Toomey, Grassley Slam 27 Years Of Improper Medicaid Payments
"To maintain public confidence in such a large commitment of national resources, it is essential to ensure these dollars are spent as
Under the traditional Medicaid program, the federal government pays roughly 58 percent of the health care costs of low-income aged, disabled, children, and families. States pick up the remaining amount. The Patient Protection and Affordable Care Act expanded Medicaid to cover low-income adults without dependents, but at a cost of 90-plus percent to federal taxpayers, giving states a huge financial incentive to improperly categorize enrollees.
The federal government is required by law to recoup any improper Medicaid eligibility-related payments when they exceed a de minimis threshold, but CMS has apparently made no efforts since 1992 to recover any of these improper payments.
The senators asked CMS for data on recoveries and eligibility error rates to better understand the depth and breadth of the problem. They also asked CMS to identify any further statutory authorities that could help enforcement and recovery efforts.
Full text of Toomey's and Grassley's letter follows.
VIA ELECTRONIC TRANSMISSION
The Honorable
Administrator
Dear Administrator Verma:
Section 1903(u) of the Social Security Act requires, except in certain limited cases, that the federal government recoup Medicaid eligibility-related improper payments in excess of three percent made by states. A series of disturbing reports by the
Collectively, the fifty-six Medicaid programs in our states and territories make up one of the largest health insurance programs in the developed world, covering an estimated 97 million individuals in 2018, including an average of 76 million in any given month. It represents a considerable investment on behalf of the American taxpayer with an anticipated
Unfortunately, throughout its history, governmental efforts to ensure Medicaid payments are spent prudently have fallen short. In 2018, the rolling national Medicaid improper payment rate was 9.79 percent.[1] This stunning error rate actually represented an improvement upon the prior year, which itself was an improvement upon 2016. For context, Medicaid often makes more erroneous payments than
Section 1903(u) of the Social Security Act requires the government to "make no payment for such period or fiscal year with respect to so much of erroneous excess payments as exceed such allowable [eligibility] error rate of 0.03," but CMS determined more than twenty years ago to focus "on prospective improvements in eligibility determinations rather than disallowances" and there have been no efforts made to recoup payments since 1992.[3] In fact, on
The apparent lack of effort in recouping misspent federal money is problematic. Recent reviews by HHS OIG of beneficiaries made newly eligible by the Patient Protection and Affordable Care Act (P.L. 111-148, as amended), also known as Obamacare, found more than seven percent of beneficiaries were potentially ineligible in Kentucky,[5] more than 25 percent were potentially ineligible in California,[6] and more than 30 percent were potentially ineligible in New York.[7] In Louisiana, a state
Diligent federal oversight and legitimate threats of enforcement and disallowances like those specified under Section 1903(u) are essential in Medicaid because the statutory funding mechanism naturally reduces incentives for states to pursue rigorous program integrity efforts. For every dollar saved by states on traditional beneficiaries, the states on average only get to keep
Our offices would like to work with you on our shared goal of ensuring that the government complies with the intent and plain language of Section 1903(u) of the Social Security Act by discouraging systematic and routine errors in Medicaid eligibility determinations by states. We believe that CMS' past actions have ignored its requirements under the law and are concerned that the
1. Has CMS attempted to recoup any improper payments related to erroneous eligibility determinations under Section 1903(u) of the Social Security Act since 1992? If so, please identify the overpayment amount and the recoveries by state and year.
2. What are the state by state Medicaid eligibility error rates since the PERM program began tracking this metric in 2008?
3. What are the state by state Medicaid eligibility error rates for traditional eligibility pathways versus the newly eligible pathway created by the Patient Protection and Affordable Care Act since the expansion in 2014?
4. What additional statutory authorities would be beneficial for the purpose of enforcing Section 1903(u)?
Thank you for your attention to these important matters.
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