blue Cross Blue Shield of 

North Carolina, Health Care Service Corporation, and Independence Blue Cross. These 

issuers together held 26 percent of total exchange enrollment in 2015.

14Specifically, we obtained data on a selection of between 25 and 30 enrollees each from 

Aetna, Anthem, and Health Care Service Corporation.
Page 6 GAO-18-269 Federal Health Insurance Exchange Enrollment

stakeholders, and selected issuers to learn about how the data on 

termination reasons are collected.15 In addition, we reviewed relevant 

PPACA provisions and federal regulations and guidance, including 

technical guidance from CMS governing the transfer of information 

between CMS and issuers participating in the FFE, and determined 

whether the agency’s relevant policies and procedures are consistent with 

standards for internal control in the federal government.16

We conducted this performance audit from July 2016 to March 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

The exchanges (including the FFE and those operated by individual 

states) provide a seamless, single point of access for eligible individuals 

to enroll in qualified health plans. For the FFE, CMS established a 

website—Healthcare.gov—as the public portal through which individuals 

may apply for coverage and select and enroll in health plans, which are 

offered at different levels of coverage, or “metal tiers”—bronze, silver, 

gold, and platinum—that reflect the percentage of covered medical 

expenses estimated to be paid by the insurer.17 The data that individuals 

provide in their application is stored in the FFE’s centralized enrollment 

system, which is maintained by CMS.

 15The industry stakeholders we interviewed were America’s Health Insurance Plans and 

the Blue Cross Blue Shield Association.

16GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.

17For example, bronze plans tend to have the lowest premiums, but subject consumers to 

the highest out-of-pocket costs (such as deductibles) when they receive health care 

services, while platinum plans tend to have the highest premiums and the lowest out-ofpocket costs. 

Individuals may also apply in person, over the phone, or by mailing in a paper application.

Background
Page 7 GAO-18-269 Federal Health Insurance Exchange Enrollment

Although CMS oversees the centralized enrollment system, both CMS 

and issuers have shared responsibility for enrollment and coverage 

functions once individuals apply for coverage:

• CMS is responsible for determining an individual’s eligibility for 

coverage and income-based federal subsidies, enrolling the 

individual, and processing subsequent coverage changes or 

terminations. For example, individuals may change their existing 

coverage by signing up under an SEP due to the birth of a child or 

relocation, or they may voluntarily terminate their coverage, or CMS 

may terminate coverage if the agency is unable to verify key 

information such as citizenship status. CMS is also responsible for 

making payments for APTCs and determining whether an enrollee is 

eligible for any cost-sharing reductions that lower enrollees’ out-ofpocket costs for expenses, such as deductibles and copayments.

• Issuers are responsible for, among other things, collecting premiums 

from enrollees, arranging for coverage through provider networks, and 

paying claims. Issuers are also responsible for processing, and 

notifying CMS of, terminations related to nonpayment of premiums or 

fraud.18

As a result of this shared responsibility, CMS and issuers notify each 

other of coverage updates by transferring data back and forth through 

electronic files known as “transaction files.” It is critical that both issuers 

and CMS have consistent, accurate, and current information on enrollees, 

because monthly APTC payments are based on enrollment data in CMS’s 

centralized system. Federal regulations require CMS to reconcile 

enrollment information with issuers on at least a monthly basis.19

Accordingly, CMS and issuers reconcile certain key data elements on a 

monthly basis through an automated enrollment reconciliation process, in 

which issuer and CMS data are compared and discrepancies are 

resolved. Through this process, APTC amounts and their effective dates 

are compared and reconciled. CMS’s data system is considered to be 

correct when considering discrepancies on overall enrollment counts or 

with key data elements, such as coverage start and end dates between 

issuer and CMS data. Therefore, CMS will not change the APTC 

 18These are generally the only types of terminations of coverage that issuers are allowed 

to make. Issuers told us that terminations for fraud are rare.

19See 45 C.F.R. § 155.400(d) (2016). 
Page 8 GAO-18-269 Federal Health Insurance Exchange Enrollment

payments based on issuers’ data that may differ from CMS’s data unless 

there are significant discrepancies.20

There are several specific steps involved in transferring data between 

CMS and issuers for initial enrollment, subsequent updates, and 

reconciliation (see fig. 1 for a high-level overview of the data transfer 

process):

• Initial enrollment: CMS forwards an outbound electronic transaction 

file to the issuer with information on the applicant, the plan selection, 

the premium, and the APTC amount. Once the issuer receives the 

initial premium payment, the issuer sends an inbound electronic 

transaction file back to CMS to confirm the enrollment. Issuers may 

not refuse to issue coverage to an individual CMS has deemed 

eligible once that individual has made the initial premium payment. 

Transaction files are transmitted electronically on a daily basis.

• Subsequent changes/terminations: Subsequent changes to the 

individual’s coverage may be initiated by enrollees, CMS, or issuers. 

For example, enrollees may request changes to their coverage 

through the portal if they experience a change in circumstance (such 

as needing to enroll under an SEP due to the birth of a child, or to 

terminate their coverage if they move to a different state); CMS may 

terminate coverage if the agency cannot verify key eligibility 

information (such as citizenship status); or issuers may terminate 

coverage if enrollees fail to pay their premiums. If CMS initiates 

changes in coverage, it notifies issuers through subsequent outbound 

transaction files, and similarly, if issuers initiate changes they notify 

CMS through subsequent inbound transaction files.

