Patient Protection and Affordable Care Act: Most Enrollees Reported Satisfaction with Their Health Plans, Although Some Concerns Exist
Published: 2016-09-12T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Patient Protection and Affordable Care Act (PPACA), enacted in 2010, included provisions that were intended to make health insurance more available and affordable for individuals seeking coverage, including the establishment of health insurance exchanges. Health insurance was made available to individuals through the exchanges beginning in 2014. While PPACA contributed to an overall expansion in health insurance coverage, experts and consumer advocates have raised concerns about enrollees' experiences with QHPs, including access to providers and affordability of care.
PPACA includes a provision for GAO to conduct an examination of exchange activities and QHP enrollees. This report describes (1) what is known about enrollee experiences with QHPs obtained through the exchanges during the first years of exchange operation, and (2) how CMS and selected states have monitored the post-enrollment experiences of those who obtained their QHPs through the exchanges. GAO examined federal and state laws, regulations, and reports, and conducted a literature review to identify original research on enrollees' experiences with QHPs obtained through the exchanges. GAO interviewed officials from CMS and five selected states—Colorado, Indiana, Montana, North Carolina, and Vermont—that varied in geography and whether the state or CMS operated the exchange on which QHPs were offered, as well as officials from stakeholder groups and consumer assisters.
section_title: What GAO Found
paragraphs: Available survey data show that most enrollees who obtained their coverage through the health insurance exchanges were satisfied overall with their qualified health plans (QHP) during the first few years that exchanges operated, according to five national surveys of QHP enrollees that GAO identified through its literature review. Specifically, most QHP enrollees who obtained their coverage through the exchanges reported overall satisfaction with their plans in 2014 through 2016, according to three national surveys. The surveys reported that QHP enrollees' satisfaction with their plans was either somewhat lower than or was similar to that of those enrolled in employer-sponsored health insurance in 2015 and 2016. To varying degrees, QHP enrollees expressed satisfaction with specific aspects of their plan, including their coverage and choice of providers, and plan affordability. Stakeholders—including experts, state departments of insurance, and others GAO interviewed—and literature GAO reviewed also revealed some concerns about QHP enrollee experiences. Some enrollees found it too expensive to pay for their out-of-pocket expenses before reaching their deductibles and have reported concerns about affording care or have been deterred from seeking care, according to experts. Some enrollees have faced difficulties understanding their QHP's coverage terminology and others have faced problems accessing care after enrollment, according to stakeholders and literature reviewed. These issues have also been identified in literature as longstanding concerns of the private health insurance market.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), and selected states GAO reviewed have monitored enrollees' post-enrollment experiences by reviewing information reported by consumers and consumer assisters. For example, CMS uses information collected from enrollees through its Marketplace Call Center—where exchange enrollees may call to request agency assistance in resolving concerns. CMS officials said that they use this information to identify trends in enrollees' post-enrollment experiences and ensure that enrollee concerns are resolved in a timely manner. They began using it in 2016 to identify issuers for compliance reviews. Similarly, officials from the five selected states' departments of insurance reported tracking consumer complaints by issuer and working to resolve all reported issues. CMS developed a survey that was administered to a sample of QHP enrollees nationwide in 2015 and 2016, to gather information about their experiences with their plans. According to CMS officials, the agency expects to use results of its 2017 and future surveys to inform its monitoring of issuers. In addition, QHP enrollees in Vermont were surveyed with respect to their satisfaction in 2015; state officials reported using the results to inform their prioritization of work. CMS and selected states also reported monitoring enrollee experiences with information received from consumer assisters—including navigators—who interact directly with QHP enrollees. CMS officials told GAO that they have used information received from federally funded navigators to troubleshoot enrollee problems, clarify policies, or develop additional training or materials for dissemination.
HHS provided technical comments on a draft of this report, which were incorporated as appropriate.

section_title: Letter
paragraphs: The Patient Protection and Affordable Care Act (PPACA), enacted in  2010, included provisions that were intended to make health insurance  more available and affordable for individuals seeking coverage. Among  these provisions, PPACA required the establishment of health insurance  exchanges—marketplaces where eligible individuals may compare and  select among qualified health plans (QHP) offered by participating private  issuers. PPACA directed each state to establish an exchange itself— referred to as a state-based exchange (SBE)—or cede the responsibility  to the Department of Health and Human Services (HHS) to establish the  exchange—referred to as a federally facilitated exchange (FFE). Health  insurance was made available through the exchanges beginning January  1, 2014. HHS’s Centers for Medicare & Medicaid Services (CMS) and  states each play a role in overseeing the exchanges, including the  oversight of QHPs. For example, CMS has direct oversight  responsibilities for all exchanges, as CMS is responsible for certifying  SBEs for operation and also directly operates the FFE, including by  ensuring plan and issuer compliance with exchange requirements. In  addition, state departments of insurance retain responsibility for  overseeing health insurance plans, including QHPs, sold in their state.
We previously reported that federal subsidies available through PPACA  for purchasing a QHP likely contributed to an expansion of health  insurance coverage. However, experts and consumer advocates have  raised questions about enrollees’ experiences with QHPs, including  access to providers and affordability of care. PPACA includes a provision  for us to conduct an examination of exchange activities, including the  experiences of enrollees in QHPs obtained through the exchanges. In  this report, we describe:  1.  what is known about the experiences of enrollees in QHPs obtained  through the exchanges during the first years of exchange operation;  and  2.  how CMS and selected states have monitored the post-enrollment  experience of those who obtained their QHPs through the exchanges.
