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Medicaid Claims for Federal Reimbursement Using Managed-Care Proxy Methodology

Federal health care benefits are generally allowable when provided to a beneficiary who is a U.S. citizen, U.S. national, or qualified alien. Generally, a qualified alien is ineligible for full-scope Medicaid services before 5 years have passed from the date he or she enters the United States with qualifying status (5-year bar). Medicaid eligibility for most qualified aliens who are subject to the 5-year bar is generally limited to emergency services (restricted-scope services). States may choose to provide full-scope services to qualified aliens who are subject to the 5-year bar using their own State funds. Furthermore, States may choose to cover full-scope services to aliens permanently residing in the United States under color of law and to children under the age of 19 regardless of immigration status. However, the costs related to nonemergency services provided to non-citizens in these groups without satisfactory immigration status are not eligible for Federal reimbursement. We will review whether States properly claimed Federal Medicaid reimbursement related to services provided to non-citizens who lacked satisfactory immigration status.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
January 2021 Centers for Medicare and Medicaid Services Medicaid Claims for Federal Reimbursement Using Managed-Care Proxy Methodology Office of Audit Services W-00-21-31554 2022