• Monthly reconciliation: CMS sends issuers a snapshot of key 

elements of the enrollment data in its centralized enrollment system in 

an outbound reconciliation file. Issuers compare the data from the file 

to their enrollment systems and identify missing enrollments or other 

discrepancies. Issuers make updates as necessary and send CMS an 

inbound reconciliation file with information about current enrollees, 

cancellations, and terminations in their systems.21 CMS then performs 

 20CMS stated that starting with May 2016 payments, issuers would be paid the policybased payments as calculated based on CMS data, except in cases of extreme variation 

(greater than 25 percent) from the manual payment amount calculated. In those cases, 

CMS will work with issuers to resolve the discrepancy.

21Issuers may also dispute the results of the automated comparison and submit the 

dispute to CMS for resolution.
Page 9 GAO-18-269 Federal Health Insurance Exchange Enrollment

an automated comparison of the data in the inbound reconciliation 

files with its centralized enrollment system and identifies any further 

discrepancies that may need to be resolved either by CMS or issuers. 

If necessary, CMS makes further updates to its data.

Figure 1: Data Transfer between CMS and Issuers for Initial Enrollment, Subsequent Updating, and Reconciliation Processes 

in the Federally Facilitated Exchange

Notes: PPACA provides certain subsidies to eligible individuals, including Advance Premium Tax 

Credits (APTC), that reduce premium costs.

In an April 2017 final rule, CMS implemented several actions that, in part, 

responded to issuer concerns about special enrollment periods and 
Page 10 GAO-18-269 Federal Health Insurance Exchange Enrollment

stability of enrollment.22 Specifically, CMS stated that the agency would 

require documentation from all individuals applying to enroll in coverage 

under an SEP to verify their eligibility for the SEP prior to enrollment.23

CMS also stated that, starting in June 2017, it would allow issuers, 

subject to state law, to apply a new premium payment to an individual’s 

past due payments before applying that premium towards a new 

enrollment.24 CMS stated that issuers would be allowed to refuse to 

provide coverage to an enrollee applying under an SEP due to loss of 

existing coverage if the issuer had previously terminated the enrollee’s 

coverage for nonpayment of premiums, unless the enrollee paid the past 

due premiums. CMS further stated that this provision was intended to 

encourage individuals to maintain continuous coverage rather than start 

and stop coverage (and thereby avoid incurring past due premiums).25

 22See 82 Fed. Reg. 18,346 (April 18, 2017) (codified at 45 C.F.R. pts. 147, 155, and 156).

23The final rule expanded on previous agency efforts to curb potential abuses of SEPs, 

including a special enrollment confirmation process that CMS had begun in June 2016, 

under which CMS required documentation of enrollees’ eligibility for the most common 

SEP categories. Enrollees who were selected for review and could not prove their 

eligibility would have their coverage terminated. Since implementing the process, CMS 

reported seeing a 20 percent drop in SEP enrollments in 2016 over 2015. See CMS: “PreEnrollment Verification for Special Enrollment Periods,” (Dec. 20, 2016), accessed August 

28, 2017, https//www.cms.gov/CCIIO/resources/fact-sheets-and-faqs/index.html.

24The final rule applies to past debt owed for coverage from an issuer in the same 

controlled group, as defined by the Internal Revenue Code, within the past 12 months.

25In the April 2017 final rule, CMS also stated that the agency would explore other policies 

that could encourage enrollees to maintain continuous coverage, such as requiring 

maintenance of continuous coverage without a 63-day break if individuals wish to avoid 

the pre-existing condition exclusion and allowing waiting periods to be imposed under 

certain circumstances. 
Page 11 GAO-18-269 Federal Health Insurance Exchange Enrollment

Approximately 4.9 million enrollees (53 percent of the 9.2 million FFE 

enrollees in 2015) maintained continuous coverage throughout the year—

that is, their coverage began between January 1 and March 1, 2015, and 

lasted through December 31, 2015. These individuals therefore had 10 or 

more months of continuous coverage, with an average length of coverage 

of 11.6 months. Most of these enrollees (83 percent) re-enrolled in 

coverage by June 2016.

The remaining 4.3 million enrollees (47 percent of the FFE enrollees in 

2015) did not maintain continuous FFE coverage throughout the year, as 

defined above.26 The average length of coverage for these enrollees was 

about 5.0 months and, for most (72 percent), coverage ended prior to the 

end of the year. (See fig. 2 for information on enrollee length of 

coverage.)

Of the 4.3 million enrollees, 38 percent re-enrolled in exchange coverage 

for 2016, although enrollees that held coverage through the end of the 

year—regardless of their length of coverage—were far more likely to have 

re-enrolled than enrollees whose coverage ended prior to the year’s 

end.27

 26This category includes individuals whose coverage CMS terminated during the year 

because the agency could not verify their citizenship status or other key information. CMS 

reported that, during 2015, the agency terminated coverage for about 500,000 enrollees 

whose citizenship status or other key information could not be verified. See CMS, 

December 31, 2015 Effectuated Enrollment Snapshot (Baltimore, Md.: Mar. 11, 2016). 

Of the 4.3 million enrollees, about 264,000 had gaps in coverage—that is, they dropped 

and resumed coverage through the FFE at least once during the year, with at least one 

day without coverage in between. Their average length of total coverage across all 

separate periods of coverage was 8.3 months. The total number of uncovered days in 

between these enrollees’ periods of exchange coverage ranged from 1 to 333 days, with 

an average of 66 days. 

