Medicaid Capitation Paid for Members Residing in Other States
Learn how the AI-generated research projects were createdOverall Conclusion
Rhode Island Medicaid paid approximately $38.4 million in capitation payments to MCOs for members who were not residing in Rhode Island, indicating noncompliance with state and federal residency requirements; controls over residency verification were not fully effective, but PARIS and Accurint data were identified as reliable data sources with corrective actions anticipated by the agency.
Source Document
Audit Scope
In collaboration with the HHS Office of Inspector General, Rhode Island Office of the Auditor General conducted a performance audit of the RI Medicaid program to determine whether capitation payments to MCOs were made on behalf of ineligible members who resided and received benefits in another state or territory for January 1, 2019 through December 31, 2021. The audit scope included evaluation of RI Medicaid’s residency verification controls (PARIS interstate matching, NCOA, Accurint usage) and the processes by which RI Medicaid terminates eligibility when members move out of state. The audit relied on testing a stratified random sample of 100 RI Medicaid members with overlapping capitation payments identified in T-MSIS data, and reviewed data from RI Briges, PARIS, Accurint, and the MCO encounter data. It also considered the impact of the Public Health Emergency (FFCRA-related continuous coverage) and related guidance, and noted that EOHHS agreed with the auditors' recommendations.
Key Findings Summary
RI Medicaid made an estimated $38.4 million in capitation payments to MCOs for members who resided in and enrolled in Medicaid programs in nine other states and Puerto Rico during January 1, 2019 through December 31, 2021.
From the 100-member sample, 60 had concurrent capitation payments in other states or territories; RI Medicaid paid 1,030 capitation payments totaling $833,082 on behalf of these 60 members.
Internal controls over residency requirements were not operating effectively to ensure eligibility was limited to Rhode Island residents; PARIS notifications were not consistently followed up; RI Medicaid did not consistently utilize Accurint data as a second validation.
AI-Assisted
AI Scope Summary
To quantify Rhode Island Medicaid's improper capitation payments due to out-of-state residency and to assess and strengthen RI Medicaid's residency verification controls and PARIS utilization.
AI-Generated Insight
This audit highlights systemic gaps in residency verification for Medicaid across states, underscoring the value of automated data matching (PARIS), secondary validation (Accurint, NCOA), and timely case management to prevent ineligible capitation payments and improve federal and state program integrity.