Washington Medicaid Managed Care Medical Loss Ratio Audit
Learn how the AI-generated research projects were createdOverall Conclusion
CMS identified eight findings requiring correction, but none resulted in an MLR recalculation below the 85% remittance threshold; the audit identified operational improvements and oversight enhancements to ensure compliance with federal MLR requirements.
Source Document
Audit Scope
CY 2021 MLR reporting by five Medicaid MCPs in Washington State (IMC and IFC programs). The audit reviewed the CY 2021 MLR Reporting Template and supporting documentation; data aggregated program-wide. CMS conducted work June 2023 to March 2025.
Key Findings Summary
Wrap-around payments for FQHCs, Rural Health Clinics (RHCs), and RHC T1015 Service Based Enhancement (RHC SBE) were not consistently classified as pass-through payments; guidance needed for accurate classification.
Incentive payments to MCPs were not consistently excluded from the MLR denominator; proper exclusion and reconciliation required.
Washington's MCPs did not consistently comply with federal MLR reporting requirements for CY 2021.
View the Findings tab to see all 8 findings
AI-Assisted
AI Scope Summary
This audit evaluated whether Washington’s five Medicaid MCPs properly submitted CY 2021 MLR reports and performed remittance calculations consistent with federal rules, examining the completeness and reasonableness of underlying data and supporting documentation, and identifying opportunities to improve state oversight and MLR reporting practices for future audits.
AI-Generated Insight
The CY 2021 Washington MLR audit shows recurring misclassification and documentation gaps in MLR reporting across five MCPs, with focus areas including SDPs, pass-through vs wrap-around payments, incentive exclusions, non-claims costs, QIA, and runout/I BN R. The findings underscore the need for clearer MLR template guidance, stricter state oversight, and standardized runout and accrual practices to strengthen accuracy in future audits.