The Obama administration has come under fire for weeks now for selectively releasing "enrollment" data for Healthcare.gov and the state exchanges. The latest figure of 2.1 million was met with skepticism by many observers, even some who are sympathetic to the administration. However, based on previously published guidance for insurers by the Centers for Medicare and Medicaid Services (CMS), it is likely any data the administration has on paid enrollments is substantially incomplete.
On October 3, two days after the launch of Healthcare.gov, CMS published a document called "Federally Facilitated Marketplace Enrollment Operational Policy & Guidance." The manual begins with a preamble that reads in part:
This draft manual will go into effect with minimal changes as of October 1, 2013. All enrollments made on or after October 1, 2013, must be processed in accordance with these requirements. It is CMS’ intention that this will be a living document, updated regularly, and supported by clarifying bulletins in the interim between updates.
Although CMS says the manual will be "updated regularly," it appears from the Regulations and Guidance page of CMS's website that the October 3 draft of the manual is the most recent version. That same page does, however, include various updates relating to the Affordable Care Act, including one just issued on December 31.
The pertinent guidance relating to the reporting of enrollment data is found in the October 3 draft manual in Section 2.4, "Relationship between Premium Payments and the Confirmation/Effectuation 834 Transaction." Some of this guidance is already outdated, such as these statements: "Issuers do not have the ability to grant grace periods for payment of the initial month’s premium" and "issuers may receive payments the day prior to the enrollee’s coverage effective date." Once it became clear that January 1 coverage would be jeopardized for many due to problems with the website, CMS worked with insurers to extend payment due dates to January 10 in some cases. California, which operates its own exchange, extended the payment deadline to January 15. Several Blue Cross Blue Shield plans, including Illinois and Texas, have extended their deadlines all the way to January 31, according to a Wednesday report from Reuters.
The portion of the guidance from the October 3 manual that directly impacts the timing of reporting, which technically only applies to the Federally Facilitated Exchanges (FFEs) but practically speaking would affect the state exchanges also, reads as follows [emphasis added]:
For purposes of generating the confirmation transaction, full payment occurs when the issuer receives full payment... of the portion of the premium for which the enrollee is responsible. We realize that some enrollees will wait until just prior to their coverage effective date to make payment, and therefore issuers may receive payments the day prior to the enrollee’s coverage effective date. In such circumstances issuers may not be able to transmit all confirmation transactions prior to the coverage effective date. However, the FFM expects QHP and QDP issuers to send all confirmation transactions by the fifth calendar day of the effective month of coverage.
Under the original guidance, this would have meant all insurers would have been required to send confirmations to CMS by January 5. However, with the payment deadlines extended to as late as January 31, those insurers presumably have until as late as February 5 to transmit the confirmation of paid enrollments for coverage effective January 1 to CMS. Again, although this guidance applies specifically to FFEs, state exchanges will need to transmit confirmations to CMS as well in order to have tax credit subsidies processed and paid to insurers.
As noted in the guidance, insurers must send confirmations after receiving payment from consumers and not wait for the balance of the payment from ant government subsidy. It is unclear when and how those subsidies will be remitted to insurers since the "back end" of the system is apparently still under construction.
February 5 may actually be an optimistic estimate of when complete paid enrollment data will be available. The following diagram is from a March 2013 version of a CMS document regarding transaction information in the FFEs:
Although revisions of this process will have changed the information flows illustrated by this diagram, the inclusion of information from state exchanges will certainly not make the accumulation of aggregate enrollment data any simpler. The public may have to wait until mid-February (or later!) to find out the true Obamacare enrollment as of its January 1, 2014 debut.