Evidence record
Medicaid Capitation Paid for Members Residing in Other States
- Jurisdiction
- Rhode Island
- Publishing agency
- Rhode Island Office of the Auditor General
- Publication date
- March 26, 2024
- Source record
- Original document linked
Findings
3
Recommendations
3
Overall 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.
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.
Findings (3)
Each finding has a stable link.
- F-776
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.
- F-777
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.
- F-778
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.
Recommendations (3)
- R-683
Improve effectiveness of PARIS automated controls over residency verification by generating high priority tasks when PARIS notifications remain unresolved for 60 days or more, developing monthly PARIS match reporting, and implementing caseworker training on resolving PARIS notifications within RIBridges.
Related finding F-778 - R-682
Improve internal controls over member residency requirements for Medicaid eligibility, including enhancing and monitoring policies to identify relocated members and initiating notification and eligibility termination if a member does not respond or provide supporting documentation of residency.
Related finding F-778 - R-684
Utilize Accurint address data as a second validation to substantiate returned mail and NCOA indicators that a member has relocated; initiate documentation requests and case closure if no response is received within the notification period.
Related finding F-778