To describe what is known about the experiences of enrollees in QHPs  obtained through the exchanges during the first years of exchange  operation, we performed a search of research databases to identify any  literature published from January 1, 2014, through April 30, 2016, that  reported original research on QHP enrollees’ overall satisfaction,  perceptions of affordability, and experience accessing care. Through this  process, we identified and reviewed the results of five national surveys of  QHP enrollees who obtained their coverage through the exchanges; the  surveys were administered between 2014 and 2016. To assess the  reliability of the data presented from these surveys, we interviewed or  corresponded with the authors of all of the survey reports, reviewed  supporting documentation to understand what the surveys measured, and  we examined the data for apparent errors. Although these surveys had  relatively low response rates, all reported that their results are nationally  generalizable within certain margins of sampling error. In addition, the  surveys each reported similar results with respect to enrollee  experiences. Thus, we found the data to be sufficiently reliable for our  purposes. (Appendix I provides more detailed information about our  literature review and the five national surveys.) We also reviewed journal  articles, working papers, and government publications, that presented  original research on QHP enrollees’ experiences with their plans after  their enrollment, including those reporting on enrollee cost-sharing and  provider network adequacy that we identified through our literature  review. We interviewed officials from CMS and five states—Colorado,  Indiana, Montana, North Carolina, Vermont—about their knowledge of  QHP enrollees’ experiences. We selected the five states to obtain  diversity in geography as well as exchange type. Colorado and Vermont  each administered an SBE, and Indiana, Montana, and North Carolina  used the FFE, for the 2014 through 2016 plan years. We interviewed  officials from each state’s department of insurance and from Colorado’s  and Vermont’s exchange offices, as well as assisters—federal or state- funded individuals who, among other things, help QHP enrollees with  addressing post-enrollment issues—from each of the five selected  states. We also interviewed experts and industry officials, including those  from the National Association of Insurance Commissioners, to obtain a  broad perspective about enrollee experiences with QHPs.
To describe how CMS and selected states have monitored the post- enrollment experience of those who obtained their QHPs through the  exchanges, we reviewed relevant federal and state documents, including  laws, regulations, guidance, and reports, and examined CMS data on the  number and type of exchange-related issues that consumers raised to the  agency in 2014 and 2015. To assess the reliability of these data, we  interviewed CMS officials and reviewed supporting documentation. We  found the data to be sufficiently reliable for our purposes. We also  interviewed knowledgeable officials from CMS and the five selected  states, including state department of insurance officials, exchange  officials, and assisters.
We conducted this performance audit from August 2015 to September  2016 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.
subsections: section_title: Background
subsections: section_title: CMS and State Oversight of QHPs
paragraphs: CMS and states share responsibilities for overseeing QHPs offered  through the exchanges. Specifically, CMS is responsible for establishing  minimum QHP certification standards that all QHPs must meet in order to  participate in any exchange. Federal regulations require that all  exchanges have procedures to certify QHPs annually to ensure  compliance with federal requirements. To be certified as a QHP, a plan  must meet certain minimum federal requirements, including those related  to, for example, the coverage of certain benefits and limits on cost- sharing. In FFE states, CMS is responsible for overseeing compliance  with these requirements; in states operating SBEs, the states are  responsible for ensuring that plans comply. CMS is responsible for  conducting oversight and monitoring of QHPs offered on the FFE, and  also requires all SBEs to develop an oversight and monitoring program.
In addition to meeting federal exchange-specific requirements, QHP  issuers must also abide by state-specific insurance regulations that apply  to all issuers offering health insurance products, as states are the primary  regulators of health insurance. Specifically, all QHPs, whether offered on  the FFE or SBE, must be offered by a health insurance issuer that is  licensed and in good standing to offer insurance coverage in each state in  which it offers QHPs. As a result, QHP issuers are subject to oversight by  the states in which they offer QHPs. As part of this oversight, state  departments of insurance manage complaint hotlines where enrollees can  notify agencies of concerns related to any health insurance plan sold in  that state, including QHPs offered on the FFE or an SBE.
section_title: Exchange Consumer Assistance Responsibilities
paragraphs: All exchanges are required to carry out certain consumer assistance  functions. Specifically, CMS requires exchanges to operate a toll-free call  center and website to address the needs of consumers and enrollees  requesting assistance and to conduct outreach and educational  activities. For example, CMS operates a Marketplace Call Center to  assist the needs of consumers in states that utilize the FFE. In addition,  all exchanges are required to have a “navigator” program to carry out  public education activities, help consumers select a QHP, and offer QHP  enrollees with assistance after their enrollment, among other things.   CMS awards grants to organizations to serve as navigators for the FFE.  All exchanges may also implement other “assister” programs that perform  many of the same or similar functions as navigators. Navigators and other  assisters are collectively referred to as “assisters.”
section_title: Financial Assistance for QHP Enrollees through the Exchanges
paragraphs: Individuals purchasing coverage through the exchanges may be eligible  to receive financial assistance to offset the cost of such coverage, and,  according to CMS, over three-fourths of QHP enrollees obtain at least  one form of such assistance. Eligibility for financial assistance is based on  income and provided in the form of premium tax credits and cost-sharing  subsidies.
One form of assistance is the premium tax credit, which is generally  available to income-eligible individuals who do not have access to health  insurance that meets certain standards. The credit is designed to reduce  an eligible individual’s cost of purchasing health insurance through the  exchange and can be paid to an enrollee’s issuer in advance to reduce  the enrollee’s monthly premium costs. The amount of the premium tax  credit varies and is designed to provide larger credit amounts to those  with lower incomes. QHP enrollees who qualify for and opt to receive  advance payments of the premium tax credit based on their income and  family size at the time of application must attest that they will file a federal  tax return for the applicable plan year. Such enrollees must reconcile on  their federal tax return the amount of advance payments received based  on their actual reported income and family size for the year. Enrollees  who qualify for premium tax credits may also be eligible to receive cost- sharing reduction assistance to help offset QHP enrollees’ out-of-pocket  expenses, including by lowering their deductibles, coinsurance and co- payments.
section_title: Available Data Show Early QHP Enrollee Satisfaction Despite Some Concerns
subsections: section_title: Available Data Show That Most Early QHP Enrollees Expressed Satisfaction with Their Plans
paragraphs: Available data from the five national surveys we identified through our  literature review show that most QHP enrollees were satisfied overall with  the plans they obtained through the exchanges. QHP enrollees have also  expressed satisfaction, to varying degrees, with specific aspects of their  plans, including their coverage, their choice of providers, and plan  affordability, according to five national surveys we reviewed.
subsections: section_title: Overall Plan Satisfaction
paragraphs: QHP enrollees who obtained their coverage through the exchanges have  reported overall satisfaction with their plans from 2014 through 2016,  according to national surveys that we reviewed. Specifically, 65 percent  or more of QHP enrollees surveyed expressed overall satisfaction with  their plans in 2014 through 2016, according to three national surveys that  asked this question of enrollees. (See table 1.)
