§ 155.1625 Determining payment errors.
(a)Review of records and error identification—
(1)Systematic review process. For each sampled record, HHS will conduct a comprehensive review of all information provided by the State Exchange using standardized review criteria.
(2)Data sources. HHS will conduct reviews using the tax household information provided under § 155.1615(b)(3), supplemented by any relevant consumer-submitted documents that were gathered by the State Exchange as part of the enrollment and eligibility process and provided to HHS. (3)Error identification. The review will identify whether the State Exchange made any errors related to the following resulting in improper payments of APTC:
(i)Enrolling or re-enrolling a consumer into a QHP for which APTC was paid.
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§ 155.1625 Determining payment errors.
(a) Review of records and error identification—(1) Systematic review process. For each sampled record, HHS will conduct a comprehensive review of all information provided by the State Exchange using standardized review criteria.
(2) Data sources. HHS will conduct reviews using the tax household information provided under § 155.1615(b)(3), supplemented by any relevant consumer-submitted documents that were gathered by the State Exchange as part of the enrollment and eligibility process and provided to HHS.
(3) Error identification. The review will identify whether the State Exchange made any errors related to the following resulting in improper payments of APTC:
(i) Enrolling or re-enrolling a consumer into a QHP for which APTC was paid.
(ii) Consumer eligibility for APTC being paid on the consumer's behalf.
(iii) Calculating the APTC amount that was paid on the consumer's behalf.
(iv) Taking required actions upon changes to a consumer's status that would affect their APTC-related eligibility or payment amount.
(4) Review standards and criteria. HHS will apply consistent review standards based on the APTC-related determination requirements established in subparts D and E of this part, and other applicable provisions of this part.
(b) Error evaluation. HHS will evaluate each error to determine an improper payment amount. For each error identified, HHS will:
(1) Calculate the correct APTC amount based on the requirements of section 36B of the Internal Revenue Code and applicable implementing regulations.
(2) Determine an improper payment amount.
(3) Document the error and improper payment amount within a Sampled Unit Assessment Package and provide the Sampled Unit Assessment Package to the State Exchange.
(4) Extrapolate the identified improper payments from the sample to estimate the total improper payment amount for the State Exchange's entire universe of APTC payments, using statistically valid methodologies that comply with OMB guidance on improper payment estimation.
(c) Reporting. HHS will report annually in the Agency Financial Report, which is made available to the public:
(1) The estimated aggregate improper payment rate for Federal and State Exchanges combined.
(2) The estimated aggregate improper payment rate for State Exchanges, and;
(3) HHS will provide to each State Exchange a report that documents the State-specific improper payment rate and error analysis.