Sneak Preview: CMS To Issue Guidance on Medicaid Determinations

November 18, 2016 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) The Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) plans to provide guidance to states explaining federal requirements for using the Express Lane Eligibility option for determining Medicaid eligibility, in response to a recent audit recommendation by the HHS Office of Inspector General.

The Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009 (Pub. L. 111-3) provided states with a new tool — Express Lane Eligibility — to simplify the identification, enrollment and retention of individuals eligible for CHIP or Medicaid. Using this option, a state’s CHIP or Medicaid program can use findings from a different agency within the state to determine eligibility, despite what may be different methods of assessing income or other eligibility factors. These other state agencies are known as Express Lane agencies.

States may, but are not required to, rely on a finding from an Express Lane agency, such as a determination of household income, without repeating the data collection, calculation or verification that an Express Lane agency had already conducted. However, before completing a determination of Medicaid eligibility for an individual, the state Medicaid agency must satisfy all other eligibility verification requirements using processes described in its Medicaid verification plan. Also, to take advantage of the Express Lane option for Medicaid, a state must submit a Medicaid state plan amendment to CMS for approval.

The OIG reviewed a sample of 157 Medicaid eligibility determinations in 10 states that had made an enrollment decision using the Express Lane option in 2014. Although the states correctly determined eligibility for 133 (85 percent) of the individuals, the OIG found that four states did not determine eligibility for 17 beneficiaries in accordance with federal requirements, and seven other beneficiaries were mistakenly identified as having been determined as eligible using the Express Lane option, yet they were actually enrolled through traditional eligibility processes. Based on the sample, the OIG estimated that some 86,672 individuals in the 10 states were potentially ineligible for Medicaid, and that about $284 million in state Medicaid payments were made on behalf of potentially ineligible beneficiaries.

For example, the OIG found that Massachusetts enrolled seven beneficiaries on the basis of eligibility information provided by a state Express Lane agency that could not provide supporting documentation for the income calculation used to determine eligibility because of a “system redesign.” In another case, Colorado determined two beneficiaries were eligible for Medicaid without following its approved state Medicaid plan. Specifically, the state plan allowed it to rely on school lunch program data for an eligibility determination, yet the state Medicaid agency relied on data from the agency overseeing the Supplemental Nutrition Assistance Program, which was not an approved Express Lane agency in the state.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

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