The overall satisfaction level of QHP enrollees was somewhat lower than  or similar to those who were enrolled in employer-sponsored health  insurance in 2015 and 2016. Specifically, one national survey reported  that 86 percent of QHP enrollees were satisfied or somewhat satisfied  with their current health plan in 2015, compared to 93 percent of  employer-sponsored health insurance enrollees. The survey did not  specifically report the reason for the difference in satisfaction levels. The  same survey in 2016 reported that overall plan satisfaction among QHP  enrollees was equivalent to those with employer-sponsored health  insurance, although other national surveys that we reviewed reported that  QHP enrollees were, for example, less satisfied with their choice of  providers or less likely to report ease in affording their premiums,  compared to those with employer-sponsored insurance.
Two of the national surveys we reviewed examined QHP re-enrollment,  which can provide additional context for QHP enrollees’ overall  satisfaction with their plans. Specifically, one national survey found that  77 percent of adult QHP enrollees that re-enrolled in the same plan for  2016 reported satisfaction with their QHP. Another national survey of  QHP enrollees reported that, in 2015, most—82 percent—of those re- enrolling selected a plan with the same insurance company and about  half stayed with the same plan. Stakeholders we interviewed and other  literature we reviewed also provided additional context for QHP enrollees’  overall satisfaction with their plans based on QHP re-enrollment and a  stable volume of consumer complaints regarding health insurance. For  example, while many factors, including financial incentives, may affect an  enrollee’s decision to re-enroll in a plan, officials from one exchange  office we interviewed told us that they consider plan re-enrollment as one  important measure of QHP enrollee satisfaction because enrollees have  the capacity to change QHPs annually. In addition, a statewide survey of  Vermont QHP enrollees found that 9 percent of QHP enrollees renewing  their coverage in 2015 switched plans, with 80 percent of renewing QHP  enrollees reporting that their plan fit their needs very or somewhat well.  Although the remaining four selected states in our review had not directly  measured QHP enrollee satisfaction, officials from all of these states’  departments of insurance told us that QHP enrollees in their states have  not reported significant problems that are unique to QHPs. In addition,  department of insurance officials from two of these selected states told us  that the volume of complaints they received for all health plans had not  increased since health insurance became available through the  exchanges in 2014.
section_title: Coverage and Choice of Providers
paragraphs: QHP enrollees who obtained their coverage through the exchanges have  rated their health insurance coverage positively and generally expressed  satisfaction with their choice of providers, according to national surveys  we reviewed. Specifically, two national surveys reported that  approximately 70 percent of QHP enrollees rated their health insurance  coverage as good, very good, or excellent in 2016.
QHP enrollees have also generally reported satisfaction with their choice  of providers, according to four national surveys we reviewed. For  example, one national survey reported that 74 percent of QHP enrollees  noted satisfaction with their choice of primary care doctor in 2016, and a  smaller portion of enrollees—59 percent—noted satisfaction with their  choice of specialists. Two other national surveys reported that more than  75 percent of QHP enrollees surveyed were satisfied with the doctors  included under their plan. The fourth national survey reported levels of  dissatisfaction, stating that 14 percent of QHP enrollees reported  dissatisfaction with their choice of doctors and other providers. (See  table 2.)
In addition to reporting satisfaction with their choice of providers, most  QHP enrollees surveyed had used their health insurance coverage in  2015 or 2016, according to four national surveys that reported this  information. For example, one national survey reported that about two- thirds of QHP enrollees reported using their plans to access care or  purchase medication. Three national surveys found that over half of  QHP enrollees reported having a regular or routine check-up. Another  national survey reported that 62 percent of QHP enrollees who needed to  see a specialist could do so within 2 weeks or less.
section_title: Plan Affordability
paragraphs: Satisfaction with plan affordability among QHP enrollees who obtained  their coverage through the exchanges was lower than for satisfaction with  plans overall and for coverage and access. Nevertheless, about half or  more of QHP enrollees surveyed reported satisfaction with their plan’s  affordability, according to the five national surveys that we reviewed. For  example, two national surveys reported that about half or more of QHP  enrollees found it easy to afford their plan’s premium costs. One  national survey found that 45 percent of QHP enrollees reported high  levels of confidence in their ability to obtain affordable care. Another  national survey reported rates of dissatisfaction, with 25 percent of QHP  enrollees reporting being very or somewhat dissatisfied with the  premiums they paid for their plans. Finally, one national survey reported  that approximately 60 percent of QHP enrollees were satisfied with  various plan costs in 2016, such as annual deductibles and copayment  amounts. (See table 3).
In addition to these five national surveys, other studies from our literature  review reported similar data regarding QHP enrollees’ satisfaction with  plan affordability. Specifically, one narrowly focused study reported that  87 percent of QHP enrollees surveyed found their coverage to be  affordable on the basis of their monthly budget. Another study reported  that many community stakeholders interviewed—including assisters,  provider representatives, and department of insurance officials—stated  that QHP enrollees could obtain care more easily and affordably than  they could prior to the advent of the exchanges.
Despite general satisfaction with plan affordability, one national survey of  enrollees reported in 2016 that their satisfaction with certain plan costs  had declined since 2014. Another national survey reported that price  was a common reason why enrollees were dissatisfied with their QHP in  2015. Enrollee dissatisfaction with premium amounts prompts some to  drop their coverage, according to experts and assisters we interviewed.  Three of the national surveys we reviewed also reported that  dissatisfaction with plan costs is a primary reason why QHP enrollees  switch plans. HHS recently reported that those who switched plans for  2016 generally moved to lower-cost plans.
section_title: Concerns Have Been Noted by Stakeholders and in Research about Some Enrollees’ Ability to Afford and Access Care
paragraphs: Although available data show most QHP enrollees were satisfied overall  with their plans, our interviews with stakeholders—including experts,  assisters, state department of insurance and exchange officials—and our  review of literature, also revealed concerns about some QHP enrollees’  ability to afford and access their care, and understand their QHP, among  other things.
subsections: section_title: Affording Care
paragraphs: Some enrollees have concerns about affording care before reaching their  deductible, according to experts we interviewed and our review of  literature. Specifically, some individuals have reported concerns affording  care, or have been deterred from seeking care, because they found it too  expensive to pay for their out-of-pocket expenses before reaching their  deductibles, according to experts we interviewed. Two national surveys  of QHP enrollees found that over a quarter of them had experienced  financial difficulties paying for their out-of-pocket health care expenses in  the prior year, with some enrollees reporting unmet health care needs  due to cost. One national survey reported that in 2016, 25 percent of  QHP enrollees reported higher-than-expected out-of-pocket costs after  using their coverage.
