OIG: Better oversight needed for Medicaid beneficiaries enrolled in two states

The HHS Office of Inspector General found states frequently pay capitation benefits for Medicaid beneficiaries enrolled in multiple states. 

In an audit published Sept. 21, the OIG said capitation payments were made for 327,497 Medicaid beneficiaries double enrolled in multiple states' Medicaid programs in August 2020. This number is an increase from 208,254 concurrent payments in August 2019. 

Capitation payments are fixed fees given to managed care organizations in exchange for making benefits available to Medicaid enrollees. 

Two states often pay for benefits for one enrollee because they lack data to identify enrollees who are receiving Medicaid benefits in more than one state. 

OIG said CMS should provide state Medicaid agencies access to the Transformed Medicaid Statistical Information System, which is a comprehensive database of enrollment, eligibility and other data. 

"CMS does not actively monitor beneficiaries concurrent Medicaid managed care enrollments; instead, it relies on the individual states to identify concurrent enrollments and potential erroneous payments," OIG said in the report. 

OIG and CMS are at odds over the recommendation. According to the audit, CMS said providing this data would be redundant, inefficient and confusing for states. 

"We maintain that our recommendations are valid and plan to continue our work with states to identify opportunities to reduce the number and amount of concurrent Medicaid capitation payments," OIG said in the report. 

Read the full audit here. 

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