Overview
CICRF did not pursue federal matching funds for qualified medical services. As a result, the Commonwealth lost an opportunity to receive federal matching funds for $49,588 in healthcare costs.
We reviewed all CICRF reimbursements from the audit period and identified a total of $99,176 out of a total of approximately $3,548,763 in reimbursements that qualified for federal matching. The Congressional Research Service’s “Medicaid Federal Medical Assistance Percentage (FMAP)” report states that Massachusetts’s federal matching assistance percentage for qualified medical services is 50%, so a total of $99,176 would have qualified for $49,588. These reimbursements were to families with MassHealth coverage and were for goods and services such as durable medical equipment, prescribed drugs, home healthcare, hospital care, and physician and laboratory services. Such items are typically eligible for federal matching funds under the state’s Medicaid program. The table below summarizes CICRF reimbursements that might have qualified for federal matching funds during the audit period.
|
Type of Eligible Medical Expense |
Total Amount Paid to Eligible Applicants |
Total Potential Federal Matching Funds Lost to the Commonwealth |
|
Health Enabling Services/Equipment |
$ 43,006 |
$ 21,503 |
|
Medication |
27,046 |
13,523 |
|
Mobility Aids |
26,224 |
13,112 |
|
Hospital, In State |
2,900 |
1,450 |
|
Total |
$ 99,176 |
$ 49,588 |
Authoritative Guidance
CICRF’s enabling legislation, Section 10 of Chapter 111K of the General Laws, requires the following:6
The department of public health, in consultation with the division of medical assistance . . . shall take all necessary steps to maximize and coordinate the availability of federal financial participation under Title XIX of the Social Security Act for [CICRF] established by this chapter to the extent that expenditures under such program are considered expenses incurred for medical assistance within the meaning of [Section 1396d(a) of Title 42 of the United States Code].
The aforesaid $99,176 of CICRF reimbursements meets the definition of Medicaid- and Medicare-covered medical expenses in Section 1396d(a)(1)–(13) of Title 42 of the US Code:
Inpatient hospital services . . . outpatient hospital services . . . other laboratory and X-ray services . . . physicians’ services . . . home health care services; private duty nursing services . . . dental services; physical therapy and related services; prescribed drugs . . . prosthetic devices . . . other diagnostic, screening, preventive, and rehabilitative services.
Reasons for Noncompliance
CICRF management told us that although in the past CICRF had claimed federal matching funds for reimbursements, it had stopped doing so because most of its reimbursements were for medical expenses that did not qualify for federal matching funds. However, as noted above, CICRF is required to maximize federal matching funds, including reimbursement for any eligible expenditures it makes. We believe that given the continuing rise in healthcare costs, CICRF should make every effort to obtain available federal matching funds, no matter how small.
Recommendation
CICRF should review all its reimbursements to determine whether any qualify for federal matching funds and should coordinate with MassHealth to seek federal matching funds for all eligible expenditures.
Auditee’s Response
DPH will continue to coordinate with MassHealth to pursue federal matching funds of qualified medical services moving forward. DPH will continue working with [the Executive Office of Health and Human Services’ Revenue Unit] to discuss ongoing monitoring and seek to maximize reimbursement.
Auditor’s Reply
Based on its response, CICRF is taking measures to address our concerns in this area.
| Date published: | April 20, 2022 |
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