CMS Issues Renewed Guidance to Ensure Medicaid Program Integrity

July 2019 ~

On June 20, CMS released a renewed guidance to state Medicaid agencies that outlines the “necessary assurances that states should make to ensure that program resources are reserved for those who meet eligibility requirements”.

According to CMS, the guidance will reduce improper Medicaid payments and helping ensure states make accurate eligibility determinations. The agency states that Medicaid eligibility for adults in expansion states has not been assessed within federal and state requirements in some states and that the failure to correctly identify eligibility could potentially result in additional Medicaid costs.

“We have seen a rapid increase in Medicaid spending in recent years and with this growth comes an increasing and urgent responsibility to ensure sound stewardship and oversight of our program resources,” CMS Administrator Seema Verma stated in the press release. “We are taking a strategic approach to managing improper payments, risks, and fraud as well as developing effective program integrity controls to ensure that government services aid their intended purposes.”

As seen in the release, since 2014, the Medicaid program has added more than 15 million new working-age, adult enrollees who primarily qualify as part of the Patient Protection and Affordable Care Act’s Medicaid (ACA) expansion. Of those 15 million enrollees, the federal government finances 90% or more of the cost.

CMS says the renewed guidance addresses concerns that followed recent audits conducted by the Office of Inspector General (OIG) which found that some states did not always determine Medicaid eligibility for expansion adults in accordance with federal and state requirements.

The guidance specifically emphasizes the agency’s expectations for states that have implemented, are in the process of, or currently considering Medicaid expansion. CMS says these states should recognize the increased risk that comes with sharing federal costs and encourages these states to provide assurances of compliance “applicable program requirements when submitting the appropriate state plan amendments”.

In an effort to better assist states in making accurate eligibility determinations and ensure appropriate financial claiming on an ongoing basis, CMS included a “readiness checklist” in the guidance. The following are highlights of the components of this program readiness checklist:

• Development of necessary program integrity expectations for contractors;
• Implementation of appropriate system and financial oversight controls;
• State plans that continually assess the ongoing accuracy of eligibility determinations and claiming of federal funding; and
• State eligibility systems that are capable of, and ready to submit required performance indicator data to CMS, including information regarding the timeliness and accuracy of eligibility determinations.

Additionally, the agency says it is preparing an assurance template (based on the program readiness checklist) for states that have already adopted the adult group where states can attest to having proper systems and procedures in place to ensure appropriate claiming of the enhanced federal match of funds.

Source(s): CMS Press Release; Oversight of State Medicaid Claiming and Program Integrity Expectations; HealthPayerIntelligence; Managed Healthcare Connect;