Medicaid and Insurance Exchanges: Additional Federal Controls Needed to Minimize Potential for Gaps and Duplication in Coverage
Published: 2015-10-09T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Due to changes in income and other factors, it is likely that under PPACA many low-income individuals will transition between Medicaid and subsidized exchange coverage. Federal regulations require that state Medicaid agencies and exchanges coordinate to facilitate these transitions, including transferring individuals' accounts to the appropriate form of coverage when eligibility changes occur. However, given the complexity of coordinating policies and procedures for both coverage types, challenges could arise during the transition process resulting in individuals experiencing coverage gaps or duplicate coverage. GAO was asked to review information related to transitions between Medicaid and exchange coverage.
In this report, among other objectives, GAO examines the extent to which the federal government had policies and procedures that minimize the potential for coverage gaps and duplicate coverage. GAO reviewed relevant federal regulations, guidance, FFE documentation, and federal internal controls standards, and interviewed CMS officials. GAO also collected information from eight states selected, among other factors, to include four FFE states.
section_title: What GAO Found
paragraphs: CMS's policies and procedures do not sufficiently minimize the potential for coverage gaps and duplicate coverage in federal exchange states. GAO found that individuals transitioning from Medicaid to exchange coverage—that is, private health insurance purchased through the exchanges created under the Patient Protection and Affordable Care Act (PPACA)—may experience coverage gaps, for example, if they lose Medicaid eligibility toward the end of a month. Individuals who experience coverage gaps may decide to forgo necessary care. In addition, GAO found that some individuals had duplicate coverage, that is, were enrolled in Medicaid while also receiving federal subsidies for exchange coverage. While some amount of duplicate coverage may be expected during the transition from exchange to Medicaid coverage and is permissible under federal law, GAO found that duplicate coverage was also occurring under other scenarios. 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.
While the Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that operates a federally facilitated exchange (FFE) in 34 states, has implemented policies and procedures that help minimize the potential for coverage gaps and duplicate coverage, GAO identified weaknesses in CMS's controls for FFE states based on federal internal control standards. Specifically:
GAO found that CMS's controls do not provide reasonable assurance that accounts—that is, records—for individuals transitioning from Medicaid to exchange coverage in FFE states are transferred in near real time. CMS regulations require that such transfers occur promptly to facilitate eligibility determinations and enrollment. However, as of July 2015, CMS was not monitoring the timeliness of transfers. CMS officials told GAO that transfers are not happening in real time, but their understanding was that states typically send transfers at least daily. Officials from three of the four selected FFE states reported that account transfers were occurring at least daily; officials from the remaining state reported that transfers were sent to CMS three times per week. To the extent transfers are not happening in a timely fashion, individuals may be more likely to have gaps in coverage.
GAO found weaknesses in CMS's controls for preventing, detecting, and resolving duplicate coverage in FFE states. For example, as of July 2015, CMS did not have procedures to detect cases of duplicate coverage. According to CMS officials, CMS planned to implement periodic checks for duplicate coverage beginning later that month. However, CMS had not yet determined the frequency of the checks, a key to their effectiveness. In addition, CMS had no specific plan for monitoring the effectiveness of the checks and other planned procedures, making it difficult for the agency to provide reasonable assurance that its procedures are sufficient or whether additional steps are needed to protect the federal government and individuals from duplicative and unnecessary expenditures.
section_title: What GAO Recommends
paragraphs: GAO recommends that CMS take three actions, including routinely monitoring the timeliness of account transfers from states, establishing a schedule for regular checks for duplicate coverage, and developing a plan to monitor the effectiveness of the checks. HHS concurred with GAO's recommendations.

section_title: Letter
paragraphs: Starting in 2014, the Patient Protection and Affordable Care Act (PPACA)  provided many low-income Americans new options for obtaining health  insurance coverage. Specifically, under PPACA, states may opt to  expand eligibility for Medicaid—the joint federal-state program that  finances health insurance coverage for certain categories of low-income  individuals—to individuals who are not eligible for Medicare and whose  incomes are at or below 133 percent of the federal poverty level (FPL).  Additionally, PPACA required the establishment in all states of health  insurance exchanges—marketplaces where eligible individuals may  compare and select among private health plans—by January 1, 2014.  States may elect to establish and operate an exchange, known as a  state-based exchange (SBE), or allow the Centers for Medicare &  Medicaid Services (CMS)—the agency within the Department of Health  and Human Services (HHS) responsible for overseeing Medicaid and the  exchanges—to do so within the state, known as a federally facilitated  exchange (FFE). In addition, PPACA provides for federal subsidies to  assist qualifying low-income individuals in affording exchange coverage,  referred to as subsidized exchange coverage. For example, individuals  may be eligible for premium tax credits if their incomes fall between 100  and 400 percent of the FPL, and they do not have access to minimum  essential coverage through government-sponsored programs, such as  Medicaid, or private insurance plans, such as employer-sponsored health  insurance.
Changes in income and other factors can change an individual’s eligibility  for Medicaid and for subsidized exchange coverage and, as many low- income individuals experience income volatility, transitions between the  two coverage types are likely under the law. Transitions may be more  likely to occur in the 29 states that as of March 2015 had expanded  Medicaid as allowed under PPACA, because in these states there is no  gap in eligibility between the coverage types. In states that have not  chosen to expand, there is generally a gap in eligibility between the two  coverage types for adults with incomes under 100 percent of the FPL.  Previous research has estimated that 6.9 million, or 7 percent, of  individuals who receive either Medicaid or exchange subsidies will  experience a change in eligibility from one to the other each year.
Questions have been raised about whether individuals transitioning  between Medicaid and exchange coverage could experience disruptions  in care if, for example, individuals are not able to continue seeing their  providers. In states with Medicaid managed care programs, where issuers  of health insurance coverage administer Medicaid benefits, individuals  may be able to remain with the same issuer when moving between  coverage types to the extent that issuers offer both types of coverage.  Some stakeholders have suggested that remaining with the same issuer  could diminish the likelihood of disruptions in care.
