Managed Care

Medicaid managed care delivers benefits through contracted health plans that receive payments to coordinate and cover enrollee services. Audit work examines how agencies set expectations, monitor plan performance, validate reported data, and protect access to care.

Managed care places substantial public spending and day-to-day service decisions with outside plans and their contractors. Weak contract monitoring, incomplete encounter data, or inaccurate financial reporting can conceal improper payments and make it difficult to determine whether enrollees received required care.

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. Medicaid agencies made unallowable capitation payments after enrollees’ deaths for 99 of the 100 sample capitation payments.

   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. DOH lacked sufficient oversight of managed care provider networks.

   Medicaid Program: Oversight of Managed Care Provider Networks · Office of the New York State Comptroller, Division of State Government Accountability · Oct 22, 2025

1. Review the $44.5 million in missed rebates and invoice manufacturers, as appropriate; where rebates cannot be sought due to missing NDCs or invalid procedure code and NDC combinations on physician-administered drug claims paid by MCOs, follow up with MCOs for proper drug information or seek recovery directly from MCOs for the missed rebates.

   Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program · Office of the New York State Comptroller, Division of State Government Accountability · Apr 5, 2023

2. The Health Plan should work with its parent company to strengthen the Health Plan’s processes and controls so that: Shared expenses reported (1) reflect valid expenses and (2) benefit the Health Plan. Timesheets are reviewed in accordance with the Commission’s and the parent company’s requirements.

   An Audit Report on Cook Children’s Health Plan, a Managed Care Organization · Texas State Auditor's Office · Jul 2022

3. Increase oversight of Local Management Entities/Managed Care Organizations provider enrollment.

   Medicaid Provider Enrollment Performance Audit · North Carolina Office of the State Auditor · Feb 2021

• 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
• Medicaid Program: Oversight of Managed Care Provider Networks
• A Performance Audit of the Office of Inspector General of Medicaid Services: Policy Options for Improved Governance and Medicaid Oversight
• 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
• Washington Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Payments to MCOs for Deceased Individuals
• Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
• Ohio Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Managed Care Improper Payment Estimate
• Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024
• School-Based Fee-for-Service Medicaid Reimbursements
• North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
• Maternal Health Outcomes
• Managed Care Incentive Payment Program
• 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
• 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
• Performance Audit Report: Pharmacy Benefit Manager Services for the Physical HealthChoices Medicaid Program in Pennsylvania
• California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State
• Medicaid Dental Benefit Program Manager - DentaQuest Informational Brief
• 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
• CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements
• Medicaid Capitation Paid for Members Residing in Other States
• Medicaid Audit Unit—Annual Report
• Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
• The Comprehensive Perinatal Services Program
• 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
• Children Enrolled in Medi‑Cal Face Challenges in Accessing Behavioral Health Care
• Maryland Department of Health – Medical Care Programs Administration Audit
• Medicaid Managed Care Contract Monitoring Follow-Up and Oversight of Health Plan Complaint and Grievance Handling Operational Audit
• New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
• An Actuarial Analysis Of The Health And Human Services Commission’s Fiscal Year 2024 Medicaid Managed Care Rates Actuarial Soundness
• Poor Accountability and Transparency Harm Medicaid Patients and Independent Pharmacies
• Medicaid Residency
• Office of Medicaid (MassHealth) — Review of Capitation Payments
• Medicaid CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program
• Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program
• Oregon Medicaid Managed Care Medical Loss Ratio Audit
• Proposition 56 Tobacco Tax The Department Of Health Care Services Is Not Adequately Monitoring Provider Payments Funded By Tobacco Taxes
• An Audit Report on the Health and Human Services Commission's Medicaid Managed Care Rate-Setting Process
• Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
• Arizona Health Care Cost Containment System—Review of Selected Behavioral Health Services
• An Audit Report on Cook Children’s Health Plan, a Managed Care Organization
• Medicaid Non-Emergency Medical Transportation Services
• Medicaid Program Integrity Examining the Health Care Authority’s oversight of efforts at state agencies
• An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
• Medicaid Provider Enrollment Performance Audit
• Medicaid Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare
• Medicaid Managed Care Program
• Analysis of Selected Medicaid Claims Data
• Improper Billing of Services Within the Medicaid Behavioral Health Program
• An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Medicaid Managed Care Improvements Needed to Better Oversee Payment Risks
• Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016