Evidence record
California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status
- Jurisdiction
- California
- Publication date
- May 2024
- Source record
- Original document linked
Findings
4
Recommendations
2
Overall conclusion
California improperly claimed Federal Medicaid reimbursement for capitation payments to noncitizens with UIS by applying an outdated proxy percentage that did not reflect the true costs of nonemergency services; recommends refund and coordination with CMS to determine reimbursements for an agreed period.
Scope
FFY 2019, October 1, 2018 through June 30, 2019; three FFY quarters; analysis of Medi-Cal managed care capitation payments for noncitizens with UIS and the proxy methodology used to separate nonemergency vs emergency costs; data from CAPMAN and MEDS; claims reviewed on Form CMS-64.
Findings (4)
Each finding has a stable link.
- F-860
The State agency improperly claimed $52,652,689 in Federal Medicaid reimbursement for capitation payments made on behalf of noncitizens with UIS during FFY 2019 (October 2018 through June 2019).
- F-859
The proxy percentage used by the State agency (39.87 percent) did not correctly account for the costs of providing nonemergency services to noncitizens with UIS; OIG calculated an alternative percentage of 48.36 percent.
- F-861
The proxy percentage was developed in the early 2000s and used without ongoing assessment, and without policies or procedures for periodic reassessment.
- F-862
CMS documentation of approval for the proxy methodology could not be located; CMS indicated it was not aware of the methodology's approval.
Recommendations (2)
- R-758
Refund to the Federal Government the improperly claimed Federal reimbursement of $52,652,689 for capitation payments made on behalf of noncitizens with UIS.
Related finding F-860 - R-759
Work with CMS to determine the amount of any improperly claimed Federal reimbursement for capitation payments made on behalf of noncitizens with UIS for an agreed-upon period not covered by the audit.
Related finding F-860