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Series: Medicaid Concurrent Eligibility

Announced on  | Last Modified on  | Series Number: W-00-24-31539
Status
Completed
Agency
Centers for Medicare and Medicaid Services, Indian Health Service

OBJECTIVE

State Medicaid agencies contract with managed care organizations (MCOs) to make services available to enrolled Medicaid beneficiaries. The contractual arrangement shifts financial risk for the cost of care to the MCO. State Medicaid agencies pay MCOs on a per-beneficiary per-month basis, and MCOs are at financial risk if the costs of care exceed those payments. If a beneficiary who resides in one State subsequently establishes residency in another State, the beneficiary's Medicaid eligibility in the previous State should end and the MCO should not receive payments for that beneficiary. Our review will determine whether States made capitation payments on behalf of beneficiaries who established residency in another State.

There are 3 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (3)

Audit of Internal Controls in Place to Identify, Record, and Track Indian Health Service Sanitation Facilities Construction Program Costs

Project A-05-22-00021 • Completed on May 30, 2025

California

Project A-05-23-00008 • Completed on July 24, 2024

Texas

Project A-05-22-00018 • Completed on September 11, 2023

TIMELINE

  • June 15, 2022
    Series Number W-00-24-31539 Assigned
  • June 15, 2022
    Project Announced

    Texas - A-05-22-00018

  • July 18, 2022
    Project Announced

    Audit of Internal Controls in Place to Identify, Record, and Track Indian Health Service Sanitation Facilities Construction Program Costs - A-05-22-00021

  • December 7, 2022
    Project Announced

    California - A-05-23-00008

  • September 11, 2023
    Project Complete - A-05-22-00018

    Texas has been marked as complete. This audit resulted in 2 recommendations.

  • July 24, 2024
    Project Complete - A-05-23-00008

    California has been marked as complete. This audit resulted in 2 recommendations.

  • May 30, 2025
    Project Complete - A-05-22-00021

    Audit of Internal Controls in Place to Identify, Record, and Track Indian Health Service Sanitation Facilities Construction Program Costs has been marked as complete. This audit resulted in 5 recommendations.

  • May 30, 2025
    Series Complete

    Medicaid Concurrent Eligibility has been marked as complete.

3 REPORT PUBLISHED

Texas Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Another State (A-05-22-00018)

23-A-05-113.01 to CMS - Closed Implemented
Closed on 11/03/2023
We recommend that the Texas Health and Human Services Commission resume and enhance procedures that are in accordance with Federal requirements and the State's unwinding process to identify and disenroll enrollees who are residing and enrolled in Medicaid managed care in another State.

23-A-05-113.02 to CMS - Closed Implemented
Closed on 11/03/2023
We recommend that the Texas Health and Human Services Commission work with CMS to consider the potential use of T-MSIS data to identify potential cases of concurrent enrollment.

View in Recommendation Tracker

Indian Health Service's Controls Over Sanitation Facilities Construction Program Projects Funded Under the Infrastructure Investment and Jobs Act Could Be Improved (A-05-22-00021)

25-A-05-067.01 to IHS - Open Unimplemented
Update expected on 11/29/2025
We recommend that the Indian Health Service consider additional project prioritization procedures to fund the highest priority SFC projects based on readiness.

25-A-05-067.02 to IHS - Open Unimplemented
Update expected on 11/29/2025
We recommend that the Indian Health Service reinforce compliance with established procedures for recording and documenting projects in the SDS prior to funding them.

25-A-05-067.03 to IHS - Open Unimplemented
Update expected on 11/29/2025
We recommend that the Indian Health Service validate the eligibility of homes and users by regularly reviewing and updating the HITS data.

25-A-05-067.04 to IHS - Open Unimplemented
Update expected on 11/29/2025
We recommend that the Indian Health Service strengthen documentation controls to appropriately ensure that all information is entered in the SDS to identify the ineligible portion of Tier 1 construction projects.

25-A-05-067.05 to IHS - Open Unimplemented
Update expected on 11/29/2025
We recommend that Indian Health Service develop formal guidance for the proration of Tier 1 design costs and Tier 2 and 3 planning costs between eligible and ineligible homes or users.

View in Recommendation Tracker

California Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Another State (A-05-23-00008)

24-A-05-089.01 to CMS - Closed Implemented
Closed on 09/26/2024
We recommend that the California Department of Health Care Services resume and enhance procedures that are in accordance with current Federal requirements to identify and disenroll enrollees who are residing and enrolled in Medicaid managed care in another State.

24-A-05-089.02 to CMS - Closed Implemented
Closed on 03/25/2025
We recommend that the California Department of Health Care Services work with CMS to consider the potential use of T-MSIS data to identify potential cases of concurrent enrollment.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services Indian Health Service
Issue Areas
Departmental Operational Issues Financial Stewardship Managed Care Public Health Issues
Target Groups
-
Financial Groups
Grants Medicaid