27Specifically, of the 4.3 million enrollees, 81 percent of those with coverage ending 

December 31, 2015, re-enrolled in coverage by June 2016, as compared to 21 percent for 

those whose coverage ended earlier. This higher rate for enrollees with coverage ending 

December 31, 2015, is likely in part because some enrollees who remained enrolled in 

December 2015 were automatically re-enrolled in coverage for 2016. (If eligible 

consumers do not make an active re-enrollment selection, CMS automatically re-enrolls 

them in their existing plan if it remains available. If that plan is no longer available, CMS 

generally automatically re-enrolls consumers in a similar plan if it identifies one, or the 

consumers would have to actively re-enroll if CMS does not identify a similar plan.)

Just over Half of FFE 

Enrollees Maintained 

Continuous Coverage 

throughout 2015; 

Length of Coverage 

Varied by Enrollee 

Characteristics
Page 12 GAO-18-269 Federal Health Insurance Exchange Enrollment

Figure 2: Length of Coverage for Federally Facilitated Exchange Enrollees, 2015

Notes: We defined enrollees with 10 or more months of continuous coverage in 2015 as those who 

began coverage by March 1, 2015, and maintained this coverage through December 31, 2015. We 

defined enrollees with gaps in coverage as those who had multiple periods of FFE coverage in 2015 

with one or more uncovered days in between. For all other enrollees, to determine total months 

covered, we assumed months to be 30.4 days long and rounded to the nearest month. We excluded 

dental coverage and the 25,599 individuals who died in 2015, per data from the Social Security 

Administration, from this analysis.

In general, we did not find notable differences in attributes of enrollees’ 

coverage (for example, by benefit level of selected plan or monthly 

premium after APTC) or enrollee demographics when comparing the two 

groups of enrollees—those who maintained continuous coverage 

throughout 2015, and those who did not. (For data on coverage and 

demographics of FFE enrollees who did maintain continuous coverage 

throughout 2015 and those who did not, see app. I.)

However, in examining the demographic and coverage characteristics of 

all FFE enrollees, we found that enrollees with certain characteristics 
Page 13 GAO-18-269 Federal Health Insurance Exchange Enrollment

tended to remain covered for a longer period of time in 2015 compared to 

other enrollees.28 For example:

• Enrollment period. Enrollees who enrolled during the open 

enrollment period had a higher average length of coverage than 

enrollees who enrolled through an SEP—9.1 months compared to 5.2 

months (see fig. 3).29 However, more individuals who enrolled through 

an SEP remained enrolled through December 31, 2015, compared to 

individuals who enrolled during open enrollment—72 percent 

compared to 64 percent.30

 28We did not test whether there was statistical correlation between these characteristics 

and average length of coverage. Since our focus was the length of time for which 

enrollees remained enrolled in exchange coverage, we excluded the approximately 

264,000 enrollees (3 percent) that dropped and resumed exchange coverage during the 

year. In addition, about 25 percent of enrollees had multiple records in 2015. (New records 

were generated when enrollees reported changes in circumstances, such as changes in 

income, or when enrollees made changes to their coverage, such as adding a family 

member after the birth of a child.) For these, we used information from their first record to 

examine their characteristics, although some characteristics, such as eligibility for APTC 

and benefit level of selected plan, could have changed between records.

29For this analysis, we considered any enrollee who enrolled by February 22, 2015, to 

have enrolled during the open enrollment period (although the open enrollment period 

ended on February 15, 2015, CMS extended it for certain individuals who attempted but 

could not complete enrollment by this date). However, some of these enrollees also 

qualified for SEPs when they enrolled. When we consider these enrollees to have enrolled 

via SEP, the average length of coverage for enrollees who enrolled via SEP becomes 7.2 

months, while the average length of coverage for those that enrolled during the open 

enrollment period remains at 9.1 months.

30This difference could have resulted from the fact that OEP enrollees enrolled earlier in 

the year and thus had more time to experience any changes in their circumstances, such 

as loss of eligibility for exchange coverage, or gaining eligibility for other coverage, prior to 

the end of the year.
Page 14 GAO-18-269 Federal Health Insurance Exchange Enrollment

Figure 3: Length of Coverage for Federally Facilitated Exchange Enrollees by Initial Enrollment Period, 2015

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. We considered any enrollee who enrolled in 2015 exchange coverage by 

February 22, 2015, to have enrolled during the open enrollment period, and any enrollee who enrolled 

later in the year and had a special enrollment reason code on their record to have enrolled via a 

special enrollment period. Enrollment period could not be classified for about 1 percent of enrollees 

due to data anomalies. To determine total months covered, we assumed months to be 30.4 days long 

and rounded to the nearest month. Since our focus was the length of time for which enrollees 

remained enrolled in exchange coverage, we excluded the approximately 264,000 enrollees (3 

percent) that dropped and resumed exchange coverage during the year.
Page 15 GAO-18-269 Federal Health Insurance Exchange Enrollment

• Age. Enrollees aged 55 or older had the highest average length of 

coverage, while those aged 25 to 34 had the lowest—9.2 months 

compared to 7.8 months.

• Reported household income. APTC-eligible enrollees who reported 

having a household income between 301 and 400 percent of the 

federal poverty level had the highest average length of coverage, 

while those who reported having a household income less than, or 

equal to, 100 percent of the federal poverty level had the lowest—8.9 

months compared to 8.0 months.31

• Eligibility for APTC. Enrollees who were eligible for APTC had a 

higher average length of coverage than enrollees who were not 

eligible for APTC—8.6 months compared to 7.8 months

• Benefit level of selected plan.

