Rhode Island's Managed Care Contract Settlements With Neighborhood Health Plan of Rhode Island Did Not Always Comply With Federal and State Requirements

The Rhode Island Executive Office of Health and Human Services, Department of Human Services (State agency), did not always make managed care contract settlements in accordance with Federal and State requirements. Specifically, the State agency did not always determine the managed care contract settlements in accordance with the terms of its contract with Neighborhood Health Plan of Rhode Island (Neighborhood). In addition, the State agency did not consistently follow its policies and procedures regarding the calculation of the final contract settlement amounts and the reporting requirements for Neighborhood. Accordingly, we do not have reasonable assurance that (1) the State agency has refunded the Federal share of all contract settlements due from Neighborhood, (2) the contract settlements were calculated using consistent and reliable capitation payment data, and (3) the contract settlements were calculated using accurate medical expense data.