“Every dollar spent for individuals not eligible to receive Ohio Medicaid services is a dollar that’s not going to residents who should be receiving assistance,” Faber said. “The Ohio Department of Medicaid needs to do more to address these issues.”
Data obtained for this audit identified 124,448 people concurrently enrolled in Ohio and at least one other state for at least three consecutive months. For 2,372 enrollees, both Ohio and at least one other state made a capitation payment for each month during the four-year audit period, the auditor’s office said.
Capitation payments are a flat rate, usually paid per person per month, by the state of Ohio to Medicaid managed care organizations. The capitation rates are set to equal the average of all recipients’ health care spending, taking factors like differing health plan and where the members live into account.
The potential financial impact to Ohio of multistate enrollees was more than $200 million, the state auditor’s office says, but Ohio Medicaid disputed those numbers, saying the auditor’s office’s extrapolation of that amount could not be considered “accurate or reliable.” Ohio Medicaid questioned the methodology the auditor’s office used to come up with that number, using a sample of 125 individuals to determine an estimated $209 million.
“(The) figure of $209 million is unreliable because it does not take into consideration the complicated process of setting actuarially sound capitation rates,” Steven Voigt, deputy director at Ohio Medicaid’s office of legal counsel and the bureau of program integrity, said in a letter to the auditor’s office.
“The amount reported was accurately calculated based on the results of our testing,” the auditor’s office said in response to Ohio Medicaid’s statement.
Three of the four years included in the audit fell under the COVID-19 public health emergency, which included a provision of continuous enrollment under Medicaid. Federal requirements made it more difficult to disenroll members based on if they potentially relocated to a different state, Ohio Medicaid said.
“(The) report did not account for the heightened federal requirements in place at that time,” Voigt said.
Faber’s report was not issued with the intent to recoup any funds, the auditor’s office said when asked if managed care organizations would be asked to return any funds.
“The estimated cost was to demonstrate the impact of concurrent enrollment and the need to improve the system to save future public dollars,” the auditor’s office said.
Anybody who is determined not to be an Ohio resident is expected to be disenrolled from Ohio Medicaid. If any fraudulent enrollment, such as identity theft, was uncovered, the auditor’s office recommended Ohio Medicaid reporting it to law enforcement.
Ohio Medicaid provides health care and other services to about 3 million lower-income residents, older adults, individuals with disabilities, pregnant women, infants and children, and others. Spending for the program reached about $28.5 billion in state fiscal year 2022, according to the auditor’s office.
For state fiscal year 2023, Ohio spent approximately $36.1 billion, including both state and federal funds, on the Medicaid program as a whole.
Most Ohioans receive Medicaid services through a managed care provider, which receives a monthly payment from the state for each enrolled recipient.
Previous audits from the state auditor’s office found other duplicate costs to the state Medicaid program. Those included a January 2022 audit, which found Ohio Medicaid had failed to recoup $118.5 million in erroneous duplicate payments and payments on behalf of individuals in prison or who were deceased.
A December 2022 audit found Ohio Medicaid was not ensuring county departments of Job and Family Services caseworkers adequately processed system alerts to determine if recipients were receiving duplicative benefits from other states, potentially costing the state between $5.3 million and $24.5 million annually, the auditor’s office said.
The Medicaid program “lacks adequate procedures to prevent concurrent enrollment from occurring, to timely identify concurrent enrollment, or to resolve concurrent enrollment between states in an efficient manner,” Faber’s report said. “(T)he data (show) that public dollars were misspent due to concurrent enrollment. All taxpayers are impacted when each State is not making every effort to guard against misspent public dollars.”
Ohio Medicaid has made improvements to its eligibility determinations, Voigt said. Ohio’s estimated Medicaid payment error rate based on eligibility determinations dropped from 43.49% in 2019 to 8.23% in 2022, Ohio Medicaid said, using data from the Centers for Medicare and Medicaid Services (CMS).
Both Faber’s report and Ohio Medicaid’s response referenced the Public Assistance Reporting Information System (PARIS), which is a data matching service matching recipients of public assistance to check if they receive duplicate benefits in two or more states.
States receive PARIS reports quarterly, Voigt said. Under CMS rules, the state cannot deny eligibility, terminate eligibility or reduce benefits for any individual based on information received PARIS unless the state has sought additional information from the individual.
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