32 Enrollees who selected higherbenefit, gold plans had the highest average length of coverage, while 

enrollees who selected lower-benefit catastrophic, plans had the 

lowest—8.8 months compared to 6.7 months. Enrollees who selected 

silver plans—the most common plan selection—had an average 

length of coverage of 8.6 months.

• State of residence. Enrollees residing in Maine had the highest 

average length of coverage, while enrollees residing in Mississippi 

had the lowest—9.4 months compared to 8.0 months.

See appendix II for additional data on the average length of coverage for 

enrollees by various characteristics.

 31Certain individuals earning up to 400 percent of the federal poverty level are eligible to 

receive APTC that can reduce premium costs for plans purchased on an exchange. The 

APTC amount is calculated on a sliding scale whereby individuals with lower income can 

receive a larger amount. 

We did not obtain data on reported household income for APTC-ineligible enrollees as 

according to CMS officials, the FFE does not collect income information for individuals 

who do not request financial assistance.

32Issuers offering exchange plans must cover certain categories of benefits at 

standardized levels of coverage, which are categorized by “metal tiers” of bronze, silver, 

gold, or platinum, depending on the portion of health care costs expected to be paid by the 

health plan. In addition to these metal tiers, catastrophic plans are available to certain 

individuals if they are under age 30 or the lowest-cost bronze plan costs more than 8 

percent of their household income.
Page 16 GAO-18-269 Federal Health Insurance Exchange Enrollment

CMS’s data on terminations of enrollee coverage due to nonpayment of 

premiums are not complete and accurate. CMS officials told us that they 

collect some information from issuers on their terminations of enrollee 

coverage for nonpayment of premiums. When issuers terminate policies, 

the inbound transaction files they send to CMS must include, among 

other elements, a revised coverage end date taking the termination into 

account. CMS uploads these data into its centralized FFE enrollment 

system.33 However, while the issuers may also include codes that 

designate the reasons for the terminations, there is no requirement for 

them to consistently do so. Data on termination codes may therefore not 

be consistently reported by issuers. CMS officials told us that data on 

reasons for termination are not tracked because they are not critical to 

ensure the accuracy of APTC payments—which is the main function of 

the reconciliation process. Officials stated that key essential variables that 

CMS does track are whether coverage is effectuated (that is, whether the 

first premium payment has been made), whether the enrollee is eligible 

for APTC payments, and whether coverage was terminated.

In addition, when issuers do report termination reason codes, these data 

are not always accurate. Specifically, CMS told us that, historically, 

issuers may have incorrectly used the nonpayment termination code for 

other types of terminations, and two issuers we interviewed 

acknowledged having done so. We compared data on terminations for 

nonpayment from CMS’s centralized enrollment system with data we 

obtained from three issuers for a small selection of enrollees.34 We found 

that for one large issuer operating in multiple states, the CMS data 

indicated that coverage for 18 of the 26 enrollees that we examined had 

been terminated for nonpayment of premiums, while the issuer data 

indicated that coverage had been terminated for other reasons, in most 

cases because it had expired at the end of the year. The issuer indicated 

 33This revised coverage end date must take into account grace periods, as appropriate. 

For APTC recipients, CMS regulations specify that the effective date for termination of 

coverage is the last day of the first month of the 3-month grace period. 45 C.F.R. § 

155.430(d)(4) (2016). In other words, if an APTC recipient pays through March and then 

stops paying premiums, the enrollee would receive coverage for the 3-month grace period 

through June 30th. However, if no premiums are paid after that grace period, the enrollee 

would be retroactively terminated with a coverage end date of April 30th and be 

responsible for any medical costs incurred after that date.

34We obtained data on a selection of between 25 and 30 enrollees each from Aetna, 

Anthem, and Health Care Service Corporation.

CMS Lacks Complete 

and Transparent Data 

on Terminations of 

Enrollee Coverage for 

Nonpayment of 

Premiums
Page 17 GAO-18-269 Federal Health Insurance Exchange Enrollment

that it likely reported these year-end terminations to CMS incorrectly as 

terminations for nonpayment of premiums.35

CMS has recently taken actions that may improve the reliability of data on 

terminations for nonpayment, but these actions do not ensure the data 

are consistently reported and recorded by CMS. Specifically, in July 2017, 

CMS indicated that it would add new codes to the transaction files for 

issuers to use to help prevent inaccurate reporting of the nonpayment 

termination code. CMS told us that it expects issuers to begin using the 

new codes in 2018. CMS’s data on terminations for nonpayment therefore 

may be more reliable beginning in 2018. However, CMS has not required 

issuers to report the termination reasons in the transaction files because, 

according to CMS officials, these data are not essential to tracking the 

accuracy of APTC payments. The agency also does not have plans in the 

near future to use the data in tracking trends in enrollment and 

termination of enrollee coverage in the FFE to assess the overall stability 

of the exchange.36

Further, CMS does not have a transparent, systematic process for issuers 

to ensure that data on terminations they initiate due to nonpayment are 

complete and accurate in the CMS system. Issuers we interviewed told us 

that they are unable to ascertain whether CMS is correctly updating the 

FFE enrollment system with the termination reason codes issuers provide 

when policies are terminated. While issuers can determine from the 

monthly reconciliation files whether CMS has updated certain issuer data 

for enrollees whose coverage was terminated (for example, the revised 

coverage end date), the files do not capture data on reasons for 

termination. Therefore, issuers are unable to determine if the CMS FFE 

data on termination reason codes matches theirs and make corrections 

where necessary.37 Some issuers told us they had requested that CMS 

add a variable to capture data on termination reasons in the monthly 

reconciliation files sent to issuers. CMS officials stated that the agency is 

in the initial stages of exploring whether this would be feasible for CMS 

 35For the remaining two issuers, the data from CMS generally matched the issuers’ data.