Cost is a driving factor in QHP enrollees’ selection of a plan. According to  three national surveys of QHP enrollees, premiums, deductibles, and  copayments were the top factors that consumers used when selecting a  QHP in 2015. In addition, an HHS analysis of QHP selection in the FFE  reported that enrollees tended to select QHPs with the lowest premiums  among those offering similar levels of coverage. Indeed, high-deductible  health plans remain popular options among QHP enrollees, potentially  because these plans tend to have lower premiums. One national survey  reported that in 2016, 46 percent of QHP enrollees chose a plan with a  high deductible. While many consumers believe at the time of their  enrollment that their QHP will be affordable, some enrollees become  overwhelmed after seeking care when trying to balance the need to pay  out-of-pocket costs in addition to monthly premiums and other life  expenses, according to experts we interviewed. Two factors that may  contribute to QHP enrollees’ dissatisfaction with plan affordability is that  many QHP enrollees have lower incomes and have been previously  uninsured; as such, these individuals may not have previously had to pay  for their health care expenses or balance the need to pay for them along  with other life expenses.
While some QHP enrollees perceive their premium and cost-sharing  amounts to be unaffordable, most have received federal subsidies that  were designed to help make their coverage more affordable. Specifically,  CMS reported that 84 percent of QHP enrollees were receiving advance  payments of the premium tax credit, and 56 percent of QHP enrollees  were receiving cost-sharing reduction assistance to help offset their out- of-pocket expenses, as of December 2015. According to one national  survey, about 60 percent of QHP enrollees paid either nothing or less  than $125 per month in premiums in 2015 and 2016—amounts reported  as comparable to those for employer-sponsored coverage.
section_title: Accessing Care
paragraphs: Some QHP enrollees who obtained their coverage through the exchanges  have faced problems accessing care after enrollment due to both midyear  changes in QHP provider networks and the unavailability of accurate  information about provider networks and formularies at the time of  enrollment, according to experts we interviewed and our review of  literature. For example, one report noted widespread confusion among  consumers and providers about which providers were included in a plan’s  network. In addition, a 2015 survey of assisters found that half of the  assisters had encountered enrollees who sought help because their  provider was not in-network. A report examining state regulation of  QHPs found that in 2014, only a minority of states enforced rules about  frequency in updating provider directories. Two recent studies of the  accuracy of provider directories for QHPs offered in Maryland and  Washington, D.C. found that about half of the psychiatrists listed in the  provider directories could no longer be reached at the phone numbers  directories listed. Officials from CMS and state departments of  insurance, as well as other stakeholders, also told us that enrollees have  faced challenges verifying their coverage or otherwise communicating  with the issuer before receiving their insurance cards, which can result in  treatment delays.
Concerns have been expressed both by some experts and in literature we  reviewed about QHP enrollees’ ability to obtain or continue care given the  increased prevalence of QHPs with narrow networks. Issuers have  increasingly begun to offer narrow network plans as a mechanism to  lower premiums; these plans offer coverage for services through a  smaller group of physicians or hospitals than the plan has covered in the  past. For example, a narrow network plan may only offer in-network  coverage through one local hospital. One analysis reported that QHPs  offered on the exchanges included 34 percent fewer providers, on  average, than plans offered outside the exchanges. Another report  identified 16 states where at least half of all QHPs offered had narrow  networks. While stakeholders have expressed concerns with these  plans, consumers continue to enroll in them and indicate they are willing  to choose a plan with a narrow network to reduce their premiums. For  example, one national survey of QHP enrollees reported that over forty  percent of those with the option for a narrow network plan in 2016  enrolled in such a plan. Another national survey found that nearly 60  percent of QHP enrollees said in 2015 that they would be willing or  somewhat willing to accept a smaller network of hospitals or doctors in  exchange for lower overall health care payments.
section_title: Understanding QHPs
paragraphs: Some QHP enrollees who obtained their coverage through the exchanges  have faced difficulties understanding how to use their plans, according to  our interviews with stakeholders and our review of literature.  Specifically, about half of nationwide QHP enrollees surveyed in 2015  had a good understanding of their plan benefits and total health coverage  costs at the time of enrollment, according to one national survey. One  factor that may contribute to enrollees’ difficulty in understanding their  plans is that because many of those who have obtained coverage through  the exchanges were previously uninsured, they may be unaccustomed to  health insurance terminology—words such as premiums, coinsurance,  deductibles, and out-of-pocket maximums—as well as health insurance  practices such as navigating plan networks and formularies. For  example, a 2015 survey of assisters reported that about three-quarters of  assisters noted that most or nearly all consumers who shopped for or  enrolled in a QHP needed help understanding basic health insurance  concepts such as deductibles and in-network services. Another study  reported that assisters spent considerable time helping QHP enrollees  understand how to use their plan, including by explaining key insurance  terms, provider networks, the financial risks of using out-of-network care,  and the use of appropriate care settings. For example, some QHP  enrollees who were previously uninsured did not realize that they should  no longer use a hospital emergency room as their primary care location.
In addition to facing difficulties understanding general health insurance  concepts, some QHP enrollees have found it challenging to understand  exchange-specific terminology, according to our review of the literature.  For example, a 2015 survey of Vermont QHP enrollees found that less  than one-third of enrollees fully understood exchange-specific terms, such  as advanced premium tax credit and cost-sharing reduction.