PPACA required the establishment of a coordinated eligibility and  enrollment process for Medicaid and exchange coverage that ensures  that individuals are enrolled in the coverage for which they are eligible  and transferred to the appropriate form of coverage if their eligibility  changes. This may require significant coordination between various  information technology (IT) systems within states, as well as between  federal and state IT systems. Given the complexity of designing  coordinated policies and systems, challenges could arise during the  transition process, including that individuals may experience gaps in  coverage or become simultaneously enrolled in both Medicaid and  subsidized exchange coverage (referred to as duplicate coverage), which  is generally not permitted under federal law.
You asked that we examine information related to individuals’ transitions  between Medicaid and exchange coverage. In this report, we examine   (1) the extent to which the federal government and states had policies  and procedures that minimize the potential for coverage gaps and  duplicate coverage when individuals transition between Medicaid and  exchange coverage; (2) the extent to which individuals are transitioning  between Medicaid and exchange coverage; and (3) the participation of  issuers in both Medicaid and exchange coverage in a state.
To examine the extent to which the federal government and states had  policies and procedures that minimize the potential for coverage gaps and  duplicate coverage when individuals transition between Medicaid and  exchange coverage, we reviewed relevant PPACA provisions as well as  federal regulations and guidance for Medicaid programs and for the  exchanges. This included reviewing regulations related to coordination  between Medicaid and the exchanges, eligibility redeterminations and  termination of both Medicaid and exchange coverage, and technical  guidance on Medicaid and exchange IT systems. We also reviewed  relevant documentation of procedures for FFE states and interviewed  CMS officials to determine whether the agency’s policies and procedures  for FFE states include internal controls that are consistent with standards  for internal control in the federal government. In addition, we collected  information from and interviewed Medicaid and, in states with SBEs,  exchange officials about state policies and procedures in eight selected  states. We selected states to include four with SBEs—Colorado,  Kentucky, New York, and Washington—and four with FFEs—Arizona,  Iowa, Texas, and Utah—and to include states that expanded as well as  states that did not expand their Medicaid programs. The eight states we  selected accounted for at least 20 percent of Medicaid and exchange  coverage enrollment nationwide (see appendix I for more information on  our selected states). To supplement information from CMS and selected  states, we interviewed representatives of five issuers, selected because  they offered both Medicaid and exchange coverage in one or more of our  selected states, as well as a trade association that represents issuers that  offered both Medicaid and exchange coverage in multiple states  throughout the country, and we reviewed related documentation. In  addition, as the Internal Revenue Service (IRS) is responsible for  reconciliation of advance payments of the premium tax credit, we  interviewed IRS officials on this process, including how the agency might  identify cases of duplicate coverage.
To examine the extent to which individuals are transitioning between  Medicaid and exchange coverage, we interviewed officials from our eight  selected states about the availability of data that would allow for analysis  of the extent of transitions and requested and analyzed the data where  available. Specifically, we analyzed data available from three of the states  on the number of individuals who transitioned (1) from Medicaid to  exchange coverage and (2) from exchange to Medicaid coverage in 2014  and whether the movement was to or from subsidized versus  unsubsidized exchange coverage. We interviewed CMS officials about  state and federal data sources that would allow for analysis of the extent  of transitions in FFE states and whether CMS had conducted or planned  to conduct any such analysis. To assess the reliability of the state data,  we performed manual tests of the data to identify any outliers or  anomalies, followed up with officials as necessary, and incorporated the  corrections we received. We determined that the data were sufficiently  reliable for the purposes of this report.
To examine the participation of issuers in both Medicaid and exchange  coverage in a state, we collected and analyzed data from our eight  selected states on the extent to which issuers offered both Medicaid and  exchange coverage in those states in 2014 and 2015, as well as the  extent to which Medicaid and exchange enrollees were enrolled in those  issuers’ plans in 2014. We also reviewed an analysis CMS performed  on the extent to which issuers offered both Medicaid and exchange  coverage in all states with Medicaid managed care in 2014. To  supplement these analyses, we interviewed officials from our selected  states about issuer participation in Medicaid and exchange coverage in  those states as well as the implications of such participation for  individuals transitioning between the coverage types. In addition, we  interviewed representatives of our selected issuers about their Medicaid  and exchange coverage in states in which they offered both, as well as  their experiences offering such coverage. To assess the reliability of the  data we received from states and CMS, we performed manual and  electronic tests of the data to identify any outliers or anomalies, clarified  with officials as necessary, and incorporated the corrections we received.  We determined that the data were sufficiently reliable for the purposes of  this report.
The information that we obtained from our selected states and issuers  cannot be generalized to other states. We conducted this performance  audit from October 2014 through September 2015 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
paragraphs: Beginning January 1, 2014, PPACA required most citizens and legal  residents of the United States to maintain health insurance that qualifies  as minimum essential coverage for themselves and their dependents or  pay a tax penalty. Most Medicaid coverage and private health insurance  coverage purchased through the exchanges qualifies as minimum  essential coverage. To expand individuals’ access to minimum essential  coverage, PPACA provided states the option to expand eligibility for  Medicaid coverage, with increased federal financing for the newly eligible  population. As of January 2014, 25 states had expanded their Medicaid  programs, and an additional 4 states had expanded as of March 2015.
Beginning in October 2013, individuals were able to shop for private  health insurance qualifying as minimum essential coverage through the  exchanges, with coverage effective beginning as early as January 1,  2014. As of March 2015, the federal government operated an FFE in 34  states, and 17 states were approved to operate SBEs (see fig. 1).  States with SBEs may use the FFE IT systems for eligibility and  enrollment functions. In 2014, two states with SBEs used the FFE IT  systems for eligibility and enrollment, while in 2015 three states with  SBEs did so.
