Eligibility and Enrollment

Eligibility and enrollment controls determine who qualifies for Medicaid, when coverage begins or ends, and whether beneficiary records remain accurate. Audits test determinations, renewals, residency, duplicate enrollment, and the timely processing of case changes.

Eligibility errors can produce payments for people who no longer qualify, interrupt coverage for eligible beneficiaries, or allow the same person to be enrolled in more than one jurisdiction. Reliable case data and timely action are also prerequisites for accurate federal reimbursement.

1. The State agency did not always terminate Medicaid managed care enrollment after receiving notification that an enrollee was incarcerated, with 29 cases where termination did not occur as required.

   Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees · U.S. Department of Health and Human Services, Office of Inspector General · Dec 2025

2. The unallowable payments occurred for the following reasons: 29 capitation payments lacked the enrollee’s date of death in the death data sources; 14 capitation payments did not have the DOD in MMIS but DOD was available via other sources (e.g., SOLQ or vital statistics); 4 capitation payments had DOD in MMIS consistent with DMF but eligibility was not updated after death; 2 capitation payments had DOD inconsistencies where MMIS DOD was after DMF DOD.

   Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees · U.S. Department of Health and Human Services, Office of Inspector General · Dec 2025

3. MassHealth paid providers $27,400 for durable medical equipment that was ordered for members who were deceased.

   Review of Durable Medical Equipment Providers · Massachusetts Office of the State Auditor · Oct 30, 2025

1. CMS should collect better data on Medicaid payments, including the source of nonfederal funding and beneficiary enrollment data across states.

   Medicaid Managed Care Improper Payment Estimate · U.S. Government Accountability Office · Jun 26, 2025

2. MassHealth should require that all members flagged by data matches submit documentation to confirm their identity. If the member does not provide documentation, then MassHealth should either pause the member’s coverage or move the member to its fee-for-service model until it can determine whether the member’s coverage should be terminated.

   Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers · Massachusetts Office of the State Auditor · Dec 31, 2024

3. Verify the residence status of live-in caregivers to ensure EVV exemptions are valid.

   Medicaid Program: Provider Compliance With the Electronic Visit Verification Program · Office of the New York State Comptroller, Division of State Government Accountability · Nov 13, 2024

• Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees
• Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees
• Review of Durable Medical Equipment Providers
• How Kentucky Failed to Prevent Over $800 Million of Medicaid Waste
• Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State
• Medicaid Payments to MCOs for Deceased Individuals
• Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
• Performance Audit of Medicaid Eligibility Determinations for Long-Term Care
• Medicaid Managed Care Improper Payment Estimate
• Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024
• Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
• Performance Audit of the Health Benefits for Immigrant Seniors and Adults
• Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers
• Medicaid Program: Provider Compliance With the Electronic Visit Verification Program
• The Oregon Eligibility System Appropriately Determines Eligibility, But Input Errors Continue to Occur
• Examining Washington’s Concurrent Medicaid Enrollments
• Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments
• Performance Audit of Selected Programs and Activities of the Division of TennCare
• California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State
• California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status
• Oversight Of Medicaid Quality Care
• Medicaid Capitation Paid for Members Residing in Other States
• The Cost of Concurrent Enrollment
• Medicaid Audit Unit—Annual Report
• Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
• Maryland Department of Health Medical Care Programs Administration Managed Care Program Audit Report
• Maryland Department of Health Medical Care Programs Administration Audit Report
• Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
• Maryland Department of Health – Medical Care Programs Administration Audit
• States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort
• Medicaid Correspondence Performance Audit
• Medicaid Residency
• Kansas Medicaid and CHIP Eligibility Determinations Audit
• Office of Medicaid (MassHealth) — Review of Capitation Payments
• Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
• The Centers for Medicare & Medicaid Services’ Eligibility Review Contractor Adequately Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program
• Medicaid and Children's Health Insurance Program Client Eligibility Determinations
• Despite the COVID-19 Public Health Emergency, the Department Can Do More to Address Chronic Medi-Cal Eligibility Problems
• Medicaid Managed Care Program
• Medicaid Eligibility Determinations: Status on the Use of Federal Tax Information
• Department of Social Services Prescription Drug Oversight
• Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016
• Review of Medicaid Provider Reimbursements made to Crest Transportation Service