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. CBH did not comply with address-change notification procedures and sent denial notices to incorrect addresses (17 denied service requests).

   Medicaid Managed Care Behavioral Health Service Denials in Philadelphia by Community Behavioral Health · Office of Inspector General, U.S. Department of Health and Human Services · Jun 2026

2. AES continued to create multiple IDs for the same individual, resulting in estimated overpayments of $235,642.66 for 119 members identified May 2024–April 2025, and challenges locating existing IDs when biographical information is incorrect.

   Multiple Identification Numbers in Texas Medicaid and CHIP · Texas Health and Human Services Commission Office of Inspector General · Jan 12, 2026

3. The automated and county-initiated processes for terminating enrollment did not consistently include inmates in non-IDOC custody or other facility types, leading to unallowable payments.

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

1. Ensure its encounter system accurately identifies members enrolled in a STAR+PLUS HCBS waiver.

   Dental Value-Added Services—Wellpoint · Texas Health and Human Services Commission Office of Inspector General · Feb 20, 2026

2. 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

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

• Medicaid Managed Care Behavioral Health Service Denials in Philadelphia by Community Behavioral Health
• Dental Value-Added Services—Wellpoint
• Multiple Identification Numbers in Texas Medicaid and CHIP
• 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
• Additional Actions Needed to Enhance Program Integrity and Save Billions
• 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
• Medicaid Correspondence Performance Audit
• Medicaid Residency
• Kansas Medicaid and CHIP Eligibility Determinations Audit
• Office of Medicaid (MassHealth) — Review of Capitation Payments
• Public Assistance Reporting Information System Alerts
• Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
• An Audit Report on Cook Children’s Health Plan, a Managed Care Organization
• The Centers for Medicare & Medicaid Services’ Eligibility Review Contractor Adequately Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program
• An Audit Report on The Health and Human Services Commission’s Oversight of the Medical Transportation Program
• Medicaid and Children's Health Insurance Program Client Eligibility Determinations
• Improper Capitation Payments
• MassHealth Payments for Hospice-Related Services for Dual-Eligible Members
• Despite the COVID-19 Public Health Emergency, the Department Can Do More to Address Chronic Medi-Cal Eligibility Problems
• Medicaid Home Help Program
• Medicaid Managed Care Program
• Medicaid Eligibility Determinations: Status on the Use of Federal Tax Information
• Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016
• Review of Medicaid Provider Reimbursements made to Crest Transportation Service