Furthermore, according to experts and assisters we interviewed, some  enrollees also face language barriers, which can compound their difficulty  in understanding how to use their QHP. Some assisters we interviewed  told us that some enrollees take time off from work in order to travel to  their offices for help translating and understanding notices they receive  from CMS and issuers.
section_title: Other Concerns
paragraphs: To varying degrees, QHP enrollees who obtained their coverage through  the exchanges have also faced a range of other challenges related to  their health insurance plans, according to assisters and state department  of insurance and exchange officials we interviewed and literature we  reviewed. For example, some assisters told us about difficulties that  enrollees have faced in updating information with CMS, including  modifying income information and adding family members to plans. An  assister also told us that enrollees have faced difficulties obtaining  information from CMS during the appeals process—for example,  information about the status of appeals in progress, or the rationale for  appeal decisions. In addition, officials from state departments of  insurance, exchange offices, and assisters told us about other state- specific challenges that enrollees have faced. According to Vermont  exchange officials and assisters we interviewed, QHP enrollees in that  state had faced some challenges related to billing. For example, enrollees  had received incorrect premium statements, bills for premiums that were  already paid but not recognized by the system, or incorrect medical bills  for services received, according to assisters in that state. In another  example, state department of insurance officials and assisters in Montana  told us that some individuals in that state had become dually enrolled in  Medicaid and a QHP after the state expanded eligibility for its Medicaid  program in 2016. This dual enrollment is problematic as individuals may  be held liable for repaying certain exchange subsidies received during the  period of duplicate coverage. Further, the federal government could be  paying twice, subsidizing exchange coverage and reimbursing states for  Medicaid spending for those enrolled in both.
section_title: CMS and Selected States Have Monitored Post- Enrollment Experiences by Reviewing Information Reported by Consumers and Assisters
paragraphs: CMS and the five selected states in our review have monitored QHP  enrollees’ post-enrollment experiences by reviewing information reported  by consumers, through call centers and enrollee surveys, as well as by  assisters. CMS and selected states use this information to ensure that  enrollee issues are resolved and to improve educational resources and  post-enrollment assistance for enrollees, among other purposes. In  addition to monitoring QHP enrollee experiences through these methods,  CMS and the selected states conduct activities to monitor QHPs. (See  App. II).
subsections: section_title: Consumer Call Centers
paragraphs: CMS uses information collected from enrollees through its call center to  monitor QHP post-enrollment experiences. QHP enrollees and their  representatives, such as assisters, may call the CMS exchange call  center to request agency assistance in resolving concerns. Using its  casework system, CMS tracks individual issues—referred to as cases— that require action on the part of an issuer, state, or CMS to resolve. In  2014 and 2015, agency officials assigned all cases to one of four broad  categories of concerns—plan and issuer, tax filing, eligibility, or legal and  administrative—as well as to subcategories within each category that  describe the general nature of the issue. Cases related to post- enrollment issues may be included in any of these categories.
To identify trends in cases and to ensure their timely resolution, CMS  officials prepare and examine weekly and monthly reports that include  information on the type and volume of cases received and resolved by  category, among other information. According to our analysis of CMS  exchange casework data, three-quarters of CMS’s casework in 2014 and  2015 was in the plan and issuer category, which includes post-enrollment  concerns such as enrollee access to services or benefits, among other  issues. (See table 4.) Appendix III includes more detailed information  about CMS QHP casework in 2015.
CMS shares relevant casework information with the appropriate agency,  issuer, or state officials for research and timely resolution, depending on  the type of action required, according to CMS officials we interviewed.  For instance, CMS officials told us that cases noting concerns about  issuer compliance are forwarded to CMS’s compliance team for further  investigation. CMS officials told us that they work with individual issuers  to ensure that cases are resolved in a timely manner and the causes of  any casework trends are addressed. For example, CMS has a monthly  call with issuers to discuss casework trends and strategies to improve  consumer experiences, in addition to providing ongoing technical  assistance with specific casework issues, according to CMS officials.
In addition to reviewing casework to resolve individual enrollee concerns,  CMS officials we interviewed reported reviewing casework data relevant  to their oversight responsibilities of issuers. For example, prior to  conducting any issuer compliance reviews, CMS officials told us that they  review relevant casework data, such as complaints, for the issuer. In  addition, CMS officials told us that, as of 2016, they have begun using  casework information to identify issuers for compliance review, including  by reviewing any outliers in volume or timely resolution of cases.
The five selected states included in our review have also used information  submitted directly by enrollees through state call centers or online  complaint systems to monitor enrollee experiences in both FFE and SBE  states. Officials from all five of the selected states’ departments of  insurance we interviewed reported tracking consumer complaints at the  issuer level and working to resolve reported issues. Four of the selected  states’ departments of insurance did not have any mechanism to track  QHP-related complaints separate from those of other plans, according to  state department of insurance officials we interviewed. One state— Indiana—began tracking QHP-related complaints in 2016 in categories  such as billing, claim delay, and pharmacy benefits. In addition to  monitoring complaints reported directly to them, state department of  insurance officials located in FFE states have access to CMS’s casework  system for all issuers operating in their state. Officials from departments  of insurance in two of the three FFE states included in our review told us  that they routinely monitored casework data in CMS’s system.
section_title: QHP Enrollee Surveys
paragraphs: CMS and the two states operating SBEs included in our review have  surveyed or plan to survey QHP enrollees to monitor their experiences.  Specifically, CMS developed a survey, which was administered to a  sample of QHP enrollees nationwide, including those in FFE and SBE  states, about their experiences with their plans in 2015 and 2016. CMS  designed the survey to capture accurate and reliable information from  consumers about their experiences with the health care and services they  had received through their QHP and to allow for effective oversight,  among other purposes. The survey, which was beta-tested in 2015, was  administered to enrollees of QHPs with more than 500 enrollees. It  included a core set of questions for enrollees on key areas of care and  service, including overall rating of their QHP, the availability of information  about their health plan and costs of care, how well they were able to get  needed care, and the accessibility of information in a needed language or  format. CMS officials told us that they ultimately expect the results of their  2017 and future surveys to, among other things, inform the agency’s  monitoring of enrollee post-enrollment experiences, as well as their  monitoring of issuers beginning in 2017. For example, CMS officials told  us that they expect to use survey results to identify issues in enrollee  overall satisfaction and access to care. CMS officials told us that they had  also shared relevant 2015 survey results, and plan to share 2016 results,  with issuers and SBEs to help inform their understanding of enrollee  experiences.
