For Immediate Release - October 17, 2012

Audit Identifies Improvements Needed in MassHealth’s Eligibility Process

State health agency does not adequately verify income and state residency information

BOSTON, MA —State Auditor Suzanne Bump today issued an audit of MassHealth, which found the process for verifying self-reported income and residency information needs improvements and may be costing the Commonwealth millions of dollars annually in Medicaid expenses.

MassHealth, with expenditures of over $12 billion, provides access to healthcare services for approximately 1.3 million eligible low- and moderate-income individuals annually.  MassHealth is the state’s largest program, accounting for almost a third of the state budget. Today’s audit report examined how MassHealth determines an individual’s eligibility for the program.

“The values of the people of Massachusetts have been reflected in the universal health insurance law which has resulted in our state leading the nation in the percentage of people with health insurance,” said Auditor Bump. “Our commitment, coupled with the economic downturn, has led more people than ever before to turn to MassHealth for public assistance with their health care. It is my duty as State Auditor to ensure that MassHealth has the strongest possible safeguards in place to protect both the taxpayers and people in need. This audit today indicates that more needs to be done.”

The audit has three findings:

  • Inconsistent with state and federal regulations, MassHealth does not fully verify applicants’ self-reported earned income at the time of application. The first verification occurs approximately one year after the applicant is enrolled and receiving benefits. In addition, MassHealth does not verify information about an applicant’s unearned income (non-wage incomes such as lottery winnings, stock dividends, pension payments, and rental income). The lack of verification creates a potential for an ineligible applicant to receive health benefits for a year before MassHealth removes them from the program.
  • MassHealth has not established a process to effectively verify the state residency of applicants and, as a result, thousands of non-Massachusetts residents may be inappropriately receiving healthcare benefits. Current MassHealth policy is to accept self-declaration of residency and to verify residency only in cases where conflicts are found within an applicant’s information.  This policy complies with MassHealth’s legal obligations but creates a process vulnerable to fraud. In 2010 MassHealth spent $6,456,195 on healthcare services for 4,643 individuals who were subsequently removed from the program for not being a Massachusetts resident, for receiving benefits from another state, or because their whereabouts were unknown. The audit suggests that MassHealth follow the lead of states such as New York, New Hampshire, and California which ask for a driver’s license, utility bills or other documentation to prove residency.
  • Despite its own policies, MassHealth does not always follow through on investigations when applications contain conflicting income or residency information. MassHealth recipients must be Massachusetts residents, but the audit cites two cases, one of a woman who provided extensive documentation of her residence in Florida, and another of a family visiting from Greece on a medical visa, where MassHealth failed to follow its own policies to investigate obvious residency conflicts.

    During fiscal year 2010 MassHealth provided health care benefits totaling over $12 million to 15,999 individuals who presented MassHealth with foreign passports or temporary visas. Even though the residency information provided by these members directly conflicts with their federal status as temporary visitors, MassHealth does not have a process for resolving their resident status.

Among other recommendations, Auditor Bump has called on MassHealth to leverage existing information held by the Internal Revenue Service, the Massachusetts Department of Revenue, Social Security, and the Department of Unemployment Assistance to verify submitted income and residency information at the time of application.     

The Office of State Auditor Suzanne Bump conducts financial, performance, and technical assessments of state government’s programs, departments, agencies, authorities, contracts, and vendors. With its reports, the OSA issues recommendations to improve accountability, efficiency, and transparency.

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Audit: MassHealth's Eligibility Determination Process for Healthcare Services pdf format of    MassHealth Eligibility Process for Healthcare Services