Evidence record
Oregon Medicaid Managed Care Medical Loss Ratio Audit
- Jurisdiction
- Oregon
- Publishing agency
- Centers for Medicare & Medicaid Services
- Publication date
- March 1, 2023
- Source record
- Original document linked
Findings
2
Recommendations
10
Overall conclusion
The audit identified areas for improvement in Oregon's Medicaid managed care MLR reporting and oversight processes. While no immediate remittance was required, implementing the recommendations will enhance compliance, accuracy, and program integrity.
Scope
This audit covers the calendar year 2019 reporting period for Oregon Medicaid Managed Care, specifically evaluating the MLR reports submitted by 15 CCOs contracted with the Oregon Health Authority. The scope includes review of the methodology, supporting documentation, and oversight procedures related to MLR calculations, remittance processes, and compliance with federal and state regulations.
Findings (2)
Each finding has a stable link.
- F-063
CMS identified 37 instances requiring correction to the reported MLR remittance calculations across all CCOs, but none resulted in a recalculated MLR below the 85% threshold, so no remittances were due.
- F-064
CMS found non-compliance with federal and state requirements in areas such as special payments, third-party vendor data, expense allocation, and quality improvement expenditures.
Recommendations (10)
- R-089
Remove health-related service costs from QIA expenditures if they do not qualify as QIA.
Related finding F-064 - R-090
Exclude fraud prevention activities from the MLR numerator until defined in regulation.
- R-091
Monitor and reconcile special payments such as QDPs and HRAs.
Related finding F-064 - R-092
Improve oversight of incentive contracts and ensure timely provider payments.
- R-093
Include QDPs and SDPs in MLR calculations as required.
Related finding F-063 - R-084
Monitor receipt of qualified directed payments and reconcile with MLR reports.
Related finding F-063 - R-085
Update instructions to disallow non-medical costs of third-party vendors, including PBMs.
Related finding F-064 - R-086
Ensure collection of underlying data from third-party vendors.
Related finding F-064 - R-087
Establish and maintain contracts with subcontractors to ensure compliance.
Related finding F-064 - R-088
Update reporting instructions to exclude non-Medicaid expenses and clarify allocation methodologies.
Related finding F-064