SBEs in two of the five selected states in our review had either already  surveyed statewide QHP enrollees about their post-enrollment  experiences or had plans to do so. Specifically, as mentioned earlier in  this report, Vermont QHP enrollees were surveyed in 2015 to assess their  satisfaction with their QHP. Officials from the state’s exchange office told  us that they used the survey results to inform their prioritization of work  related to improving enrollee experiences, such as developing better  methods to educate enrollees on financial literacy and health insurance  information, and to work with issuers to ensure that consumers with  complaints are using the appropriate channels for filing them. While they  have no plans to repeat the survey, officials from the state’s exchange  office told us that they plan to add questions to another statewide survey  that is conducted every two years or develop a shorter survey as an  attempt to monitor QHP enrollee experiences over time. Officials from  Colorado’s exchange office told us in July 2016 that they were in the  process of surveying statewide QHP enrollees in 2016 about their  experiences with their plans, including those related to post-enrollment.
section_title: Assisters
paragraphs: CMS and states have also monitored enrollee experiences with  information received from assisters. CMS receives some post-enrollment  information from navigators and other assisters on an ongoing basis as it  relates to enrollees in FFE states. For example, federally funded  navigators are required to report the number of post-enrollment meetings  they have held with QHP enrollees on a weekly basis, and, according to  CMS, the agency plans to require such navigators to report more detailed  information related to their post-enrollment work with enrollees. In  addition, post-enrollment issues are occasionally discussed during weekly  meetings that CMS officials hold with navigators to discuss their ongoing  work, according to CMS officials and navigators we interviewed. While the  requirement to report post-enrollment information to CMS is only  applicable to federally funded navigators, agency officials told us that they  occasionally receive some post-enrollment information from other  assisters, or from consumer advocacy groups who work with them, on an  informal basis. For example, CMS officials reported receiving some  information from assisters about low levels of health literacy among QHP  enrollees.
CMS officials told us that they use information they receive from  navigators and other assisters to help them troubleshoot FFE enrollee  problems, clarify policy, and develop additional training or materials for  dissemination. Specifically, CMS circulates weekly newsletters to  federally funded navigator grantees that address current areas of interest  among navigators. Recent topics in these newsletters have included  conducting culturally competent outreach and the appeals process. One  navigator we interviewed told us they found these newsletters helpful  because they explained relevant issues and presented solutions. CMS  officials told us that they have also developed webinars to address post- enrollment issues identified by assisters; recent webinars addressed  topics such as helping consumers after the open enrollment period,  transitioning from a QHP to other coverage, and assisting consumers  during the tax-filing seasons.
The five selected states in our review, including those using the FFE and  operating an SBE, have also gathered some information about enrollees’  post-enrollment experience from assisters, including navigators, operating  in their state, according to state department of insurance officials and  assisters we interviewed. The amount of information that assisters shared  with these selected state officials varied and tended to be informal, as the  selected states’ departments of insurance do not require navigators and  assisters operating in their state to report any information about  consumers’ post-enrollment experiences, according to officials and  assisters we interviewed.
Exchange offices in the two selected states in our study that operated an  SBE, Colorado and Vermont, required their state-funded assisters to  routinely report information about the post-enrollment assistance they  provided, according to officials and assisters, and, officials from the state  exchange offices told us that they use this information to, among other  things, identify and address any problems related to enrollees’  experiences with their QHPs, or identify training needs.
To the extent that assisters report information about consumers’ post- enrollment experiences to state officials in either FFE or SBE states, the  information they provide tends to be about individual issues as they work  with consumers to address them, according to the assisters and officials  from state departments of insurance and exchange offices we  interviewed. However, we found that assisters operating in four of the five  selected states included in our review have also shared information about  trends in QHP enrollee post-enrollment experiences to state department  of insurance and exchange officials. For example, according to an official  at the Montana department of insurance, assisters informed state officials  about QHP enrollees who were found to be dually enrolled in Medicaid  and have worked with state department of insurance and CMS officials to  address the issue. Similarly, assisters operating in North Carolina and  Colorado also told us that they have shared information with their  department of insurance and exchange office, respectively, about trends  in consumers’ experiences, including those related to post-enrollment that  the issuer has the responsibility to resolve.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for comment; HHS provided  technical comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional  committees, 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 staffs 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 key contributions to this report  are listed in Appendix IV.
section_title: Appendix I: Methodology Information for Literature Review and Five National Surveys
paragraphs: To examine what is known about the early experiences of enrollees in  qualified health plans (QHP) obtained through the exchanges, we  conducted a structured search of research databases using various  combinations of relevant search terms including, “Affordable Care Act,”  “qualified health plan,” “marketplace,” and “exchange,” to identify any  literature published from January 1, 2014, through April 30, 2016, that  reported on QHPs obtained through the exchanges. We then reviewed  the abstracts for 643 articles and the full text of 275 of those articles to  determine whether they included information about QHP enrollees’ post- enrollment experiences and otherwise met our inclusion criteria. Our  inclusion criteria included journal articles and government publications, as  well as policy briefs or papers. Based on these steps, we identified 5  nationally representative surveys whose results were published in 14  articles between June 19, 2014, and July 7, 2016, and then summarized  the QHP enrollee experiences on which these articles reported.
To assess the reliability of the data presented in these surveys, we  interviewed or corresponded with the authors of all of the survey reports,  reviewed supporting documentation to understand what the surveys  measured, and we examined the data for apparent errors. Although the  surveys had relatively low response rates, they each reported that their  results are nationally generalizable within certain margins of sampling  error. In addition, the surveys reported similar results with respect to  enrollee experiences. Based on these steps, we found the data to be  sufficiently reliable for our purposes. The key methodological attributes of  the five surveys are presented in table 5.
subsections: section_title: The Commonwealth Fund Affordable Care Act Tracking Survey
paragraphs: The Commonwealth Fund, Americans’ Experiences with ACA  Marketplace Coverage: Affordability and Provider Network Satisfaction,  Findings from the Commonwealth Fund Affordable Care Act Tracking  Survey, February – April 2016 (New York: July 7, 2016).