PPACA also created federal subsidies for exchange coverage, most  notably the premium tax credit available to eligible individuals with  household incomes between 100 and 400 percent of the FPL. Individuals  eligible for Medicaid or other minimum essential coverage, such as  qualifying employer-sponsored coverage, are not eligible for the premium  tax credit. The tax credit is refundable and is generally paid to issuers in  advance to reduce enrollees’ premium costs for exchange plans.  Advance payments of this tax credit are known as advance premium tax  credits (APTC) and are calculated based on an eligible individual’s family  size and anticipated household income relative to the cost of premiums  for a benchmark plan. According to HHS, approximately 87 percent of  individuals selecting a plan for the 2015 coverage year in FFE states  qualified for the APTC, with an average per person, monthly APTC  amount ranging from $155 in Arizona to $534 in Alaska, and an average  reduction in premiums of about 72 percent. In addition to the premium  tax credit, PPACA provides for cost-sharing reductions to reduce out-of- pocket costs, such as deductibles and copayments, for eligible individuals  with household incomes between 100 and 250 percent of the FPL.
subsections: section_title: Medicaid and Exchange Eligibility and Enrollment Policies and Procedures
paragraphs: PPACA required the establishment in all states of a coordinated eligibility  and enrollment process for Medicaid and the exchanges. Since the  enactment of the law in March 2010, CMS has issued regulations and  technical guidance outlining aspects of this coordination. In particular,  exchanges and state Medicaid agencies must enter into agreements with  one another to ensure prompt eligibility determinations and enrollment of  individuals in the appropriate programs regardless of where they apply,  and must transmit individuals’ account information—that is, their  records—via secure electronic interface. However, the mechanisms  through which this coordination occurs may vary depending on the state.
In FFE states, CMS has established an account transfer process  through which accounts for individuals enrolled in or applying for  exchange or Medicaid coverage are electronically transmitted  between CMS and state Medicaid agencies where appropriate. If  individuals apply for coverage in an FFE state, CMS is responsible for  determining or assessing individuals’ eligibility for Medicaid and  determining eligibility for exchange coverage, including exchange  subsidies and, if applicable, facilitating enrollment in an exchange  plan. If CMS determines or assesses that an individual is or may be  eligible for Medicaid, it must transfer the individual’s account to the  appropriate state Medicaid agency for enrollment, where appropriate.  Individuals may also apply for coverage directly through the state  Medicaid agency. In this case, the state is responsible for determining  eligibility for Medicaid and, for individuals determined ineligible,  transferring accounts to CMS for a determination of eligibility to enroll  in subsidized exchange coverage.
Conversely, states with SBEs are responsible for determining  eligibility for both Medicaid and exchange coverage, including  exchange subsidies, as well as enrolling individuals in the appropriate  programs.
There are differences in eligibility and enrollment policies for Medicaid  and exchange coverage.
Medicaid. Individuals may enroll in Medicaid coverage at any point in  time during the year, with their coverage effective as of the date of  application, reported eligibility change, or earlier. Individuals enrolled  in Medicaid are generally required to report any changes—such as  changes to income or household composition—that may affect their  Medicaid eligibility. Outside of self-reported changes, eligibility for  Medicaid must generally be redetermined every 12 months. When  individuals are determined ineligible for Medicaid, states are required  to send them notification that their coverage will be terminating at  least 10 days prior to their Medicaid termination date. In addition,  states may opt to extend Medicaid coverage through the end of the  month if it would otherwise be terminated earlier in the month.
Exchange coverage. Individuals’ options for enrollment in exchange  coverage are generally restricted to an annual open enrollment period  that starts near the end of the calendar year, unless they experience a  change that qualifies them for a special enrollment period.  Exchange coverage is generally prospective, meaning that individuals  must select an exchange plan by a certain date in order to have  coverage effective the following month. If individuals choose to end  their exchange coverage, they must generally provide advance notice  at least 14 days before the requested termination date. As with  Medicaid, individuals enrolled in subsidized exchange coverage are  required to report any changes that may affect their eligibility.  Eligibility for subsidized exchange coverage is redetermined during  open enrollment and any time an individual reports a change,  regardless of when coverage began during the year. If individuals are  determined ineligible for continued subsidized exchange coverage,  such subsidies must be terminated or they may be held liable for  repayment of the APTC as part of the reconciliation process with IRS.
The coordination of federal payments for individuals transitioning between  Medicaid and subsidized exchange coverage is addressed through  Medicaid’s third party liability rule and IRS’s reconciliation process for the  APTC. Specifically:
Third party liability in Medicaid. Where individuals are enrolled in  Medicaid along with another form of coverage, Medicaid operates as  the payer of last resort. This means that the other source of coverage  must pay to the extent of its liability before Medicaid pays, referred to  as third party liability. For example, for individuals enrolled in both  Medicaid and exchange coverage for some period of time, the issuer  of exchange coverage is required to pay to the extent of its liability  before Medicaid does.
Reconciliation of the APTC with the IRS. Individuals enrolled in  exchange coverage and receiving the APTC must file federal income  tax returns with the IRS to reconcile the amount of the premium tax  credit allowed with the amount received in advance, and may be liable  to pay back any excess credits received during the taxable year. For  individuals transitioning from exchange coverage to Medicaid during  the year, this reconciliation could include repayment of APTC received  after an individual was determined eligible for Medicaid.
section_title: Issuer Requirements for Participation in Medicaid Managed Care and Exchange Coverage
paragraphs: Most state Medicaid programs have implemented managed care  systems, under which the state pays contracted issuers a set amount per  beneficiary per month to arrange for all covered services and the issuer  assumes the risk for the cost of providing those services. In states that  offer managed care in their Medicaid programs, issuers have the potential  to participate in both Medicaid and the exchange market. Issuers  approved to offer Medicaid managed care, exchange coverage, or both,  must comply with applicable state and federal requirements for the  respective programs. For example, issuers offering Medicaid managed  care must comply with any applicable state and federal restrictions on  marketing their plans to Medicaid beneficiaries. In addition, some states  may require issuers contracting with the Medicaid program to offer such  coverage statewide, while in other states issuers may offer their Medicaid  coverage statewide or to enrollees in selected geographic regions within  the state. Issuers of exchange coverage have the option of offering their  exchange plans statewide or within selected geographic regions.
section_title: CMS’s Policies and Procedures Do Not Sufficiently Minimize the Potential for Coverage Gaps and Duplicate Coverage in Federal Exchange States
paragraphs: Information from CMS and selected states and issuers indicates that  individuals transitioning from Medicaid to exchange coverage may  experience coverage gaps, and that duplicate coverage is occurring  under several scenarios. CMS and our selected states had a number of  enrollment policies, IT mechanisms, and consumer education efforts that  minimize the potential for coverage gaps and duplicate coverage;  however, our assessment of CMS’s policies and procedures for FFE  states found that additional controls are needed.
subsections: section_title: Individuals Transitioning between Medicaid and the Exchanges May Experience Coverage Gaps or Duplicate Coverage under Certain Circumstances
paragraphs: Officials from CMS and four of our eight selected states told us that  individuals may experience gaps in coverage when transitioning between  Medicaid and exchange coverage, though they did not have information  on the extent to which such gaps were occurring. Specifically, as  Medicaid coverage is effective as of the date an eligibility change is  reported or earlier, officials from two states explained that coverage gaps  should generally not occur for individuals who lose eligibility for exchange  coverage and are transitioning to Medicaid. However, as exchange  coverage is generally prospective, coverage gaps could occur in the other  direction. In particular, officials from one state told us that individuals who  lose eligibility for Medicaid toward the end of a month may be more likely  to experience coverage gaps because they would have a short window of  time to enroll in exchange coverage so that coverage is effective the first  day of the following month. Individuals who experience gaps in  coverage may decide to forgo necessary care rather than pay out-of- pocket, which could negatively affect health outcomes and result in sicker  individuals enrolling in exchange coverage.