36In November 2017, officials told us that CMS is exploring whether to require issuers to 

report termination reasons in the transaction files, but these discussions are in the very 

early stages and no decisions have been made yet. 

37While issuers can send updated enrollee information to CMS through another 

transaction file, there is still no mechanism for issuers and CMS to systematically verify 

the accuracy of data on reasons for terminations. 
Page 18 GAO-18-269 Federal Health Insurance Exchange Enrollment

and issuers, but that it will require significant resources and time to 

develop.

Although CMS’s recent changes may improve its data, they do not ensure 

the agency will have complete and transparent data on terminations for 

nonpayment of premiums. According to federal internal control standards, 

federal agencies should obtain and use relevant, reliable data to achieve 

their objectives.38 Without complete and accurate data, CMS may be 

allowing enrollees who lost exchange coverage for nonpayment of 

premiums to re-enroll under SEPs although, under federal regulations, 

these individuals are ineligible to do so.39 Issuers reported that this had 

occurred.40 CMS officials told us that the agency is exploring options to 

have its system automatically prevent certain enrollees with prior 

terminations for nonpayment from enrolling in coverage under an SEP for 

loss of existing coverage, but noted that this functionality would depend 

on receiving reliable data on terminations for nonpayment from issuers.41

Further, without reliable data, CMS may not be able to assess the effects 

of its April 2017 policy allowing issuers to apply enrollees’ new premium 

payments toward unpaid premiums over the past 12 months. This is 

because the agency lacks the complete and accurate data that would be 

 38See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.

39Under CMS’s regulations, individuals may not enroll under an SEP for loss of minimum 

essential coverage if they lost their coverage due to nonpayment of premiums. However, it 

is possible that individuals who lost coverage due to nonpayment of premiums and later 

re-enrolled in exchange coverage via this type of SEP had lost other minimum essential 

coverage, such as Medicaid, in between. 

40Issuers were not able to provide us data on the extent to which this had occurred. 

According to CMS, issuers lack complete data available on circumstances that could 

lawfully allow such a consumer to re-enroll under a SEP, such as loss of Medicaid and 

employer sponsored insurance.

41CMS noted that in the absence of such a system, the agency is now allowing issuers (or 

issuers in the same control group) to refuse to effectuate new coverage in cases of 

enrollees who have a record of termination due to nonpayment of premiums unless the 

individual pays the past due premiums. See 82 Fed. Reg. 18346, 18362-63 (April 18, 

2017). However, this change may still not ensure proper use of SEPs. Specifically, issuers 

lack complete data on CMS’s eligibility decisions. In addition, one issuer told us that their 

systems may not be able to identify enrollees whose coverage they had terminated for 

nonpayment of premiums because, once the enrollee’s coverage was terminated and the 

balance due written off, the enrollee’s records were no longer retained.
Page 19 GAO-18-269 Federal Health Insurance Exchange Enrollment

necessary to ensure that issuers are correctly identifying enrollees 

terminated for nonpayment.

In its role as administrator of the FFE, it is important for CMS to assess 

the overall stability of the exchange by, among other things, tracking 

trends in enrollment and termination of enrollee coverage and addressing 

issuers’ concerns, where appropriate, to ensure their continued 

participation in the exchange. Issuers have raised concerns that the SEP 

regulations potentially allow individuals to enroll in coverage despite 

having their coverage terminated for nonpayment of premiums. However, 

CMS does not have the data needed to determine the extent of these 

problems. While CMS has made some efforts to improve the accuracy of 

the agency’s data on terminations for nonpayment, it has not indicated 

whether the agency will require issuers to consistently and accurately 

report these data. Moreover, CMS has no way to ensure the reliability and 

transparency of the data, because the existing process—the exchange of 

monthly reconciliation files between CMS and issuers—does not have a 

place to capture these data. CMS could capitalize on this existing 

process, already familiar to issuers, by adding a variable that captures 

data on termination reasons to the monthly reconciliation file and tracking 

its accuracy. By taking this step, in addition to requiring issuers to report 

these data, CMS could help ensure it has reliable and transparent data on 

terminations of enrollee coverage for nonpayment of premiums, and it 

could use these data to assess the effects of CMS policies and the overall 

stability of the exchange.

We are making the following two recommendations to CMS:

• The Administrator of CMS should ensure that CMS has complete data 

on terminations of enrollee coverage for nonpayment of premiums by 

requiring issuers to report these data. (Recommendation 1)

• The Administrator of CMS should provide a transparent process for 

issuers and CMS to systematically reconcile discrepancies in their 

data on terminations of enrollee coverage for nonpayment of 

premiums. (Recommendation 2)

We provided a draft of this report to HHS. HHS provided written 

comments, which are reprinted in appendix III. HHS concurred with our 

first recommendation to require issuers to report data on terminations of 

enrollee coverage for nonpayment of premiums. HHS noted that it 

Conclusions

Recommendations

Agency Comments 

and Our Evaluation 
Page 20 GAO-18-269 Federal Health Insurance Exchange Enrollment

currently collects information on termination reasons on enrollment 

transactions with issuers, and that it would review the requirements for 

collection of these data to identify possible improvements. HHS also 

concurred with our second recommendation to ensure a transparent 

process for issuers and CMS to systematically reconcile discrepancies in 

their data on terminations of enrollee coverage for nonpayment of 

premiums. HHS stated that it would consider how to incorporate 

reconciliation of these data into its existing monthly data reconciliation 

process with issuers, balancing issuer and agency burdens against the 

benefits of doing so. 

