Objective

To determine whether the Department of Health (Department) made improper Medicaid managed long-term care (MLTC) premium payments on behalf of ineligible enrollees. The audit covered the period from January 2015 to March 2021.

About the Program

Many of the State’s Medicaid recipients are enrolled in MLTC plans, which provide long-term care services, such as home health care and nursing home care, for people who are chronically ill or disabled. For the year ended December 31, 2020, Medicaid paid MLTC plans $15.5 billion in premiums for 329,618 recipients enrolled in MLTC.

The Department contracts with Maximus Health Services, Inc. (Maximus) to conduct initial eligibility assessments for individuals who choose to voluntarily enroll in MLTC (other individuals meeting certain criteria are automatically enrolled). To be eligible, all individuals must be assessed as needing community-based long-term care (CBLTC) services for more than 120 days. After the initial assessment, MLTC plans were responsible for performing semi-annual assessments of their own members to determine whether the members should remain in their plans.

MLTC plans are responsible for initiating disenrollment of enrollees when it is determined they are no longer MLTC eligible (e.g., enrollees who did not receive any CBLTC services in a month, deceased recipients), and Maximus is responsible for processing the disenrollments. The Department can recover premium payments made to MLTC plans for ineligible enrollees.

Key Findings

• Medicaid paid about $701 million in improper MLTC premium payments on behalf of 52,397 recipients who were no longer eligible for MLTC. The Department has not developed adequate oversight to ensure MLTC plans timely identify individuals who are ineligible for MLTC.
• Medicaid paid $2.8 billion in MLTC premium payments on behalf of 51,947 recipients who received a limited number of CBLTC services. For instance, 22,048 recipients only received between 1 and 30 days of services during 6-month assessment periods. Given that the average monthly MLTC premium for these recipients was about $4,500, the Department should develop a process to monitor the MLTC program to ensure members are properly assessed and are receiving the care they need.

Key Recommendations

• Review the $701 million in premium payments and make recoveries, as appropriate.
• Develop a process to ensure timely MLTC disenrollment of recipients who are no longer eligible.
• Monitor MLTC recipients to ensure they were properly assessed for enrollment and are receiving the appropriate level of care.