The Centers for Medicare & Medicaid Services’ Eligibility Review Contractor Adequately Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program
Learn how the AI-generated research projects were createdOverall Conclusion
We determined that CMS’s eligibility review contractor correctly determined Medicaid eligibility for the beneficiaries associated with all 100 sampled claims. Based on our sample results, CMS’s eligibility review contractor adequately determined Medicaid eligibility for three States (Connecticut, Pennsylvania, and Virginia) under CMS’s PERM program in accordance with Federal and State requirements. Accordingly, this report contains no recommendations.
Source Document
Audit Scope
Audit covered 1,311 Medicaid claims totaling $3,372,346 ($1,936,385 Federal share) included in the eligibility review component of the CMS PERM program for three Cycle 1 States—Connecticut, Pennsylvania, and Virginia. The States were judgmentally selected based on total Medicaid payments, individual State eligibility error rates, and the types of eligibility errors identified by CMS’s eligibility review contractor. A random sample of 100 Medicaid claims (total) for the 3 States totaling $277,748 ($149,628 Federal share) was reviewed. The audit work was conducted from April 2020 through November 2021. The objective was to assess the adequacy of the PERM program by determining whether CMS’s contractor conducted eligibility reviews for selected States in accordance with Federal and State requirements. The PERM program uses a 3-year rotational cycle to produce and report the Medicaid improper payment rate, with Cycle 1 covering the 2017-2018 payments year (RY 2019) and including Connecticut, Pennsylvania, Virginia among others. The three States for this audit were Connecticut, Pennsylvania, and Virginia.
Key Findings Summary
The report contains no recommendations.
CMS’s eligibility review contractor correctly determined Medicaid eligibility for the beneficiaries associated with all 100 sampled claims.
Based on the sample results, CMS’s eligibility review contractor adequately determined Medicaid eligibility for three States (Connecticut, Pennsylvania, and Virginia) under the PERM program in accordance with Federal and State requirements.
AI-Assisted
AI Scope Summary
To assess the adequacy of CMS’s PERM eligibility reviews by evaluating whether the contractor determined Medicaid eligibility for selected states in accordance with Federal and State requirements for the Reporting Year 2019 cycle.
AI-Generated Insight
This audit confirms that CMS’s PERM eligibility reviews for the sampled claims were correctly determined and in accord with Federal and State requirements, reinforcing the integrity of the PERM process for measuring Medicaid improper payments. The findings cover Cycle 1 states Connecticut, Pennsylvania, and Virginia with a random sample of 100 claims, but the scope is limited to three states and the Reporting Year 2019 period, so conclusions should not be generalized to all states or cycles.