Information from selected states and issuers indicated that duplicate  coverage—that is, enrollment in both Medicaid and subsidized exchange  coverage—was occurring under the three scenarios outlined below, the  first of which is permitted under federal law. However, the full extent to  which duplicate coverage was occurring was unknown.
Scenario 1: Individuals who are completing the transition from  subsidized exchange to Medicaid coverage. According to officials  from three of our eight selected states, some amount of duplicate  coverage may be expected for individuals transitioning from  subsidized exchange coverage to Medicaid. For example, if an  individual with subsidized exchange coverage reports a change and is  determined eligible for Medicaid on September 16th, the individual  could have duplicate coverage for the period of September 16th  through September 30th. This is primarily due to differences in the  effective dates of coverage. Medicaid coverage is effective as of the  date an eligibility change is reported or earlier—while in general  exchange coverage can only be terminated prospectively, generally  with at least 14 days advance notice. The period of duplicate  coverage could be extended if the Medicaid eligibility determination  takes longer—and per federal regulations it can take up to 45 days for  applicants not applying on the basis of disability. This transitional  period of duplicate coverage is permitted under the law; that is,  individuals are permitted to be enrolled in both types of coverage  through the end of the month of the Medicaid eligibility  determination.
Scenario 2: Individuals who do not end their subsidized  exchange coverage after being determined eligible for Medicaid.  One of our selected states identified that 3,500 individuals had  duplicate coverage at some point from January to July 2014, in part  because some of the individuals did not end their subsidized coverage  after being determined eligible for Medicaid. Individuals may not end  subsidized exchange coverage for a variety of reasons, including that,  depending on their income level and plan selection, some individuals  receiving subsidies may not have to make a premium payment and  thus may not realize they are still enrolled and need to take steps to  end their coverage. If individuals do not end coverage, but stop  paying premiums once Medicaid coverage begins, the APTC must still  be paid out for a 3-month grace period after premium payments have  ceased, though issuers must return the APTC amount for the final   2 months of this period under certain circumstances.
Scenario 3: Individuals who enroll in subsidized exchange  coverage when already enrolled in Medicaid. One of our selected  issuers reported that a small number of individuals enrolled in one of  the issuer’s Medicaid plans and later also obtained subsidized  coverage through one of its exchange plans—18 individuals as of  February 2015. Officials from the Medicaid agency in the state  where this issuer operates also told us that they had identified cases  of duplicate coverage by selecting a small sample of individuals from  one of their Medicaid issuers, and that they had heard from some  other issuers in the state that they had members enrolled in both  coverage types. Additionally, another of our selected issuers reported  that one of its plans had experienced a number of instances of  duplicate coverage—which tended to last for many months—and that  the volume had increased during 2015 open enrollment for exchange  coverage, likely because Medicaid coverage was not identified.
To the extent duplicate coverage occurs, there could be financial  implications for the federal government. In cases where the state  Medicaid program has identified that an individual is enrolled in exchange  coverage—and Medicaid is operating as the payer of last resort—there  may not be a significant difference in federal costs for the individual  during the period of duplicate coverage compared with what would have  been spent if duplicate coverage had not occurred. However, evidence  suggests that some states may face challenges identifying exchange  coverage. We recently found that states face challenges identifying  whether Medicaid enrollees have other sources of coverage, which could  include exchange coverage. In addition, officials from our four selected  FFE states told us that they do not currently have access to exchange  enrollment information, and that such information could help them better  identify information on Medicaid enrollees’ other sources of coverage.  CMS officials told us that CMS has provided exchange enrollment data to  one state that requested it for third-party liability purposes, and the  agency would consider the appropriateness of providing such data to  other states if requested.
If the state is not aware of an individual’s exchange coverage, the federal  government could be paying twice—that is, subsidizing exchange  coverage and reimbursing states for Medicaid spending for the same  individual. The risk of duplicate payments may be higher in states with  higher Medicaid managed care penetration as the state pays issuers a  monthly fee for each enrolled individual, regardless of whether services  are received. The tax reconciliation process for the APTC has the  potential to reduce the financial implications of any duplicate payments.  However, according to IRS officials, the IRS will generally not have the  information necessary to identify duplicate coverage as part of reconciling  the amount of the APTC an individual may owe until 2016—that is, the tax  filing season for tax year 2015—when states are required to report  Medicaid enrollment data to IRS. Officials told us that once IRS begins  receiving the data their ability to identify the need for repayment due to  duplicate coverage will depend on the quality of the data and the IRS’s  available resources. Officials said that depending on resources, they may  check for Medicaid coverage for each individual receiving the APTC or for  a sample of individuals.
Duplicate coverage could also have financial implications for individuals.  As long as individuals end subsidized exchange coverage upon receiving  their Medicaid eligibility determination, they would generally not be liable  for repaying the APTC received during the transitional period of duplicate  coverage discussed in the first scenario above; however, according to  CMS officials, individuals would be responsible for their portion of the  exchange premiums during this period. To the extent duplicate coverage  occurs outside of the transitional period and the IRS identifies duplicate  coverage during the tax reconciliation, individuals may be liable for  repaying all or a portion of the APTC received.
section_title: CMS and States Had Policies and Procedures That Minimize the Potential for Coverage Gaps and Duplicate Coverage, but Additional Controls Are Needed in Federal Exchanges
paragraphs: CMS and our selected states had policies and procedures that minimize  the potential for coverage gaps or duplicate coverage when individuals  transition between Medicaid and the exchanges.
