California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State

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.

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.