Florida Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Another State

02-16-2023 | A-05-21-00028 | Complete Report | | Report in Brief

Why OIG Did This Audit

Florida pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee. Previous OIG audits found that State Medicaid agencies have improperly made capitation payments on behalf of enrollees who were residing and enrolled in Medicaid in another State. We are concerned that the concurrent Medicaid enrollment identified in our previous audits could be an issue that negatively impacts Florida's Medicaid program.

Our objective was to determine whether Florida made capitation payments on behalf of Medicaid enrollees who are concurrently enrolled in a Medicaid managed care program in another State.

How OIG Did This Audit

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Translation

Our audit covered $15.8 million in Medicaid managed care capitation payments for August 2020 made by Florida on behalf of 55,164 Florida enrollees who were concurrently enrolled in a managed care program in another State during the period of July 1 through September 30, 2020 (audit period).

To identify our population of enrollees who had concurrent enrollment during our audit period, we compared CMS's Transformed Medicaid Statistical Information System (T-MSIS) data from 47 States, the District of Columbia, and Puerto Rico. We then identified all associated August 2020 capitation payments that Florida made.

What OIG Found

Florida made August 2020 Medicaid managed care capitation payments totaling $15.8 million on behalf of 55,164 enrollees who were concurrently enrolled for Medicaid benefits in another State. Of the 100 enrollees in our stratified random sample, we determined that 56 enrollees were residing and enrolled for Medicaid benefits in Florida. However, Florida made August 2020 capitation payments totaling $22,624 ($15,336 Federal share) on behalf of 44 Florida Medicaid managed care enrollees who were residing and concurrently enrolled for Medicaid in another State. On the basis of our sample results, we estimated that Florida incurred costs of $6.9 million ($4.7 million Federal share) for August 2020 capitation payments made on behalf of enrollees who were residing and concurrently enrolled in another State.

What OIG Recommends and Florida Comments

We recommend that Florida resume and enhance procedures that are in accordance with Federal requirements and the State's unwinding plan to identify and disenroll enrollees who are residing and enrolled in Medicaid managed care in another State when the PHE ends, and work with CMS to consider the potential use of T-MSIS data to identify potential cases of concurrent enrollment.

In written comments on our draft report, Florida concurred with our recommendations and described the actions that it plans to take to address them. Florida's actions include: (1) resuming procedures to identify individuals with Medicaid coverage in other States and closing benefits as appropriate and (2) meeting with CMS to determine whether there is a plan of action that CMS and Florida can take to use T-MSIS data to identify potential cases of concurrent enrollment.

Filed under: Centers for Medicare and Medicaid Services