Enrollment-related: CMS and selected states had enrollment policies  and procedures that minimize the potential for coverage gaps by  facilitating alignment of Medicaid and exchange coverage periods. For  example, for individuals transitioning from Medicaid to exchange  coverage, CMS requires that, as long as individuals select an  exchange plan on or before the day that Medicaid coverage ends,  exchanges must ensure that coverage is effective on the first day of  the following month. In contrast, most individuals enrolling in  exchange coverage must select a plan by the fifteenth of the month in  order to have a coverage effective date for the first day of the  following month. Additionally, in February 2015, CMS adopted a new  regulation governing premium payments in FFE states, allowing  individuals transitioning from Medicaid 30 calendar days from  enrolling in exchange coverage to pay their first premium. At the  state level, officials from one state told us they increased the deadline  for mailing notification of Medicaid coverage termination to 20 days  prior to termination instead of the minimum required 10, so that  individuals have more time to shop for a plan on the exchange.  Additionally, officials from all of our selected states reported extending  Medicaid coverage to at least the end of a month even when an  individual becomes ineligible for Medicaid coverage earlier in the  month.
IT-related: CMS and selected SBE states also had IT-related policies  and procedures that minimize the potential for coverage gaps as well  as duplicate coverage. For example, in FFE states, when individuals  are determined potentially eligible for subsidized exchange coverage,  CMS conducts automated checks of state IT systems to determine if  individuals already have Medicaid coverage, thus helping to prevent  duplicate coverage. At the state level, officials from all four of our  selected SBE states reported that their states had implemented  integrated eligibility and enrollment systems for Medicaid and  exchange coverage that, among other things, helped avoid gaps in  coverage by making eligibility determinations in real time: in other  words, at the time an individual reports a change. Officials also said  that these integrated systems included system rules that help prevent  duplicate coverage by not allowing an individual to be determined  eligible for Medicaid and exchange subsidies simultaneously. In  addition, officials from three of these states noted that their systems  automatically terminate subsidized exchange coverage once  individuals are determined eligible for Medicaid, while officials in the  fourth state said their systems would have this ability beginning in  September 2015.
Consumer education-related: Both CMS and an SBE state reported  including guidance on exchange websites that could help individuals  avoid coverage gaps and duplicate coverage during the transition  between Medicaid and exchange coverage. For example, CMS has  added guidance on coverage transitions on the FFE website that  outlines the steps individuals must take when they have subsidized  exchange coverage and are later determined eligible for Medicaid,  including that they are responsible for ending subsidized exchange  coverage. CMS also notifies individuals in FFE states of this  responsibility when they are enrolling in exchange coverage. Similarly,  officials from one of our SBE states said that they have tried to  improve the clarity of instructions on their exchange website, because  most individuals are making eligibility changes online.
Despite the steps CMS has taken, its current policies and procedures do  not sufficiently minimize the potential for coverage gaps and duplicate  coverage in the 34 states that had an FFE in 2015. According to federal  internal control standards, in its responsibilities for administering and  overseeing Medicaid and the exchanges, CMS should design and  implement necessary policies and procedures to enforce agency  objectives and assess program risk. These policies and procedures  should include internal controls, such as conducting monitoring to assess  performance over time, that provide reasonable assurance that an  agency has effective and efficient operations and that program  participants are in compliance with applicable laws and regulations. We  identified a number of weaknesses in CMS’s controls for minimizing  coverage gaps and duplicate coverage for individuals transitioning  between Medicaid and exchange coverage in FFE states.
subsections: section_title: Control Weaknesses Related to Coverage Gaps
paragraphs: With regard to coverage gaps, we found that CMS’s controls do not  provide reasonable assurance that the accounts of individuals  transitioning from Medicaid to exchange coverage in FFE states are  transferred by states in near real time, which puts individuals in these  states at greater risk of experiencing such gaps. Specifically, federal  regulations require that state Medicaid agencies should transfer accounts  to CMS promptly and without undue delay. However, according to CMS  officials, as of July 2015, the agency was not monitoring the timeliness of  account transfers from states, and thus CMS would not be aware if  account transfers from FFE states were happening promptly. CMS  officials told us that account transfers are not happening in real time, but  their understanding was that states typically send transfers at least  daily. Officials from three of our four selected FFE states reported that  account transfers were occurring at least daily, while officials from the  remaining state reported that transfers were sent to CMS three times per  week.
Given the number of steps involved in the transition from Medicaid to  exchange coverage, individuals may be more likely to have gaps in  coverage to the extent account transfers from states to CMS are not  happening in a timely fashion. For example, if a state sends a notification  of termination on September 20, individuals could have just over a week  to have their accounts transferred, apply for exchange coverage, and  select a plan to avoid a coverage gap (see fig. 2).
With regard to duplicate coverage, we found weaknesses in CMS’s  controls for preventing, detecting, and resolving duplicate coverage in  FFE states.
Vulnerabilities in methods to prevent individuals from  maintaining subsidized exchange coverage after being  determined eligible for Medicaid. Individuals in FFE states might  not end subsidized exchange coverage when they are determined  eligible for Medicaid. According to CMS officials, in April 2015, the  agency revised the notice individuals receive when they are  determined eligible or potentially eligible for Medicaid to make clear  individuals are responsible for doing so. However, individuals who  apply for Medicaid directly through their state Medicaid agency may  not receive such notification. In addition, CMS does not have  procedures to automatically terminate subsidized exchange coverage  when individuals are determined eligible for Medicaid, though CMS  officials told us that they are considering options for doing so in the  future.
Vulnerabilities in methods to prevent individuals enrolled in  Medicaid from enrolling in subsidized exchange coverage. While  CMS generally checks for Medicaid coverage before initially  determining someone eligible for subsidized exchange coverage,  officials recognized that there are limitations to this check.  Specifically, officials said these checks identify at a point in time  whether the person is enrolled in Medicaid. Thus, if, for example, the  Medicaid determination was pending, CMS would not know that from  the check. Also, according to CMS officials, CMS is not able to  conduct checks for Medicaid for the small percentage of individuals  who do not provide social security numbers on their applications.  Further, CMS did not perform a check for Medicaid coverage for the  1.96 million individuals who were auto-reenrolled in exchange  coverage during 2015 open enrollment for FFE states. The absence  of such a check increases the risk that duplicate coverage occurring  during the year would continue when individuals are enrolled in  subsidized exchange coverage for another year.
