California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State
Learn how the AI-generated research projects were createdOverall Conclusion
We estimated that the State agency incurred costs of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments made on behalf of enrollees who were residing and concurrently enrolled for Medicaid in another State. This amount represents potential monthly savings to California’s Medicaid program that, if annualized, would amount to approximately $239 million ($186 million Federal share) in program savings.
Source Document
Audit Scope
Audit period July 1, 2021 through September 30, 2021; covered August 2021 capitation payments totaling $36.4 million for 108,800 enrollees concurrent in another State; stratified random sample of 100 enrollees reviewed.
Key Findings Summary
The State agency paid August 2021 Medicaid managed care capitation payments totaling $36.4 million on behalf of 108,800 enrollees who were concurrently enrolled in California and another State.
Based on the stratified random sample of 100 enrollees, 46 were residing and concurrently enrolled in another State, and the audit estimated a total cost of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments to enrollees residing and concurrently enrolled in another State.
The State agency did not consistently receive notification when enrollees moved out of California, and did not terminate enrollment for enrollees who notified of moving due to FFCRA continuous enrollment provisions during the PHE.
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AI-Assisted
AI Scope Summary
Future audits should examine whether California and other states have robust, timely processes to detect concurrent Medicaid enrollment using PARIS and T-MSIS data, verify residency, and disenroll nonresidents promptly to prevent capitation overpayments, with attention to procedures during or after public health emergencies.
AI-Generated Insight
The audit highlights a persistent risk of improper capitation payments from concurrent Medicaid enrollment across states. Strengthening data-sharing and residency verification (via PARIS, T-MSIS) and timely disenrollment procedures is critical to reduce avoidable costs, especially in the context of public health emergency provisions that temporarily loosened enrollment rules.
Audit Objectives
To determine whether the State agency made capitation payments on behalf of Medicaid enrollees who were concurrently enrolled in a Medicaid managed care program in another State.
Audit Findings (5)
The State agency paid August 2021 Medicaid managed care capitation payments totaling $36.4 million on behalf of 108,800 enrollees who were concurrently enrolled in California and another State.
Based on the stratified random sample of 100 enrollees, 46 were residing and concurrently enrolled in another State, and the audit estimated a total cost of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments to enrollees residing and concurrently enrolled in another State.
The State agency did not consistently receive notification when enrollees moved out of California, and did not terminate enrollment for enrollees who notified of moving due to FFCRA continuous enrollment provisions during the PHE.
Examples include enrollees residing in Oregon while concurrently enrolled in California and Oregon, and an enrollee who notified a move to Tennessee but whose enrollment was not terminated; both cases resulted in capitation payments in both States.
The PARIS system was used to identify potential concurrent enrollment and approximately 60,000 PARIS matches per quarter were reviewed, with prioritization given to high-risk matches; however staffing limitations constrained processing of all matches.
Recommendations (2)
Resume and enhance procedures to identify and disenroll enrollees who are residing and enrolled in Medicaid managed care in another State in accordance with current Federal requirements.
Work with CMS to consider the potential use of T-MSIS data to identify potential cases of concurrent enrollment.