Audit of the Commonwealth Health Insurance Connector Authority
January 16, 2018 · Commonwealth Health Insurance Connector Authority · Read the full official report on mass.gov ↗
Published January 16, 2018 Audit covers July 1, 2014 – June 30, 2016 Under Suzanne M. Bump · 2011–2023
source
“CCA did not ensure that its database was accurate.”
Read the plain-English breakdown
This is a state performance audit of the Massachusetts Health Connector, the agency that helps residents get affordable health insurance, covering July 1, 2014 through June 30, 2016.
“This report details the audit objectives, scope, methodology, findings, and recommendations for the audit period, July 1, 2014 through June 30, 2016.”
Auditors checked whether the Health Connector was properly confirming who qualified for benefits and whether people were getting adequate customer service.
“In this performance audit, we determined whether CCA was properly verifying the eligibility of applicants and individuals/families currently receiving benefits and whether CCA was providing a sufficient level of customer service.”
If addresses and eligibility records are wrong, people could receive public health insurance help they do not qualify for, or receive the wrong level of help.
“By not performing periodic verifications of program participants’ addresses and then using the addresses to update its database, CCA may be providing participants with benefits or a level of benefits to which they are not entitled.”
For an ordinary Massachusetts resident, this matters because the Health Connector is supposed to help people get affordable coverage and make sure that help goes only to eligible residents.
“People who do not meet the required income eligibility levels to participate in the Commonwealth’s Medicaid program (MassHealth) are referred to CCA, whose function is to help them obtain affordable health insurance.”
The Auditor said the Health Connector needed better controls over both its eligibility database and its contractor’s customer-service performance.
“CCA did not ensure that Dell Marketing LP met all of the customer service standards and service-level agreements (SLAs) that were established in CCA’s contract with Dell.”
The report recommended that the Health Connector fix and regularly review its database, monitor contractor performance, and cross-train staff who review invoices.
“CCA should immediately take the measures necessary to update the information in its database.”
The audit found concrete examples of bad address data, including addresses that were businesses instead of homes, and also found missed penalties against the customer-service contractor.
“In some instances, the home addresses were commercial properties, not residences, including a church and a warehouse in Hyannis, a strip mall in Middleborough, and a check-casher/tax-preparer business in Salem.”
APTC means federal help paid in advance to lower a person’s monthly health insurance premium, based on expected yearly household income.
“The amount of the APTC is calculated by CCA based on a member’s projected annual household income and is applied by CCA to the member’s monthly insurance premium.”
What the Auditor checked
- Did not comply Does CCA conduct residency requirement tests to ensure that all applicants receiving benefits meet the criteria established by Section 502.000 of Title 130 of the Code of Massachusetts Regulations?
- Did not comply Has CCA established a system to monitor and measure customer service to satisfy the requirements for availability, choice, and adoption of private health insurance plans to eligible individuals and groups?
What the Auditor found
Why it matters: CCA may have provided benefits, or incorrect benefit levels, to participants who were not entitled to them.
Standard: Title 130 of the Code of Massachusetts Regulations requires verification of eligibility factors including residency. ( Section 502.003 of Title 130 of the Code of Massachusetts Regulations; Section 503.002 of Title 130 of the Code of Massachusetts Regulations )
2 recommendations
- CCA should review its verification process and ensure that adequate controls exist to require database information to be reviewed for completeness and accuracy and updated regularly.agency: agreed
- CCA should immediately update the information in its database.agency: agreed
Agency response & Auditor reply
Auditor: "Based on its response, CCA is taking measures to address our concerns in this area."
Why it matters: CCA risked paying more than it should and not ensuring that customers received required service levels.
Standard: CCA's contract with Dell required review of payment vouchers, verification of contract compliance, and penalties for missed performance metrics.
2 recommendations
- CCA should implement internal controls to monitor performance metrics and determine Dell's compliance with service-level agreements.agency: agreed
- CCA should cross-train key personnel responsible for reviewing invoices for accuracy.agency: agreed
Agency response & Auditor reply
Agency: "As a result of this control, CCA believes that the discrepancies identified by the audit will not recur."
Auditor: "Based on its response, CCA is taking measures to address our concerns in this area."
Verified dollar findings
Money the entity was owed but failed to assess or collect - unassessed penalties, underpaid incentives.
Identified dollar findings that do not fall in a named band.
Contract sizes, limits, thresholds, and fund balances - scale figures, never counted as money found.
More audits of this entity
Other Office of the State Auditor reports on Commonwealth Health Insurance Connector Authority .
- Audit of the Commonwealth Health Insurance Connector Authority (December 23, 2024)Authority / Commission · December 23, 2024