No methods to detect and resolve duplicate coverage. As of July  2015, CMS did not have procedures to detect and resolve cases of  duplicate coverage in FFE states. Further, CMS had generally not  provided FFE states with exchange enrollment information that they  would need to identify cases of duplicate coverage.
While CMS has not conducted a formal risk assessment to identify the  potential causes of duplicate coverage in FFE states, CMS officials told  us that the agency has a number of planned steps to address the risk.  The planned approach focuses on taking steps to identify and resolve  rather than prevent duplicate coverage. Specifically, CMS has plans to  implement periodic checks for duplicate coverage starting in the summer  of 2015, and CMS officials told us in July 2015 that the first check would  occur later that month. CMS officials estimated that the first check will  take about 2 to 3 weeks to perform and will involve, among other steps,  querying each FFE state’s Medicaid system. According to the officials,  after the first check is complete CMS will notify individuals found to have  duplicate coverage that they must contact the FFE to update their  coverage information. Further, in 2016, if CMS can build the IT  functionality to do so, the agency plans to begin automatically terminating  exchange subsidies if individuals identified through the checks do not  respond within 30 days of being notified. CMS officials told us that they  are considering performing the periodic checks ahead of future open  enrollment periods for exchange coverage, which could help prevent  duplicate coverage among those automatically reenrolled in exchange  coverage. CMS officials told us that the planned checks and notification  process are a more efficient way of detecting and resolving duplicate  coverage compared to providing exchange enrollment information to  states and requiring them to identify duplicate coverage, which CMS  would then need to resolve.
The effectiveness of CMS’s plans to address duplicate coverage will  depend in part on how frequently the checks are conducted and, as of  July 2015, CMS had not yet decided the frequency. CMS officials told us  that they are considering performing the checks on a regular basis— possibly quarterly—but said the frequency of the checks will depend in  part on the agency’s analysis of the first check, including the level of effort  required by state Medicaid agencies. Determining the frequency of the  checks after completing an analysis of the first check is reasonable and  could provide CMS with important insights. However, until CMS  establishes the frequency of its checks, the risk of duplicate coverage  going undetected continues to exist. Further, the less frequently the  checks are conducted, the longer duplicate coverage could last if  individuals do not independently take steps to end their subsidized  exchange coverage. For example, for individuals who have subsidized  exchange coverage and are determined eligible for Medicaid, if the  checks are conducted monthly, duplicate coverage could last up to   2 months longer than what might be expected during the transition period;  if quarterly, up to 4 months; and if biannually, up to 7 months (see   fig. 3).
In addition, while CMS officials told us that they intend to monitor the  results of the periodic checks, they do not have a specific plan to routinely  monitor the effectiveness of their planned checks and other procedures.  According to CMS officials, the agency is exploring metrics to help  measure the success of the periodic checks, such as identifying the  number of people who received notification of duplicate coverage and  subsequently ended their subsidized exchange coverage. However, CMS  has not set a level of duplicate coverage that it deems acceptable, both in  terms of the time period for which individuals have duplicate coverage  and the proportion of Medicaid or exchange enrollees that experience  duplicate coverage within a given time frame. Without such thresholds, it  will be difficult for the agency to provide reasonable assurance that its  procedures are sufficient or whether additional steps are needed.
section_title: Limited Data Show Small Percentages of Enrollees Transitioned between Coverage Types, but Transitions May Increase in the Future
paragraphs: Data from three of our selected states—Kentucky, New York, and  Washington—indicated that collectively over 70,000 individuals  transitioned between Medicaid and exchange coverage in 2014.  Specifically, the three states—all of which were SBE states that had  expanded Medicaid—reported that about 73,000 individuals transitioned  in 2014 (see table 1). These individuals accounted for between   7.5 percent and 12.2 percent of exchange coverage enrollment and less  than 1 percent of Medicaid enrollment in those states. Data from the  three states also indicated that most individuals transitioned to or from  subsidized exchange coverage, rather than unsubsidized exchange  coverage. While states were not able to provide data on the  demographics of those transitioning, New York officials told us that it was  likely mostly adults transitioning, because children have access to CHIP.  In New York, CHIP covers children up to 400 percent of FPL—the same  income limit as that set for the premium tax credit—compared with the  Medicaid limit for adults of 133 percent of FPL. While individuals  transitioning accounted for a relatively small percentage of enrollment, the  total number of individuals transitioning across states could be significant.  Out of the 25 states that had expanded Medicaid as of January 2014, we  estimate that Kentucky, New York, and Washington accounted for   22.9 percent of total Medicaid and CHIP enrollment and 18.3 percent of  total exchange enrollment in 2014.
The data from the three states may understate the extent to which  transitions between Medicaid and exchange coverage could occur in  those states in future years. In particular, the number of individuals  moving from Medicaid to exchange coverage may be greater in future  years than in 2014. Individuals newly eligible for and enrolled in Medicaid  in early 2014 would not have gone through their first annual  redetermination of Medicaid eligibility, and officials in one state told us  that they did not expect to see a lot of movement from Medicaid to  exchange coverage until those redeterminations began. In addition, the  number of individuals moving from exchange coverage to Medicaid in the  three states may be greater in future years. Annual redeterminations of  eligibility for subsidized exchange coverage are to occur during the  annual open enrollment period for exchange coverage, which may extend  from the end of a calendar year through the beginning of the following  calendar year. As 2014 was the first year of exchange coverage, the  data for this year reflected, at the maximum, only changes resulting from  annual redeterminations of eligibility during the end of the calendar year— the beginning of the open enrollment period for 2015 exchange  coverage.
Where selected SBE states were not able to provide data on transitions  between Medicaid and exchange coverage, officials told us they were  developing or improving the functionality to track those data.
In Colorado, which was not tracking transitions in 2014, officials told  us that tracking transitions was considered a high priority. Officials  told us that, as of July 2015, the state had made changes to its IT  system that would provide the functionality to track transitions and  they anticipated being able to do so later that year.
