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Series: Medicaid Managed Care Capitation Payments on Behalf of Incarcerated Enrollees

Announced on  | Last Modified on  | Series Number: SRS-A-25-024
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

States contract with Medicaid managed care organizations to provide specific services to Medicaid enrollees, usually in return for a predetermined periodic payment known as a capitation payment. Section 1905 of Title XIX of the Social Security Act, 42 CFR § 435.1009, and guidance from CMS state that Federal financial participation is generally not available for services provided to adult inmates of public institutions except when the individual is not in a prison setting and becomes an inpatient in a medical institution. We will determine whether select States made unallowable capitation payments to Medicaid managed care organizations on behalf of individuals incarcerated in State prisons.

There are 6 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (5)

Project OAS-25-04-100 • Announced on Apr 23, 2025

Project OAS-25-04-117 • Announced on Jun 16, 2025

Project OAS-25-05-119 • Announced on Jun 30, 2025

Project OAS-25-02-074 • Announced on Oct 15, 2025

Project OAS-26-05-013 • Announced on Nov 5, 2025

COMPLETED PROJECTS IN THIS SERIES (1)

Illinois Medicaid

Project A-05-24-00019 • Completed on December 18, 2025

TIMELINE

  • July 15, 2024
    Series Number SRS-A-25-024 Assigned
  • July 15, 2024
    Project Announced

    Illinois Medicaid - A-05-24-00019

  • April 23, 2025
    Project Announced

    Project OAS-25-04-100

  • June 16, 2025
    Project Announced

    Project OAS-25-04-117

  • June 30, 2025
    Project Announced

    Project OAS-25-05-119

  • October 15, 2025
    Project Announced

    Project OAS-25-02-074

  • November 5, 2025
    Project Announced

    Project OAS-26-05-013

  • December 18, 2025
    Project Complete - A-05-24-00019

    Illinois Medicaid has been marked as complete. Report Published

  • Today
    5 Audits In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

1 REPORT PUBLISHED

Illinois Made Unallowable Managed Care Capitation Payments on Behalf of Incarcerated Medicaid Enrollees (A-05-24-00019)
  • Illinois made unallowable capitation payments totaling $263,186 ($229,423 Federal share) on behalf of 48 of the 100 incarcerated Medicaid managed care enrollees in our stratified random sample.
  • On the basis of our sample results, we estimated that during our audit period Illinois made unallowable capitation payments on behalf of incarcerated Medicaid enrollees totaling at least $9.5 million ($8.3 million Federal share).
No recommendations were issued as a part of this report.
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Managed Care
Target Groups
-
Financial Groups
Medicaid