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Medicaid Audit Unit Completed Audits, March 2, 2023 through March 1, 2024

An overview of the audit conducted by the Medicaid Audit Unit over the past year.

Table of Contents

Overview

During this reporting period, the Office of the State Auditor (OSA) released one audit report on MassHealth’s compliance with state and federal laws, regulations, and other applicable authoritative guidance. This report identified an estimated $84,832,094 for capitation payments1 made on behalf of members who were residing outside of Massachusetts. The report also provided several recommendations to strengthen internal controls and oversight in MassHealth’s program administration. The following is a summary of our Medicaid audit work.

Office of Medicaid (MassHealth)—Review of Capitation Payments

The purpose of this audit was to determine whether MassHealth ensured that it did not make capitation payments to managed care organizations (MCOs) on behalf of ineligible members who were residing and receiving benefits in other states or US territories. OSA conducted the audit as part of our ongoing independent statutory oversight of the state’s Medicaid program.

OSA reported one finding in this audit:

  1. MassHealth made an estimated $84,832,094 in capitation payments on behalf of members who were residing outside of Massachusetts.

OSA’s recommendations to MassHealth were as follows:

1.    MassHealth should revise its policies and procedures regarding its data matches for member eligibility. Specifically, MassHealth should require that all members flagged by data matches submit documentation to substantiate that they reside in Massachusetts. If the member does not provide this documentation, MassHealth should either pause this member’s coverage or move the member to its fee-for-service model until it can determine whether the member’s coverage should be terminated.

2.    MassHealth should investigate and resolve all instances where its data matches indicate that a member is enrolled in another state’s Medicaid program.

3.    MassHealth should provide members with written instructions during the annual enrollment process on how to unenroll from MassHealth if they move outside of Massachusetts.

4.    MassHealth should consult with CMS to see if it can gain access to the Transformed Medicaid Statistical Information System (T-MSIS),2 which MassHealth can use in its eligibility detection and residency verification process.

1.   Capitation payments are set payments to a managed care organization from MassHealth to provide healthcare for its members. These payments are paid monthly for each MassHealth member enrolled in the managed care organization.

2.    T-MSIS is a database maintained by the federal CMS that contains Medicaid data from all 50 states, the District of Columbia, and the US territories to maintain an accurate, up-to-date, and complete data set of eligibility, enrollment, and healthcare service claims data about Medicaid members.

Date published: March 1, 2024

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