The Centers for Medicaid & Medicare (CMS) has issued new Medicaid eligibility guidance that aims to ensure states are effectively vetting adults enrolling in coverage through the Affordable Care Act’s (ACA's) expansion.
The guidance (PDF) includes a checklist that state regulators can use to monitor eligibility criteria and payment compliance. States can use that checklist to prepare for an audit or another review, according to CMS.
CMS has taken several steps since 2017 to cut down on fraud, waste and abuse in Medicaid. Doing so is crucial, officials said, because Medicaid enrollment has swelled thanks to the ACA’s expansion—and the federal government covers 90% of the costs for those new enrollees.
Fifteen million working-age adults have enrolled in the expanded Medicaid program over the last five years, according to CMS.
“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 said in a statement.
"We are taking a strategic approach to managing improper payment, risks and fraud as well as developing effective program integrity tools to ensure that government services aid their intended purposes,” Verma said.
Elements on the checklist include ensuring Medicaid programs have appropriate integrity expectations in place for contractors, that they’re continually assessing the accuracy of eligibility criteria and making sure systems are in place to send indicator data on these fronts to CMS.
Reviews conducted by the Department of Health and Human Services' Office of Inspector General have raised concern that some states are failing to make Medicaid eligibility determinations based on federal and state regulations, especially for the expansion population.
CMS said that the guidance is also applicable to states that have not rolled out expanded Medicaid but may be considering it.
Moving forward, CMS said it is working to build a template for states that have enrolled a substantial number of new beneficiaries under Medicaid expansion to prove that they have the appropriate vetting procedures in place. This will ensure states are claiming the additional federal funding appropriately, according to the agency.
Some states may be put under oversight review in the future, according to CMS.