BOSTON — MassHealth erroneously paid more than $84 million in care-related charges to residents who lived in other states, Auditor Diana DiZoglio’s office concluded in a new report that the executive branch criticized as “overbroad” and “misleading”.
State law requires members of MassHealth, which combines Medicaid and the Children’s Health Insurance Program under one umbrella, to live in Massachusetts to remain eligible.
The auditor’s office reviewed the “capital payments,” which MassHealth makes to managed care organizations to coordinate health care for its members, between Jan. 1, 2018, and Sept. 30, 2018. 2021 and said that millions of dollars were invested in services for external services. state residents.
Altogether, DiZoglio’s office estimated that MassHealth made about $84.8 million in capitation payments during the audit period on behalf of members living elsewhere, out of a total of $2.4 billion in capitation payments in this period.
“Our audits serve as a tool for state agencies to help ensure greater transparency, accountability and fairness,” DiZoglio said in a statement along with the 22 page report. “It is unacceptable that, due to a lack of proper oversight by MassHealth, nearly $85 million in overpayments went to MCOs for out-of-state residents who were concurrently enrolled in the ‘out-of-state health care. Taxpayers deserve better, and I strongly urge MassHealth to adopt the recommendations of this audit.’
DiZoglio’s office asked MassHealth to review its “data matching” procedures to better detect when members receiving benefits actually live in other states. The program would have to stop coverage or move members to a “fee-for-service model” if they haven’t submitted documentation showing they live here, the auditor’s office said.
In a multi-page response published in the final report, the Health and Human Services Executive Office disagreed with many of the audit’s findings and methodology.
The audit used a sample of 100 MassHealth members, 63 of whom resided in nine other states or Puerto Rico and had enrolled in that territory’s Medicaid program while still on MassHealth’s rolls. Auditors then came up with the overall estimate of $84.8 million based on the out-of-state residents they found in the sample group, which EOHHS said produced “a misleading conclusion about the ‘tax impact of any error’.
“While the draft report acknowledges the existence of variable capitation payment amounts, the report indicates that the audit focused on a sample of 100 members that is not drawn from all members of MassHealth MCO, but from the higher capitation payment amounts,” MassHealth wrote in its response. “By focusing only on the highest dollar amounts (rather than dividing the sample in a way that reflects the distribution of MassHealth members in each MCO rating category), the result of the 100-member sample does not appears representative of the total MCO population and will greatly inflate the dollar amount of the extrapolated finding.”
MassHealth also argued that much of the sample time period overlapped with the COVID-19 pandemic, when “member residency fluctuated more than normal” and federal law temporarily limited state Medicaid programs from reassessing which members were still eligible.
The Healey administration is months into a massive yearlong effort to redetermine eligibility for the first time since the public health emergency began, a process that policymakers hope will reduce enrollment by up to 400,000 people and will free up $1.9 billion in spending. which can be allocated to other State budget uses in fiscal year 2024.
During the first two months of the process, about 35,000 Bay Staters left MassHealth, but the program’s overall enrollment it has still increased slightly in this period due to typical monthly growth.
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