As agreed with your office, unless you publically announce the contents 

of the report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to the 

Secretary of Health and Human Services and other interested parties. In 

addition, the report is available at no charge on the GAO website at 

http://www.gao.gov. 

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made major contributions to this report 

are listed in appendix IV.

John E. Dicken

Director, Health Care
Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015

Page 21 GAO-18-269 Federal Health Insurance Exchange Enrollment

Table 1 provides information on demographic characteristics for federally 

facilitated exchange (FFE) enrollees that maintained continuous coverage 

throughout 2015—defined as beginning coverage by March 1, 2015, and 

maintaining it without any gaps through December 31, 2015—and for all 

other 2015 FFE enrollees. Table 2 provides information on the 

characteristics of these enrollees’ coverage. Table 3 provides the extent 

to which enrollees maintained continuous coverage throughout 2015 by 

their state of residence.

Table 1: Demographic Characteristics of Continuously Covered, and All Other, 

Federally Facilitated Exchange Enrollees, 2015

Characteristic Enrollees who maintained 

continuous coverage 

throughout 2015 (%)

All other 

enrollees (%)

Age as of December 

31, 2015

0-17 years 8 11

18-24 8 10

25-34 15◆ 21◆

35-44 15 16

45-54 22 19

55+ 32◆ 23◆

Gender Female 55 55

Male 45 45

Number of family 

members on policya 1 67◆ 74◆

2+ 33◆ 26◆

Reported household 

income as a 

percentage of the 

federal poverty levela,b

<=100% 1 1

101-150 38 39

151-200 24 22

201-250 12 11

251-300 7 6

301-350 4 3

351-400 2 2

Unknown 12 16

Legend: ◆ = difference of 5 or more percentage points between enrollees who maintained 

continuous coverage throughout 2015 and all other enrollees.

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Of the 9.2 million enrollees, 4.9 million maintained continuous coverage 

throughout the year, which we defined as coverage that began by March 1, 2015, and ended on 

December 31, 2015. The remaining 4.3 million enrollees did not maintain continuous coverage 

throughout the year, and included about 264,000 enrollees with gaps in coverage—that is, enrollees 

who dropped and then resumed coverage through the federally facilitated exchange in 2015 with a 

Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015
Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015

Page 22 GAO-18-269 Federal Health Insurance Exchange Enrollment

gap of at least one day in between. Where enrollees had multiple records, we used information from 

their first record to examine their characteristics.

a

For our analyses of number of family members and reported household income, where multiple 

family members were included on a policy, we used data from the principal policy holder’s record only 

and excluded the other family members from analysis.

b

These data reflect CMS’s calculation of enrollees’ adjusted federal poverty level using the 2014 

poverty guidelines published by the Department of Health and Human Services. In 2014, the federal 

poverty level for a family of 4 in the 48 contiguous states and the District of Columbia was $23,850. 

The “unknown” category consists of enrollees who were not eligible for advance premium tax credits. 

According to CMS officials, the federally facilitated exchange does not collect income information for 

individuals who do not request financial assistance.

Table 2: Coverage Characteristics for Continuously Covered, and All Other, 

Federally Facilitated Exchange Enrollees, 2015

Characteristic Enrollees who maintained 

continuous coverage 

throughout 2015 (%)

All other 

enrollees (%)

Enrollment perioda,b Open enrollment 97◆ 66◆

Special enrollment 2◆ 32◆

Reason for special 

enrollmenta Loss of minimum essential coverage

50◆ 56◆

Attesting to denial of 

Medicaid eligibility

35◆ 23◆

Change in eligibility 

for premium tax 

credits or costsharing reductions

6 4

Moved to new 

service area

3 3

Adoption or baby 

born in household

2 2

Otherc 5◆ 12◆

Number of plans 

held during the year

1 85 86

2+ 15 14

Number of issuers 

from which plans 

were held

1 96 96

2+ 4 4

Benefit level of 

selected plana Catastrophic <1 1

Bronze 19 21

Silver 70 69

Gold 7 7

Platinum 3 3

Eligibility for 

advance premium 

tax creditsa

Eligible 91 88

Ineligible 9 12
Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015

Page 23 GAO-18-269 Federal Health Insurance Exchange Enrollment

Characteristic Enrollees who maintained 

continuous coverage 

throughout 2015 (%)

All other 

enrollees (%)

Eligibility for costsharing reductionsa Eligible 75 74

Ineligible 25 26

Monthly premium 

after advance 

premium tax 

creditsa,d

<$50 27 29

50-75 10 10

76-100 8 8

101-150 13 13

151-200 10 10

>200 33 29

Re-enrollment in 

exchange coverage 

for 2016e

Re-enrolled 83◆ 38◆

Did not re-enroll 17◆ 62◆

Legend: ◆ = difference of 5 or more percentage points between enrollees who maintained continuous 

coverage throughout 2015 and all other enrollees.

