Evidence record
Ohio Medicaid Managed Care Medical Loss Ratio Audit
- Jurisdiction
- Ohio
- Publishing agency
- Centers for Medicare & Medicaid Services
- Publication date
- July 25, 2025
- Source record
- Original document linked
Findings
3
Recommendations
11
Overall conclusion
While no remittances were required based on the findings, the audit identified multiple areas for improvement in Ohio’s oversight and reporting processes to ensure compliance with federal requirements and enhance program integrity.
Scope
The audit covered the CY 2020 reporting period for Ohio Medicaid managed care plans, including six MCPs operating under Medicaid Managed Care and Medicaid MyCare programs, with a focus on MLR reporting, remittance calculations, and oversight procedures.
Findings (3)
Each finding has a stable link.
- F-037
CMS identified 23 instances requiring correction to the MLR remittance calculations, but none resulted in a recalculated MLR below the remittance threshold (86% for MMC and 85% for MyCare).
- F-038
CMS found areas of noncompliance with federal and state Medicaid requirements across all MCPs.
- F-039
Errors in reporting templates and inconsistencies in data submission were identified, including misreporting taxes, QIA expenses, and risk corridor settlement amounts.
Recommendations (11)
- R-051
Correct errors in risk corridor and MLR reporting templates and ensure consistent runout periods.
Related finding F-039 - R-052
Revise reporting instructions to exclude non-Medicaid expenses from the MLR.
Related finding F-039 - R-053
Implement a regular reporting mechanism for special payment programs.
- R-043
Monitor receipt of State Directed Payments (SDP) and pass-through payments and reconcile with MCPs’ MLR reports.
- R-044
Include SDP in numerator and reflect SDP revenue in denominator.
- R-045
Update MLR reporting instructions to report only service-related costs for special payments and total reimbursement from the state.
- R-046
Guide MCPs on the proper inclusion of healthcare quality activity expenses.
Related finding F-039 - R-047
Require MCPs to collect all underlying data from third-party vendors and establish contracts with subcontractors.
Related finding F-039 - R-048
Request information on expense allocation methodologies, especially for non-claims expenditures.
Related finding F-039 - R-049
Require contracts with providers related to incentive payments and collect evidence of timely payments.
- R-050
Create separate line items for each special payment in MLR reports.
Related finding F-039