Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
Learn how the AI-generated research projects were createdOverall Conclusion
CMS did not concur with the recommendations. The OIG maintains that the recommendations are valid and will continue to work with States to identify opportunities to reduce the number and amount of concurrent Medicaid capitation payments. The audit highlighted that concurrent enrollment led to significant potential duplicate capitation payments across states, with a sizable estimated cost and potential near-term savings if data-driven reconciliations and monitoring were enhanced. The PARIS system exists but data timing and access limitations limited effectiveness, and the COVID-19 public health emergency backdrop influenced enrollment and eligibility actions.
Source Document
Audit Scope
The audit examined capitation payments for Medicaid managed care beneficiaries who were concurrently enrolled in two states. It covered the middle month of each three-month audit window and spanned August 2019 and August 2020, corresponding periods of July-September 2019 and July-September 2020. The population was identified by matching CMS Transformed Medicaid Statistical Information System (T-MSIS) data across 47 states plus the District of Columbia and Puerto Rico to find beneficiaries with concurrent enrollment in two states. The audit included capitation payments made by two States for the same beneficiary during August 2019 and August 2020, and calculated descriptive statistics (counts of beneficiaries, number of payments, and total payment values) and illustrative comparisons (e.g., a case example). It did not require statistical sampling and focused on payments in the two-state concurrence scenario, using T-MSIS data and CMS Form CMS-64 reporting where relevant. The scope also notes CMS’s lack of active monitoring for concurrent enrollments and their limited data sharing (PARIS vs. T-MSIS) as contextual factors affecting identified payments. The period corresponds to the three-month windows around August 2019 and August 2020 and the related monthly capitation payments in those windows.
Key Findings Summary
All 47 States reviewed made capitation payments on behalf of Medicaid beneficiaries who were concurrently enrolled in two States.
In August 2019, 208,254 concurrently enrolled beneficiaries; in August 2020, 327,497.
Medicaid program incurred costs of approximately $72.9 million in August 2019 and $117.1 million in August 2020 for capitation payments associated with beneficiaries in one of the two concurrently enrolled States.
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AI-Assisted
AI Scope Summary
To determine whether States paid capitation payments for Medicaid beneficiaries who were concurrently enrolled in a Medicaid managed care program in two States, and to assess data-driven options to prevent duplicate capitation payments.
AI-Generated Insight
The OIG audit reveals a systemic issue where Medicaid capitation payments were made for beneficiaries concurrently enrolled in two states, resulting in substantial potential overpayments. Despite CMS’s reliance on PARIS and concerns about data timeliness, the audit demonstrates that centralized data analysis (via T-MSIS) can reveal multi-state eligibility and payment overlaps that States and CMS can leverage to stop duplicate payments and save hundreds of millions annually. The report underscores the need for improved data access and cross-state reconciliation, especially as states navigate the COVID-19-era policy relaxations and unwind ongoing eligibility actions.