Consumers can enroll in a PPACA qualified health plan offered through a marketplace, or change their previously selected qualified health plan, after the annual open enrollment period concludes if they qualify for an SEP. Under CMS regulations, a consumer may qualify for an SEP due to a specific triggering event, and generally would have up to 60 days after the event to select and enroll in a qualified health plan. Examples of qualifying events include but are not limited to losing minimum essential health coverage of the individual or his or her dependent; gaining a dependent or becoming a dependent through marriage, birth, adoption, placement for adoption, or placement in foster care, or through a child-support order or other court order; gaining access to new qualified health plans as a result of a not enrolling during the annual open enrollment period, or other enrollment period for which the consumer qualified, was unintentional, inadvertent, or erroneous and is the result of error, misrepresentation, misconduct, or inaction by the Marketplace or its agents; applying for Medicaid or the Children’s Health Insurance Program during the open enrollment period, or other enrollment period for which the consumer qualified, and being determined ineligible after the enrollment period ended; and demonstrating to the marketplace that the individual meets other exceptional circumstances as the marketplace may provide. While PPACA requires marketplaces to verify application information to determine eligibility for enrollment and income-based subsidies—such as verifying U.S. citizenship, nationality, or lawful presence—there is no specific legal requirement to verify the events that trigger an SEP. Specifically, there is no specific legal requirement that federal or state marketplaces (1) request documents to support an SEP triggering event or (2) authenticate the documents submitted to support an SEP event to determine whether those documents are fictitious. According to CMS officials and state officials, consumers that claim eligibility to enroll during an SEP must attest under penalty of perjury that they meet the conditions of eligibility for an SEP. In February 2016, however, CMS announced plans to begin requesting supporting documentation to verify certain events that would trigger an SEP. Specifically, CMS announced its intention to establish a Special Enrollment Confirmation Process in which consumers who enroll or change plans using an SEP through the federal Marketplace will be directed to provide documentation for any of the following triggering events: (1) loss of minimum essential coverage; (2) permanent move; (3) birth; (4) adoption, placement for adoption, placement for foster care or child support or other court order; or (5) marriage. According to the notice, CMS will provide consumers with lists of qualifying documents, such as a birth or marriage certificate. In June 2016, CMS announced that it would begin requesting some supporting documentation beginning on June 17, 2016. State-based marketplaces are not required to follow CMS’s Special Enrollment Confirmation Process, but states may choose to follow this guidance or establish their own processes, according to CMS officials. States may also choose to accept a consumer’s attestation of the SEP triggering event without further verification. For example, according to state officials from Covered California, the state-based marketplace accepts self-attestation and requests supporting documents for a random sample of eligible consumers for certain SEP triggering events. According to officials from the DC Health Benefit Exchange Authority, the state-based marketplace accepts self-attestation for three of the six SEP triggering events we tested. We have previously testified and reported on various aspects of PPACA enrollment controls as part of our ongoing work in this area. For example, in July 2014 we testified on our undercover attempts to obtain health-care coverage offered by the federal Marketplace for coverage- year 2014 using fictitious identities and false documentation. We were successful in 11 out of 12 attempts to do so. In October 2015, we testified on similar undercover testing for coverage-year 2015 where we were successful in 17 of 18 attempts. In February 2016 we issued a report addressing CMS enrollment controls and the agency’s management of enrollment-fraud risk. The February 2016 report included eight recommendations, which are discussed below, to strengthen CMS oversight of the Marketplace. In September 2016, we issued two reports and testified about addressing the potential vulnerabilities to fraud in the application, enrollment, and eligibility-verification controls of the federal Marketplace and selected state marketplaces for PPACA’s second and third open enrollment periods, for 2015 and 2016 coverage, respectively. In our February 2016 report, we recommended that the Secretary of Health and Human Services direct the Acting Administrator of CMS to: (1) conduct a feasibility study and create a written plan on actions that CMS can take to monitor and analyze the extent to which data hub queries provide requested or relevant applicant verification information; (2) track the value of enrollee subsidies that are terminated or adjusted for failure to resolve application inconsistencies, and use this information to inform assessments of program risks; (3) regarding cost-sharing subsidies that are terminated or adjusted for failure to resolve application