#eligibility redeterminations

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MEDICAID'S IMPROPER PAYMENTS AND INCREASED SPENDING

According to federal agency data from PaymentAccuracy.gov and the Office of Management and Budget, the federal government spent an estimated $247 billion in improper payments in 2022. The data also uncovered that the Department of Health and Human Services' Medicaid program made up the majority of these payments at $80.6 billion. Medicaid has become the largest single budget item on states' budgets, and in order for the program to continue being solvent, states must address Medicaid's improper payment problem. Recently, states have started Medicaid eligibility redeterminations as a result of the end of the Coronavirus Public Health Emergency continuous enrollment provision. As of June 29th, at least 1,536,000 enrollees have been disenrolled. Some states are expecting the eligibility redeterminations to decrease program costs; however, KFF is predicting that it's possible that state Medicaid spending will increase as the enhanced FMAP expires. Medicaid cannot afford increased program spending while losing billions in improper payments. A frequent misunderstanding is that improper payments come from fraud and abuse when in truth, the vast majority stem from prosaic, mundane issues such as eligibility errors and old data systems. One way plan administrators could reduce improper payments and improve program efficiency immediately is to adopt technology solutions that help identify primary commercial payers to avoid making claims payments in error.

Reduce Improper Payments And Cost Avoid With Quality Data

Health plans have trouble identifying primary coverage on pharmacy and medical claims because the data they access is not current, available, complete, or accurate. Thus, plans have no choice but to pay claims in error and chase reimbursement once other health insurance (OHI) is discovered. Regrettably, for Medicaid plans, the actual monies recovered remain around twenty cents on the dollar.

Syrtis Solutions recognized that Medicaid plans needed a method to determine active OHI coverage to adjudicate claims properly. ProTPL, launched in 2010, is a real-time point-of-sale cost avoidance service for government-funded healthcare programs that delivers powerful, accurate, and actionable eligibility data. The solution gives health plans the ability to cost avoid Rx and medical claims and the associated costs of recovery.

Medicaid's improper payments are costing billions of dollars every year, and program expenses are climbing. Consequently, states are likely to begin considering cutting benefits. To stay solvent and continue providing care to the most vulnerable populations, Medicaid must improve its fiscal oversight of program expenditures and make certain that program resources are spent appropriately. Currently, the best place to start saving resources and reducing improper payments is to provide Medicaid payers access to clean and actionable eligibility data that they can rely on.

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[syrtissolutions]

PHE/FFCRA Medicaid Eligibility Redeterminations

On January 31, 2020, the Department of Health and Human Services (DHHS) declared the Coronavirus a public health emergency. Since then, the Public Health Emergency (PHE) has been renewed nine times, but it is scheduled to expire this August unless it is extended again. Its end will have a significant impact on Medicaid, when one considers that millions of program recipients will lose the coverage that the PHE and corresponding legislation provided. Shortly after the PHE was announced, Congress passed the Families First Coronavirus Response Act (FFCRA). The legislation served to provide relief throughout the pandemic by expanding Medicaid to prevent coverage losses for vulnerable populations while at the same time providing fiscal relief to states. The FFCRA was able to accomplish this by raising the federal medical assistance percentage (FMAP) by six-point-two percent. Additionally, the FFCRA altered the maintenance of eligibility (MOE) requirements by prohibiting states from altering eligibility or removing members from the program, and changed enrollment processes until the end of the pandemic. Because of the changed Medicaid eligibility criteria, enrollment in the Medicaid program surged during the pandemic. A report by KFF estimated that program enrollment grew by twenty-five percent or 22.2 million enrollees between FY 2019 and FY 2022. Out of those enrolled, MOE enrollment growth accounted for 18.7 million new enrollees. With the end of the PHE approaching, states will need to reassess their Medicaid budgets considering that they will no longer receive the FFCRA's boost in funding. Moreover, the MOE requirements will expire, and states will need to begin eligibility redeterminations. As a result, KFF estimates that anywhere between 5.3 million and 14.2 million enrollees could lose coverage. According to Medicaid.gov, this will be the "single largest health coverage transition event since the first open enrollment period of the Affordable Care Act." Coordinating benefits to ensure eligible beneficiaries continue receiving coverage during the transition will be critical. CMS has released guidance to assist states with eligibility redeterminations, transitions between coverage programs, and resuming normal eligibility and enrollment operations. According to the guidance, states will have twelve to fourteen months to conduct redeterminations. Additionally, DHHS will give a 60-day notice on when the PHE will end to help states prepare. Considering the surge in Medicaid enrollment because of the FFCRA and the upcoming expiration of provisions, it will be interesting to see how many individuals will remain eligible to receive the Medicaid program's important health care benefits. In some instances, the circumstances for some individuals will have improved, so they will no longer require assistance. However, some beneficiaries may be eligible for additional benefits. Eligibility redeterminations will certainly be a daunting task for Medicaid plans; however, it will be an opportunity to ensure that the most vulnerable populations are receiving benefits and that program resources are being preserved. Keep reading.