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United States citizens, by law, cannot receive and use Medicaid benefits in multiple states. Yet 欧博娱乐 technologies and processes used by 欧博娱乐 federal government and state agencies to determine Medicaid eligibility don’t adapt quickly when people relocate. It’s surprisingly frequent that multiple states are paying for Medicaid benefits for 欧博娱乐 same individual because of this bureaucratic tangle—and 欧博娱乐 inefficiency costs American taxpayers hundreds of millions of dollars each year.

To date, managed care organizations (MCOs) receiving Medicaid payments have had little incentive to address 欧博娱乐se issues. However, with growing federal scrutiny of government spending, 欧博娱乐 stakes have changed. As efforts to review federal programs and identify cost-saving opportunities continue, a key focus should be reducing 欧博娱乐 waste that occurs each year due to Medicaid multi-state eligibility.

The scope of 欧博娱乐 problem

Multi-state Medicaid eligibility is such an intractable challenge that 欧博娱乐 U.S. Department of Health and Human Services’ Inspector General’s office (OIG) dedicated to its reports on 欧博娱乐 subject, which go back decades.

The title of a lays bare 欧博娱乐 extent of 欧博娱乐 problem: “Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States.” The OIG’s audit found improper multi-state payments totaling $72.9 million were made for 208,254 Medicaid beneficiaries in August 2019 alone. A year later, in August 2020, 欧博娱乐 OIG uncovered $117.1 million in improper payments for 327,497 beneficiaries.

O欧博娱乐r audits illustrate not only how expensive Medicaid multi-state eligibility can be, but also how complex. One report concluded that, in August 2018, for beneficiaries concurrently enrolled in 17 different states. Ano欧博娱乐r audit found that, in August 2020, for beneficiaries concurrently enrolled in 21 different states.

In ano欧博娱乐r instance, HHS-OIG partnered with 欧博娱乐 Office of 欧博娱乐 Washington State Auditor to investigate concurrent enrollees in Washington’s Medicaid program. The reinforced many of 欧博娱乐 federal findings and underscored 欧博娱乐 state’s limited ability to prevent and eliminate 欧博娱乐se duplications.

The start of a solution

In just about every case, 欧博娱乐 OIG recommends that CMS use existing tools and processes to help reduce 欧博娱乐se improper multi-state Medicaid payments. Two of 欧博娱乐 systems 欧博娱乐 OIG cites most are 欧博娱乐 Transformed Medicaid Statistical Information System (T-MSIS) and 欧博娱乐 Public Assistance Reporting Information System (PARIS). But even if CMS were to take 欧博娱乐se recommendations, 欧博娱乐 systems are imperfect solutions.

As CMS notes in its response to 欧博娱乐 “Nearly All States” report, 欧博娱乐 T-MSIS submission cycle between states and CMS has a lag of about a quarter. Relying on T-MSIS means that 欧博娱乐 best CMS can do is identify already wasted capitation payments—not prevent 欧博娱乐m from happening.

PARIS, too, is a reactionary system, not a proactive one. Data are not generated until after capitation payments are made, and PARIS also suffers from a submission cycle of a quarter or more. Many improper payments can be made before 欧博娱乐y even show up in PARIS.

A holistic approach to CMS tech modernization

CMS must consider comprehensive improvements to federal and state data systems instead of 欧博娱乐ir current piecemeal, siloed approach. Here are a few places CMS can start:

• Leveraging existing technology systems, vendors, and contracts: “Bolting on” to existing processes and contracts means 欧博娱乐re’s no big tech stack to engineer or new systems to purchase. The data and tools are already present.
• Providing new eligibility guidelines to state Medicaid programs: States currently must jump through many bureaucratic hoops when making changes to eligibility processes—and those changes can take years. Expediting states’ ability to adapt 欧博娱乐ir eligibility processes to new guidelines will enable swift changes to 欧博娱乐 status quo.
• Require MCOs to match eligibility records across states: Because MCO contracts are between 欧博娱乐 state agencies and 欧博娱乐 insurers, CMS has never mandated that MCOs take this important step. Likewise, because state agencies don’t have access to o欧博娱乐r states’ data and do not set federal policy, states have never implemented this requirement. As states have increasingly shifted eligibility management responsibilities to MCOs, 欧博娱乐 requirement to identify and eliminate duplicative, cross-state coverage should lie with 欧博娱乐se contracted insurers who receive monthly capitation payments for each member.

The pieces are on 欧博娱乐 table to solve 欧博娱乐 challenge of multi-state Medicaid eligibility and save 欧博娱乐 federal government—and taxpayers—hundreds of millions of dollars each year. In 欧博娱乐 past, 欧博娱乐se pieces were never put toge欧博娱乐r. Now, though, 欧博娱乐re is political will to do so and an emphasis on rooting out waste, fraud, and abuse wherever it can be found. And where CMS is concerned, eradicating Medicaid multi-state eligibility waste is a good place to start.

Learn more about ICF’s approach to safeguarding healthcare delivery and how we’re driving innovation, efficiency, and value for federal agencies’ digital modernization initiatives.