inconsistencies, consider and document whether it would be feasible to create a mechanism to recapture those costs; (4) identify and implement procedures to resolve Social Security number inconsistencies where the Marketplace is unable to verify Social Security numbers or applicants do not provide them; (5) reevaluate CMS’s use of certain incarceration status data and determine to either use these data or accept applicant attestation on status in all cases; (6) create a written plan and schedule for providing Marketplace call center representatives with access to information on the current status of eligibility documents submitted to CMS’s documents processing contractor; (7) conduct a fraud-risk assessment, consistent with best practices described in GAO’s framework for managing fraud risks in federal programs, of the potential for fraud in the process of applying for qualified health plans through the federal Marketplace; and (8) fully document prior to implementation, and have readily available for inspection thereafter, any significant decision on qualified health-plan enrollment and eligibility matters, with such documentation to include details such as policy objectives, supporting analysis, scope, and expected costs and effects. In formal comments on a draft of the report, HHS concurred with our recommendations and outlined a number of steps it plans to take to implement them. In an April 2016 letter, HHS described a number of specific actions it had taken in response to our eight recommendations, such as creating an integrated project team to perform the Marketplace fraud-risk assessment. In May 2016, we requested that CMS provide detailed documentation and other evidence to help corroborate the various actions described in the HHS letter. As of November 2016, CMS’s response to this request was pending. Consequently, we consider all eight recommendations to remain open as of November 2016, pending corroborating information. We will continue to monitor HHS’s progress in implementing them. Implementing these recommendations as intended, such as performing the fraud-risk assessment, could help address some of the control vulnerabilities we identified during our SEP tests as well. Concerning our current work, the federal or selected state-based marketplaces approved subsidized coverage for 9 of our 12 fictitious applicants seeking coverage during an SEP for 2016. Three of our 12 fictitious applicants were denied. Figure 1 summarizes the outcome of the 12 fictitious applications, which are discussed in greater detail below. The federal and selected state-based marketplaces requested supporting documentation for 6 of our 12 fictitious applicants who initially applied online or by telephone seeking coverage during an SEP. On the basis of our design for the scenario, we provided the federal and selected state- based marketplaces either no supporting documentation or fictitious documentation related to the SEP triggering event. As described below, in some instances we provided fictitious documents to the federal and selected state-based marketplaces to support the SEP triggering event and were able to obtain and maintain subsidized health coverage. Our applicant experiences are not generalizable to the population of applicants or marketplaces. The federal or selected state-based marketplaces approved coverage and subsidies for 9 of our 12 fictitious applicants who initially applied online or by telephone seeking coverage during an SEP, as of October 2016. For these 9 applications, we were approved for APTC subsidies, which totaled about $1,580 on a monthly basis, or about $18,960 annually. These 9 applicants also each were approved for CSR subsidies, putting them in a position to further benefit if they used medical services. However, in our tests, our fictitious applicants did not seek medical services. The federal or state-based marketplaces denied coverage for 3 of our 12 fictitious applicants. Specifically: One applicant stated that the applicant did not receive any response from the marketplace after attempting to enroll in a health plan in a community center in January 2016. This fictitious applicant claimed that the applicant had applied for coverage to the federal Marketplace and that the applicant did not discover the applicant was not enrolled in a health plan until June 2016—about 6 months after the applicant’s claimed initial contact with the marketplace. The marketplace representative stated that the applicant needed to follow up with the marketplace and select a health plan within 60 days of the SEP- triggering event, which in this case was misinformation or misrepresentation by a non-Marketplace entity providing enrollment assistance in January of 2016. Under CMS regulations, for this type of triggering event the marketplace may define the length of the SEP as appropriate based on the circumstances, up to a maximum of 60 days. The second fictitious applicant who applied for coverage to the state- based marketplace and was denied coverage claimed that the applicant initially tried to enroll in January 2016 and was told by a certified enrollment counselor that the applicant qualified for a high deductible plan, but did not qualify for a premium tax credit or CSR. When the applicant followed up with the state-based marketplace to obtain additional information, the marketplace representative requested the name of the enrollment counselor with whom the applicant initially applied for health coverage in January 2016.