Evidence record
Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
- Publication date
- September 2022
- Source record
- Original document linked
Findings
7
Recommendations
1
Overall conclusion
CMS did not concur with the recommendations. The OIG maintains that the recommendations are valid and will continue to work with States to identify opportunities to reduce the number and amount of concurrent Medicaid capitation payments. The audit highlighted that concurrent enrollment led to significant potential duplicate capitation payments across states, with a sizable estimated cost and potential near-term savings if data-driven reconciliations and monitoring were enhanced. The PARIS system exists but data timing and access limitations limited effectiveness, and the COVID-19 public health emergency backdrop influenced enrollment and eligibility actions.
Scope
The audit examined capitation payments for Medicaid managed care beneficiaries who were concurrently enrolled in two states. It covered the middle month of each three-month audit window and spanned August 2019 and August 2020, corresponding periods of July-September 2019 and July-September 2020. The population was identified by matching CMS Transformed Medicaid Statistical Information System (T-MSIS) data across 47 states plus the District of Columbia and Puerto Rico to find beneficiaries with concurrent enrollment in two states. The audit included capitation payments made by two States for the same beneficiary during August 2019 and August 2020, and calculated descriptive statistics (counts of beneficiaries, number of payments, and total payment values) and illustrative comparisons (e.g., a case example). It did not require statistical sampling and focused on payments in the two-state concurrence scenario, using T-MSIS data and CMS Form CMS-64 reporting where relevant. The scope also notes CMS’s lack of active monitoring for concurrent enrollments and their limited data sharing (PARIS vs. T-MSIS) as contextual factors affecting identified payments. The period corresponds to the three-month windows around August 2019 and August 2020 and the related monthly capitation payments in those windows.
Findings (7)
Each finding has a stable link.
- F-237
Medicaid program incurred costs of approximately $72.9 million in August 2019 and $117.1 million in August 2020 for capitation payments associated with beneficiaries in one of the two concurrently enrolled States.
- F-240
An example showed Illinois paid $378 and Ohio $534 in August 2020 for the same beneficiary, with an average of $456.
- F-241
The study estimated potential monthly savings to the Medicaid program of about $72.9 million in August 2019 and $117.1 million in August 2020, with annualized savings approaching $1 billion if reconciled.
- F-235
All 47 States reviewed made capitation payments on behalf of Medicaid beneficiaries who were concurrently enrolled in two States.
- F-236
In August 2019, 208,254 concurrently enrolled beneficiaries; in August 2020, 327,497.
- F-238
CMS does not actively monitor beneficiaries’ concurrent Medicaid managed care enrollments and does not provide States with national enrollment data to identify concurrent enrollments.
- F-239
Two States often made capitation payments for the same Medicaid beneficiary because they did not have full access to data needed to identify concurrent enrollment in another State.
Recommendations (1)
- R-244
Provide States with matched T-MSIS enrollment data that identify Medicaid beneficiaries who were concurrently enrolled in a Medicaid managed care program in two States, and assist States with utilizing the data as needed to reduce future capitation payments made on behalf of beneficiaries concurrently enrolled in two States.
Related finding F-238