The Commonwealth Fund, Americans’ Experiences with ACA  Marketplace and Medicaid Coverage: Access to Care and Satisfaction,  Findings from the Commonwealth Fund Affordable Care Act Tracking  Survey, February – April 2016 (New York: May 25, 2016).
The Commonwealth Fund, Are Marketplace Plans Affordable? Consumer  Perspectives from the Commonwealth Fund Affordable Care Act Tracking  Survey, March-May 2015 (New York: Sept. 25, 2015).
The Commonwealth Fund, To Enroll or Not To Enroll? Why Many  Americans Have Gained Insurance Under the Affordable Care Act While  Others Have Not (New York: Sept. 25, 2015).
The Commonwealth Fund, Americans’ Experiences with Marketplace and  Medicaid Coverage, Findings from the Commonwealth Fund Affordable  Care Act Tracking Survey, March-May 2015 (New York: June 12, 2015).
The Commonwealth Fund, Are Americans Finding Affordable Coverage in  the Health Insurance Marketplaces? (New York: Sept. 18, 2014).
The Commonwealth Fund, Gaining Ground: Americans’ Health Insurance  Coverage and Access to Care after the Affordable Care Act’s First Open  Enrollment Period, (New York: July 10, 2014).
section_title: Deloitte Center for Health Solutions Survey of US Health Care Consumers
paragraphs: Deloitte Center for Health Solutions, 2016 Survey of US Health Care  Consumers: A Look at Exchange Consumers. (Washington, D.C.: May  11, 2016).
Deloitte Center for Health Solutions, Public Health Insurance Exchanges:  Opening the Door for a New Generation of Engaged Health Care  Consumers, 2015 Survey of US Health Care Consumers (Washington,  D.C.: Aug. 3, 2015).
section_title: Kaiser Family Foundation Survey of Non-Group Health Insurance Enrollees
paragraphs: Kaiser Family Foundation, Survey of Non-Group Health Insurance  Enrollees, Wave 3 (Menlo Park, CA: May 20, 2016).
Kaiser Family Foundation, Survey of Non-Group Health Insurance  Enrollees, Wave 2 (Menlo Park, CA: May 21, 2015)
Kaiser Family Foundation, Survey of Non-Group Health Insurance  Enrollees (Menlo Park, CA: June 19, 2014).
section_title: PerryUndem Survey of Individuals Who Purchased Health Plans Through the Health Insurance Marketplace
paragraphs: PerryUndem Research/Communication, GMMB, and the Robert Wood  Johnson Foundation, Results From a Survey of Individuals Who  Purchased Health Plans Through the Health Insurance Marketplace  (October 2015).
section_title: Urban Institute Health Reform Monitoring Survey
paragraphs: Urban Institute, Health Reform Monitoring Survey, Health Care Access  and Affordability among Low- and Moderate-Income Insured and  Uninsured Adults under the Affordable Care Act, (Washington, D.C.: April  21, 2016).
section_title: Appendix II: CMS and Selected States’ Oversight of Qualified Health Plans
paragraphs: CMS and the selected states we reviewed conduct oversight of qualified  health plans (QHP) offered on the exchanges to ensure that they comply  with federal standards. This oversight generally includes certifying that  QHPs have met these federal standards before consumers enroll in the  QHP, although CMS also conducts a post-certification review as part of  its oversight to ensure that certified QHPs are ready for enrollees to use  in the plan year. To ensure that issuers are continuing to meet standards  during the plan year, CMS and states also conduct compliance reviews  and other ongoing monitoring activities. CMS and state oversight  activities vary, depending on whether states utilized the federally  facilitated exchange (FFE) or a state-based exchange (SBE). In 2016, 34  states utilized the FFE and 17 states operated an SBE.
subsections: section_title: QHP Certification Reviews
paragraphs: In order for a QHP to be offered on the exchanges, CMS, the SBE, or  state department of insurance officials must first certify that the QHP  meets all relevant federal standards. Specifically, QHP issuers must be  state licensed and meet a range of other standards in order for the plan to  be offered on either the FFE or a SBE. For example, these other  standards include serving a geographic area that is established without  regard to racial, ethnic, language or health status factors and providing  enrollees with access to a sufficient number and type of covered  providers to assure all services will be accessible without unreasonable  delay.
For all QHPs offered on the FFE, CMS reviews plan information and is  responsible for ensuring that the plan meets federal standards prior to the  annual open enrollment period. Issuers submit an application with plan  data to CMS for review, and CMS officials told us they review all  applications for current and new issuers and send information to issuers  with corrections prior to certification. Officials from two selected FFE  states said that they conducted reviews for QHP certifications in parallel  with CMS using the same federal exchange standards and submitted  recommendations for QHP certification to CMS. CMS officials told us that  they examine the information and recommendations submitted by states  and may conduct additional reviews to investigate any concerns that state  officials may have had during their certification review of plans.
CMS also conducts post-certification reviews of QHPs offered on the  FFE. Agency officials told us that these reviews are focused on high  priority and consumer-focused areas to ensure that issuers continue to  meet certification standards and that certified QHPs are ready for  enrollees to use in the plan year. From 2014 to 2016, CMS officials said  they conducted at least one post-certification review for all QHP issuers in  FFE states. For example, to ensure that consumers have up to date and  accurate formulary information specific to their QHP, since 2014 CMS  officials reviewed formulary information and coverage displayed on  selected issuer’s website. (See table 6 for the number of CMS post- certification reviews by focus area from 2014 to 2016.)
SBEs are responsible for developing a process to certify the QHPs in  their state to ensure compliance with federal standards and are  responsible for certifying the plans prior to the annual open enrollment  period. Exchange officials from the two selected SBE states confirmed  that they have a process in place to review and certify QHPs using the  federal standards.
section_title: Compliance Reviews and Other Ongoing Monitoring Activities
paragraphs: To ensure that QHPs offered on the FFE and SBEs are continuing to  meet standards throughout the plan year, CMS and selected states also  conduct compliance reviews to varying degrees to ensure compliance  with federal and state requirements, among other ongoing monitoring  activities. Specifically, CMS conducts compliance reviews of QHPs  offered by issuers in the FFE to ensure compliance with exchange-related  standards, and SBE states are required to have oversight processes in  place to ensure compliance with the same standards. Officials in the  selected state departments of insurance we reviewed, both in the FFE  and SBE states, state that they oversee issuers selling health insurance  in their state to ensure compliance with state requirements and certain  other standards.
