Ohio Medicaid Managed Care Medical Loss Ratio Audit
Learn how the AI-generated research projects were createdOverall Conclusion
While no remittances were required based on the findings, the audit identified multiple areas for improvement in Ohio’s oversight and reporting processes to ensure compliance with federal requirements and enhance program integrity.
Source Document
Audit Scope
The audit covered the CY 2020 reporting period for Ohio Medicaid managed care plans, including six MCPs operating under Medicaid Managed Care and Medicaid MyCare programs, with a focus on MLR reporting, remittance calculations, and oversight procedures.
Key Findings Summary
CMS identified 23 instances requiring correction to the MLR remittance calculations, but none resulted in a recalculated MLR below the remittance threshold (86% for MMC and 85% for MyCare).
CMS found areas of noncompliance with federal and state Medicaid requirements across all MCPs.
Errors in reporting templates and inconsistencies in data submission were identified, including misreporting taxes, QIA expenses, and risk corridor settlement amounts.
AI-Assisted
AI Scope Summary
The audit aimed to assess the accuracy and compliance of Ohio Medicaid managed care plans' Medical Loss Ratio reporting for 2020, focusing on supporting documentation, data accuracy, and oversight mechanisms to ensure proper financial management and adherence to federal regulations.
AI-Generated Insight
The audit underscores the importance of rigorous oversight, accurate data reporting, and transparent contractual practices in Medicaid managed care to ensure financial accountability and quality of care. Addressing identified deficiencies can strengthen compliance and optimize program performance.
Audit Objectives
To determine if MCPs submitted annual MLR reports to Ohio pursuant to federal requirements.
To verify if annual MLR reporting and minimum MLR remittance calculations are supported by the underlying data and supporting documentation.
Audit Findings (3)
CMS identified 23 instances requiring correction to the MLR remittance calculations, but none resulted in a recalculated MLR below the remittance threshold (86% for MMC and 85% for MyCare).
CMS found areas of noncompliance with federal and state Medicaid requirements across all MCPs.
Errors in reporting templates and inconsistencies in data submission were identified, including misreporting taxes, QIA expenses, and risk corridor settlement amounts.
Recommendations (11)
Correct errors in risk corridor and MLR reporting templates and ensure consistent runout periods.
Revise reporting instructions to exclude non-Medicaid expenses from the MLR.
Implement a regular reporting mechanism for special payment programs.
Monitor receipt of State Directed Payments (SDP) and pass-through payments and reconcile with MCPs’ MLR reports.
Include SDP in numerator and reflect SDP revenue in denominator.
Update MLR reporting instructions to report only service-related costs for special payments and total reimbursement from the state.
Guide MCPs on the proper inclusion of healthcare quality activity expenses.
Require MCPs to collect all underlying data from third-party vendors and establish contracts with subcontractors.
Request information on expense allocation methodologies, especially for non-claims expenditures.
Require contracts with providers related to incentive payments and collect evidence of timely payments.
Create separate line items for each special payment in MLR reports.