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Of the 9.2 million enrollees, 4.9 million maintained continuous coverage 

throughout the year, which we defined as coverage that began by March 1, 2015, and ended on 

December 31, 2015. The remaining 4.3 million enrollees did not maintain continuous coverage 

throughout the year, and included about 264,000 enrollees with gaps in coverage—that is, enrollees 

who dropped and then resumed coverage through the federally facilitated exchange in 2015 with a 

gap of at least one day in between.

a

For these analyses, where enrollees had multiple records, we used information from their first record 

to examine their characteristics.

b

We considered any enrollee who enrolled in 2015 exchange coverage by February 22, 2015, to have 

enrolled during the open enrollment period, and any enrollee who enrolled later in the year and had a 

special enrollment reason specified on their record to have enrolled via a special enrollment period. 

Percentages in this category do not sum to 100 because according to CMS officials, the enrollment 

period for 1 percent of 2015 exchange enrollees could not be classified due to data anomalies.

c

The “other” category includes special enrollment granted due to circumstances such as marriage, 

owing a tax penalty for not having health coverage in 2014, or other exceptional circumstances.

d

For our analysis of premiums, where multiple family members were included on a policy, we used 

data from the principal policy holder’s record only, and excluded the other family members from 

analysis. We calculated premium amounts at the policy level; where multiple family members were on 

a policy, per-enrollee costs would be lower.

e

According to CMS officials, data for the latter half of 2016 were not available from CMS at the time of

our review. We therefore examined whether individuals had re-enrolled in exchange coverage for 

2016 as of June 30, 2016.
Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015

Page 24 GAO-18-269 Federal Health Insurance Exchange Enrollment

Table 3: Proportion of Federally Facilitated Exchange Enrollees Who Maintained 

Continuous Coverage throughout 2015, by State 

State Enrollees who maintained continuous 

coverage throughout 2015 (%)

Maine 65

Montana 63

South Dakota 61

Alaska 59

North Dakota 59

Nebraska 58

New Hampshire 58

Virginia 58

West Virginia 58

Oregon 57

Wisconsin 57

Arkansas 56

Delaware 56

Indiana 56

Michigan 56

Missouri 56

Kansas 56

Alabama 55

New Mexico 55

North Carolina 55

Pennsylvania 55

Utah 55

Illinois 54

Louisiana 54

Ohio 54

South Carolina 54

Arizona 53

Wyoming 53

New Jersey 52

Oklahoma 52

Tennessee 52

Florida 51

Georgia 51

Iowa 51
Appendix I: Demographic and Coverage 

Characteristics of Federally Facilitated 

Exchange Enrollees, 2015

Page 25 GAO-18-269 Federal Health Insurance Exchange Enrollment

State Enrollees who maintained continuous 

coverage throughout 2015 (%)

Mississippi 49

Nevada 49

Texas 48

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Of the 9.2 million enrollees, 4.9 million maintained continuous coverage 

throughout the year, which we defined as coverage that began by March 1, 2015, and ended on 

December 31, 2015. The remaining 4.3 million enrollees did not maintain continuous coverage 

throughout the year, and included about 264,000 enrollees with gaps in coverage—that is, enrollees 

who dropped and then resumed coverage through the federally facilitated exchange in 2015 with a 

gap of at least one day in between. Where enrollees had multiple records, we used information from 

their first record to determine their state of residence.
Appendix II: Average Length of Coverage for 

Federally Facilitated Exchange Enrollees, 2015

Page 26 GAO-18-269 Federal Health Insurance Exchange Enrollment

Table 4 provides information on average length of coverage for all 9.2 

million federally facilitated exchange enrollees in 2015 by various 

demographic characteristics. Table 5 provides information on average 

length of coverage for these enrollees by characteristics of the enrollees’ 

coverage. Table 6 provides information on average length of coverage for 

enrollees by their state of residence.

Table 4: Average Length of Coverage for Federally Facilitated Exchange Enrollees 

by Demographic Characteristics, 2015

Characteristic Average length of 

coverage (in months) 

Age as of December 31, 2015 0-17 years 7.9

18-24 8.1

25-34 7.8

35-44 8.3

45-54 8.7

55+ 9.2

Gender Female 8.5

Male 8.4

Number of family members on 

policya 1 8.2

2+ 8.9

Reported household income as a 

percentage of the federal poverty 

levela, b

<=100% 8.0

101-150 8.3

151-200 8.6

201-250 8.7

251-300 8.8

301-350 8.9

351-400 8.9

Unknown 7.8

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Since our focus was the length of time for which enrollees remained enrolled 

in exchange coverage, we excluded the approximately 264,000 enrollees (3 percent) that dropped 

and then resumed exchange coverage during the year from our analysis. Where enrollees had 

multiple records, we used information from enrollees’ first record in 2015 to determine their 

characteristics. Our analysis of average length of coverage assumes a month to be 30.4 days long.

a

For our analyses of number of family members and reported household income, where multiple 

family members were included on a policy, we used data from the principal policy holder’s record 

only, and excluded the other family members from analysis.

b

These data reflect CMS’s calculation of enrollees’ adjusted federal poverty level using the 2014 

poverty guidelines published by the Department of Health and Human Services. In 2014, the federal 

poverty level for a family of 4 in the 48 contiguous states and the District of Columbia was $23,850. 

Appendix II: Average Length of Coverage for 

Federally Facilitated Exchange Enrollees, 

2015
Appendix II: Average Length of Coverage for 

Federally Facilitated Exchange Enrollees, 2015

Page 27 GAO-18-269 Federal Health Insurance Exchange Enrollment

The “unknown” category consists of enrollees who were not eligible for advance premium tax credits. 

According to CMS officials, the federally facilitated exchange does not collect income information for 

individuals who do not request financial assistance.