In New York, officials reported being in the process of developing the  functionality to track transitions from Medicaid to exchange coverage,  and, in July 2015, the officials told us that they had recently started  tracking these transitions.
In Washington, a state already tracking transitions, officials told us  that, as of July 2015, they had a project underway to begin looking at  the demographics of those transitioning, including age and gender.
Selected states and CMS could not provide data on the extent to which  individuals are transitioning between Medicaid and exchange coverage in  FFE states. Officials from all four of our selected FFE states told us that  the state did not have access to exchange enrollment information, and  therefore the state was not able to provide data on transitions between  Medicaid and exchange coverage. Similarly, as of July 2015, CMS could  not provide data on transitions between Medicaid and exchange coverage  in FFE states. CMS officials told us that the FFE and state Medicaid IT  systems are not integrated in a way that would allow for real-time tracking  of transitions. Additionally, though CMS has access to both exchange  and Medicaid enrollment data for FFE states, officials told us that, as of  July 2015, they could not use those data to determine the number of  individuals transitioning retrospectively. Officials explained that, for  example, there was no single, unique identifier for an individual between  the data sets, making it difficult to match people between the two data  sets. CMS officials told us that, as of May 2015, representatives from  CMS as well as from the Office of the Assistant Secretary for Planning  and Evaluation had been working for about a year on a methodology for  examining transitions. Officials said these efforts have primarily focused  on analyzing transitions in SBE states, but that the findings may inform  how to perform such an analysis for FFE states.
section_title: At Least One Issuer Offered Both Coverage Types in Most States, but Many Individuals Transitioning May Not Stay with Their Issuer
paragraphs: Information from our selected states and CMS indicated that most states  with Medicaid managed care had one or more Medicaid issuers that also  offered coverage through the state’s exchange. Seven out of our 8  selected states—all but Iowa—reported having at least 1 issuer offering  both Medicaid and exchange coverage in the state in 2014, ranging from  2 to 13 issuers. These results are consistent with an analysis completed  by CMS that indicated, in the 40 states with Medicaid managed care, the  majority—33—had 1 or more issuers offering both Medicaid and  exchange coverage in 2014. CMS did not identify any issuers offering  both types of coverage in the remaining 7 states.
However, information from our selected states also indicated that in some  states, the majority of Medicaid and exchange enrollees may not be  enrolled with issuers offering both types of coverage. In the 7 selected  states with issuers offering both types of coverage, the issuers accounted  for between 8 and 76 percent of Medicaid enrollment and 19 and   74 percent of exchange enrollment where data were available from states  (see table 2). The proportion of Medicaid enrollees in plans offered by  issuers that also offer exchange coverage is affected by the proportion of  Medicaid enrollees who participate in managed care in the state, as  enrollees in fee-for-service Medicaid would not be enrolled with an issuer.  For example, in Colorado, which had a relatively low percentage of  Medicaid enrollees in plans offered by issuers also offering exchange  coverage, the majority, or about two-thirds, of Medicaid enrollees were in  fee-for-service as of February 2015 according to state officials.
Additionally, not all individuals enrolled with issuers offering both types of  coverage would be able to remain with their issuer when transitioning,  due to differences in issuers’ service areas for their Medicaid and  exchange coverage. For example, one of the two issuers that offered both  types of coverage in Kentucky in 2014 offered Medicaid coverage  statewide, but offered exchange coverage in just 15 of the 120 counties in  the state, representing about 41 percent of the state’s population. The  other issuer offered exchange coverage statewide and Medicaid  coverage in 111 counties, representing about 76 percent of the  population. In 7 counties, representing about 5 percent of the population,  neither of the issuers offered both Medicaid and exchange coverage.
A larger proportion of individuals may have the opportunity to remain with  their issuer when transitioning between the coverage types in future  years. In 2015, the total number of issuers offering both Medicaid and  exchange coverage increased in 3 of our selected states. In addition,  information from selected states indicated that in some cases, issuers  that already offered both Medicaid and exchange coverage in some  counties within a state began to do so in additional counties in 2015.  Evidence from selected issuers also suggests that a growing number of  individuals may have the opportunity to remain with their issuer moving  forward—for example, representatives from one issuer reported that the  number of states in which the issuer offered both types of coverage grew  from 3 states in 2014 to 16 states in 2015. Representatives from another  issuer told us that, given the complexities of offering two new types of  coverage, it had so far chosen not to offer exchange coverage in some  states in which it was newly participating in Medicaid but anticipated  beginning to offer exchange coverage in those states in future years.
While a growing number of individuals may have the opportunity to  remain with their issuer when transitioning between the coverage types,  the extent to which individuals will choose to do so will likely depend on a  number of factors, including the following:
Desire to change plans. Studies suggest that some individuals are  likely to change plans—which may be offered by different issuers— when provided the option to do so. This change may be positive,  such as in cases where the new plan better addresses the individual’s  health care needs.
Cost of exchange plans. Individuals may be less likely to remain  with their issuer when transitioning from Medicaid to the exchange if  issuers offering both types of coverage are unable to offer competitive  premiums for their exchange plans. Representatives from two  selected issuers that offered both types of coverage reported that they  had relatively low exchange market share in 2014 most likely because  they were unable to offer competitive premiums, but said they were  able to offer lower premiums in 2015 and have seen or expected to  see increased enrollment.
Awareness of issuer participation in both types of coverage.
Individuals transitioning between coverage types may not be aware  that their issuer also offers plans in the new coverage type. For  example, in some states Medicaid managed care marketing  restrictions may prohibit issuers from marketing their exchange plans  to existing Medicaid enrollees. For instance, representatives from  one selected issuer reported piloting an outreach program in some  states to inform Medicaid members whose coverage was terminating  about the issuer’s exchange plans, but noted that the issuer was not  permitted to operate this program in at least one state. In addition,  issuers may operate under different names in Medicaid and for their  exchange coverage, which could make it difficult for individuals to  identify whether their issuer operates in the new coverage type.
Auto-assignment in Medicaid managed care. Many states with  managed care auto-assign individuals to issuers either at the initial  eligibility determination or if an individual does not select his or her  own plan within a certain time period. While such individuals may  have the opportunity to change their Medicaid issuer after auto- assignment, they may choose not to do so or may not be aware of this  ability, which may affect their likelihood of remaining with their issuer  when transitioning from exchange coverage.