To identify QHP issuers in the FFE for compliance reviews, CMS uses a  risk-based process that leverages information gathered from CMS  account managers who work directly with QHP issuers, the certification  review process, and the issuers’ compliance histories, including their  performance in addressing identified issues. These compliance reviews  assess QHPs’ compliance with a range of federal exchange standards,  such as the requirement for issuers to maintain state licensure. In 2014  and 2015, key priority areas for CMS reviews included whether QHP  issuers were covering prescription drugs in accordance with federal  regulations and the readability of health plan notices for enrollees. In  2015, CMS conducted compliance reviews of QHPs offered by 32 issuers  located in 15 states, representing 14 percent of all issuers offering QHPs  on the FFE that year, and, in 2014, CMS conducted compliance reviews  of QHPs offered by 23 issuers located in 14 states, representing 13  percent of all issuers offering QHPs on the FFE that year.
As a result of its 2014 compliance reviews, CMS identified a range of  issues, including the following examples:
Some issuers had been excluding information from their QHP provider  directories about whether providers were accepting new patients.
Some issuers had not developed a procedure for resolving certain  types of QHP consumer concerns.
Some issuers sent notices to QHP enrollees that omitted required  information explaining how those with limited English proficiency can  access language services to understand their health plan notice.
Once compliance reviews are completed, CMS officials said account  managers follow up with issuers during the benefit year to monitor and  ensure the resolution of identified issues.
CMS requires all states operating SBEs to implement oversight and  monitoring policies and procedures for their exchanges as a way to help  ensure compliance with federal standards. As part of both the application  to implement an SBE and required annual reporting, exchange officials  must demonstrate their readiness to conduct plan management and  oversight under the same federal standards as required for the FFE,  including QHP certification and ensuring ongoing QHP compliance.  Exchange officials from our selected states told us they have processes  in place to report annually to CMS, and they conduct oversight activities  in varied ways. Colorado exchange officials told us they rely on issuers  complying with their contracts with the exchange office, which are  required for an issuer to offer QHPs on the exchange and include an  agreement on standards such as QHP certification, market conduct, and  resolving enrollee concerns. Vermont exchange officials said they have  enhanced their oversight and monitoring program.
Additionally, officials we interviewed from our selected states’  departments of insurance in the both FFE and SBE states told us that  they conduct compliance reviews of QHP issuers in the same way for all  issuers offering health plans issued in their state, both on and off the  exchange, to ensure compliance with state insurance rules and federal  health insurance market standards, which are generally applicable to all  plans, whether offered on or off an exchange. The selected states’  compliance reviews vary in scope and frequency—for instance, officials  from Colorado told us that compliance reviews are conducted on an ad- hoc basis if there is a complaint of potential non-compliance, and officials  from Montana told us that they conduct compliance reviews using  retrospective data from the previous four to five years, and also  investigate federal and state standard violation allegations. Officials from  the selected state departments of insurance also told us that they  generally conduct their oversight and monitoring activities at the issuer  level and therefore were unable to readily separate out data on QHPs or  QHP enrollee experiences. An official from one state department of  insurance told us that it was important to maintain a level playing field and  keep monitoring standards and policies the same for both QHPs and non- QHPs.
section_title: Appendix III: CMS Exchange Consumer Casework Data for 2015
paragraphs: CMS operates a Marketplace Call Center to assist the needs of  consumers in states that utilize the federally facilitated exchange (FFE).  CMS records and tracks issues—referred to as cases—that require action  on the part of an issuer, state, or CMS to resolve. According to CMS,  cases may include requests, such as those related to an address change,  complex questions—for example, relating to tax filings, as well as  individual complaints.
In 2015, all cases were assigned to one of four categories—plan and  issuer concerns, tax filing issues, eligibility, and legal and administrative— and to subcategories within each category that describe the general  nature of the case. CMS officials described the main case categories as  follows:
Plan and Issuer Concerns: This category includes cases where  issuers have the capacity or responsibility to resolve cases, such as  disenrollment or premium payment.
Tax Filing Issues: Cases in this category involve enrollee issues  related to their tax form. Exchange enrollees are required annually to  reconcile the amount of premium tax credit (a federal subsidy that is  applied towards qualified health plan premiums) allowed based on  reported income with the amount of premium tax credit received in  advance.
Eligibility: Cases in this category primarily consist of issues that  consumers experienced prior to enrolling in a qualified health plan,  such as technical errors on the exchange Web site, or questions  regarding eligibility for the advanced premium tax credit.
Legal and Administrative: This category includes consumer  allegations of fraud or inappropriate release of enrollee information.
In 2015, most cases were assigned to the plan and issuer category and,  within that category, issuer enrollment/disenrollment was the most  frequently assigned subcategory. This subcategory included cases of  consumers having concerns with being properly enrolled or dis-enrolled  by an issuer, such as when an issuer has not processed enrollment  information sent from the exchange in a timely manner. The tax filing  issues category became the second most frequently assigned category in  2015 when enrollees were required to submit tax information related to  their qualified health plan. CMS officials told us that a significant portion of  the cases in this category dealt with enrollees requesting an extra copy of  their tax form, disagreeing with the information on their tax form, or  requesting to update their mailing address. The eligibility category  primarily included issues related to consumer requests for special  enrollment periods and questions relating to the advanced premium tax  credit, according to CMS. Lastly, CMS officials reported that the legal and  administrative category includes cases such as a consumer alleging fraud  committed against them that is then used in their program integrity review  process. Table 7 shows the number and percentage total of cases by  subcategory within the four main categories in the casework system in  2015.
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Kristi Peterson, Assistant  Director; Patricia Roy, Analyst-in-Charge; Laura Sutton Elsberg; Kate  Nast Jones; and Joanna Wu made key contributions to this report. Also  contributing were Leia Dickerson; Sandra George; and Laurie Pachter.