Table 5: Average Length of Coverage for Federally Facilitated Exchange Enrollees 

by Coverage Characteristics, 2015

Characteristic Average length of 

coverage (in months)

Enrollment perioda,b Open enrollment 9.1

Special enrollment 5.2

Reason for special 

enrollmenta Loss of minimum essential coverage 6.9

Attesting to denial of Medicaid eligibility 8.0

Change in eligibility for premium tax 

credits or cost-sharing reductions

7.7

Moved to new service area 6.5

Adoption or baby born in household 7.2

Otherc 6.4

Number of plans 

held during the year 

1 8.3

2+ 9.8

Number of issuers 

from which plans 

were held 

1 8.4

2+ 10.4

Benefit level of 

selected plana Catastrophic 6.7

Bronze 8.2

Silver 8.6

Gold 8.8

Platinum 8.5

Eligibility for advance 

premium tax creditsa Eligible 8.6

Ineligible 7.8

Eligibility for costsharing reductionsa Eligible 8.5

Ineligible 8.4

Monthly premium 

after advance 

premium tax 

creditsa,d

<$50 8.1

50-75 8.3

76-100 8.4

101-150 8.4

151-200 8.4

>200 8.8

Re-enrollment in 

exchange coverage 

for 2016e

Re-enrolled 9.9

Did not re-enroll 6.2

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269
Appendix II: Average Length of Coverage for 

Federally Facilitated Exchange Enrollees, 2015

Page 28 GAO-18-269 Federal Health Insurance Exchange Enrollment

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Since our focus was the length of time for which enrollees remained enrolled 

in exchange coverage, we excluded the approximately 264,000 enrollees (3 percent) that dropped 

and then resumed exchange coverage during the year from our analysis. Our analysis of average 

length of coverage assumes a month to be 30.4 days long.

a

For these analyses, where enrollees had multiple records, we used information from their first record 

to examine their characteristics.

b

We considered any enrollee who enrolled in 2015 exchange coverage by February 22, 2015, to have 

enrolled during the open enrollment period, and any enrollee who enrolled later in the year and had 

special enrollment reason code on their record to have enrolled via a special enrollment period.

c

The “other” category includes special enrollment granted due to circumstances such as marriage, 

owing a tax penalty for not having health coverage in 2014, or other exceptional circumstances.

d

For our analysis of premiums, where multiple family members were included on a policy, we used 

data from the principal policy holder’s record only, and excluded the other family members from 

analysis. We calculated premium amounts at the policy level; where multiple family members were on 

a policy, per-enrollee costs would be lower.

e

According to CMS officials, data for the latter half of 2016 were not available when we requested 

data from CMS. We therefore examined whether individuals had re-enrolled in exchange coverage for 

2016 as of June 30, 2016.

Table 6: Average Length of Coverage for Federally Facilitated Exchange Enrollees 

by State, 2015

State Average length of coverage (in months)

Maine 9.4

Montana 9.3

South Dakota 9.2

Alaska 9.1

North Dakota 9.1

New Hampshire 9.0

Oregon 9.0

Virginia 8.9

Wisconsin 8.9

Indiana 8.8

Nebraska 8.8

New Mexico 8.8

West Virginia 8.8

Alabama 8.7

Arkansas 8.7

Delaware 8.7

Kansas 8.7

Michigan 8.7

Missouri 8.7

Utah 8.7
Appendix II: Average Length of Coverage for 

Federally Facilitated Exchange Enrollees, 2015

Page 29 GAO-18-269 Federal Health Insurance Exchange Enrollment

State Average length of coverage (in months)

Illinois 8.6

North Carolina 8.6

Pennsylvania 8.6

South Carolina 8.6

Arizona 8.5

Ohio 8.5

Tennessee 8.5

Wyoming 8.5

Louisiana 8.4

New Jersey 8.4

Oklahoma 8.4

Florida 8.3

Georgia 8.3

Iowa 8.3

Nevada 8.2

Texas 8.1

Mississippi 8.0

Source: GAO analysis of data from the Centers for Medicare & Medicaid Services. | GAO-18-269

Notes: There were 9.2 million federally facilitated exchange enrollees in coverage year 2015, 

excluding dental coverage and the 25,599 individuals who died in 2015, per data from the Social 

Security Administration. Since our focus was the length of time for which enrollees remained enrolled 

in exchange coverage, we excluded the approximately 264,000 enrollees (3 percent) that dropped 

and then resumed exchange coverage during the year from our analysis. Where enrollees had 

multiple records, we used information from enrollees’ first record in 2015 to determine their state of 

residence. Our analysis of average length of coverage assumes a month to be 30.4 days long.
Appendix III: Comments from the Department 

of Health and Human Services

Page 30 GAO-18-269 Federal Health Insurance Exchange Enrollment

Appendix III: Comments from the 

Department of Health and Human Services
Appendix III: Comments from the Department 

of Health and Human Services

Page 31 GAO-18-269 Federal Health Insurance Exchange Enrollment
Appendix III: Comments from the Department 

of Health and Human Services

Page 32 GAO-18-269 Federal Health Insurance Exchange Enrollment
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 33 GAO-18-269 Federal Health Insurance Exchange Enrollment

John Dicken, (202) 512-7114 or dickenj@gao.gov

In addition to the contact named above, William Hadley (Assistant 

Director), Iola D’Souza (Analyst in Charge), Richard Lipinski, Peter MannKing, and Priyanka Sethi Bansal made key contributions to this report. 

Also contributing were Muriel Brown, Laurie Pachter, and Emily Wilson.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101013)
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