Finally, for individuals transitioning between Medicaid and exchange  coverage, the benefits of remaining with the same issuer for continuity of  care are uncertain. Representatives of some selected issuers reported  that covered benefits, cost-sharing, and drug formularies for their  Medicaid and exchange plans differed to some extent due in part to  differences in state and federal requirements for Medicaid and exchange  coverage, with Medicaid requiring coverage of additional services and  lower cost-sharing as compared to exchange coverage. These  differences will likely persist regardless of whether individuals remain with  the same issuer. However, officials from some selected states told us that  remaining with the same issuer when transitioning may allow individuals  to keep their health care providers, which could lead to improved  continuity of care. There is some evidence to suggest that certain issuers  offering both Medicaid and exchange coverage offer similar provider  networks. Specifically, representatives of three selected issuers that  traditionally offered Medicaid coverage reported leveraging their existing  Medicaid provider networks when expanding to the exchange, and two of  the issuers noted that most providers elected to participate. At the same  time, some officials told us that provider networks for issuers offering both  types of coverage could differ. Whether individuals transitioning between  the coverage types are able to keep their providers may depend in part  on the specific exchange plan they choose, as issuers often offer multiple  plan options on the exchange, some of which may have more similar  provider networks to Medicaid than others.
section_title: Conclusions
paragraphs: Through the creation of subsidized exchange coverage and the state  option to expand Medicaid eligibility under PPACA, many low-income  individuals have a new pathway to maintain health coverage despite  changes in income or other factors. Federal and state Medicaid and  exchange policies and procedures influence the extent to which  individuals are able to seamlessly transition between coverage types,  including whether they are able to transition without a gap in coverage  and whether they end up enrolled in both Medicaid and subsidized  exchange coverage for extended periods of time. To the extent coverage  gaps and duplicate coverage occur, individuals may decide to forgo  needed care or may unnecessarily be paying any remaining share of  exchange premiums after APTC when they should only be enrolled in  Medicaid. Additionally, duplicate coverage could mean that the federal  government is paying for both Medicaid and subsidized exchange  coverage for some individuals.
SBE states are better positioned to minimize the potential for coverage  gaps and duplicate coverage to the extent they are able to share  enrollment data across Medicaid and the exchange as well as build  controls into their IT systems to prevent duplicate coverage. For FFE  states as well as SBE states using the FFE IT systems, CMS  implemented several policies and procedures and has additional controls  planned that represent positive steps towards minimizing coverage gaps  and duplicate coverage. However, as per federal internal control  standards, those plans do not sufficiently address the risks. In particular,  CMS does not currently track and has no plans to track the timeliness of  account transfers from states, which could increase the potential that  individuals transitioning from Medicaid to the exchange will experience  coverage gaps. Additionally, CMS has not determined the frequency of its  planned checks for duplicate coverage, a factor that will be critical to their  effectiveness, and does not have a plan—including target levels of  duplicate coverage the agency deems acceptable—for monitoring the  checks and other procedures. Despite the addition of the checks,  vulnerabilities related to preventing duplicate coverage are likely to  persist, as, for example, the automated check for Medicaid during  eligibility determinations for subsidized coverage will continue to have  limitations. Thus, given the potential financial implications of duplicate  coverage and if the checks identify that it is occurring at a significant rate,  additional steps could protect the federal government and individuals from  unnecessary and duplicative expenditures.
Our findings indicate that a relatively small proportion of Medicaid and  exchange enrollees may be transitioning between coverage types, and  thus the incidence of coverage gaps and duplicate coverage could be  limited. However, to the extent that transitions increase in the future— particularly if exchange enrollment continues to grow and if additional  states expand Medicaid—improvements to CMS controls to minimize  coverage gaps and duplicate coverage for these individuals will be  increasingly important.
section_title: Recommendations for Executive Action
paragraphs: To better minimize the risk of coverage gaps and duplicate coverage for  individuals transitioning between Medicaid and the exchange in FFE  states, we recommend that the Administrator of CMS take the following  three actions:  1.  Routinely monitor the timeliness of account transfers from state  Medicaid programs to CMS and identify alternative procedures if near  real time transfers are not feasible in a state.  2.  Establish a schedule for regular checks for duplicate coverage and  ensure that the checks are carried out according to schedule.  3.  Develop a plan, including thresholds for the level of duplicate  coverage it deems acceptable, to routinely monitor the effectiveness  of the checks and other planned procedures to prevent and detect  duplicate coverage, and take additional actions as appropriate.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS and IRS for comment. In its  written comments—reproduced in appendix II—HHS concurred with our  recommendations. With regard to our first recommendation, HHS  commented that HHS monitors and reviews account transfers through  standard weekly reporting and that, if there are concerns with the  frequency of transfers, HHS resolves any issues with the states.  However, knowing the frequency of account transfers—that is, how often  the state is sending them electronically to HHS—may not provide enough  information without HHS also having information on the timeliness of  states' transfers—that is, the amount of time it takes the state to transfer  an individual's account after making a determination that the individual is  no longer eligible for Medicaid. Thus, HHS using its weekly reporting  process has the potential to meet our recommendation if the process  monitors not only the frequency of transfers but also the timeliness of  transfers. With regard to our other recommendations, HHS stated that its  first check for duplicate coverage was underway in August 2015, and that  HHS will analyze the rate of duplicate coverage identified and gather  input from states on the level of effort needed to conduct the check in  order to establish the frequency of checks going forward. HHS also stated  that it will monitor the rate of duplicate coverage identified in periodic  checks. Finally, HHS stated that it is working to implement additional  internal controls to reduce duplicate coverage, including automatically  ending subsidized exchange coverage for individuals also found to have  been determined eligible for Medicaid or CHIP who have not ended this  coverage themselves. HHS also provided technical comments, which we  incorporated as appropriate. IRS had no comments on the draft report.
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If you or your staffs have any questions about this report, please   contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov or  John E. Dicken 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 III.
section_title: Appendix I: Information on States Selected for Our Review
subsections: section_title: State States that expanded Medicaid Arizona
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Susan Barnidge, Assistant  Director; Priyanka Sethi Bansal; Keith Haddock; Laurie Pachter;   Vikki Porter; Rachel Svoboda; and Emily Wilson made key contributions  to this report.