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THE MEDICAID LANDSCAPE: JANUARY DEVELOPMENTS

Our monthly Medicaid news brief highlights the latest developments shaping program integrity and financial compliance. This summary captures key updates from the past month across legislation, research, and enforcement activity.

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STATES CONFRONT MEDICAID COSTS WITH POLICY AND TECHNOLOGY

Across the United States, Medicaid has become a significant financial concern for state governments. What was once a safety net program is now consuming nearly a third of state budgets, forcing lawmakers to reckon with rising costs and inefficiencies. Medicaid expansion, prolonged enrollment protections, and pandemic-driven increases have pushed participation to historic highs, and with it, the cost to maintain the program has ballooned.

Now, facing mounting deficits and a shifting policy environment, states are acting decisively to get Medicaid spending under control.

IMPROPER PAYMENTS FUEL THE SPENDING SURGE

A significant source of Medicaid’s financial pressure lies in its high rate of improper payments. In fiscal year 2023 alone, the Centers for Medicare & Medicaid Services (CMS) reported over $50 billion in payments that shouldn't have happened, most tied to missing or unverifiable eligibility documentation.

Cumulatively, improper Medicaid payments have cost taxpayers over $543 billion in the past decade. These aren’t just accounting errors—they reflect deep operational flaws that make the program vulnerable to waste, abuse, and fraud.

POLICYMAKERS LAUNCH INTEGRITY INITIATIVES

In response, several states are deploying tough new policies to restore program integrity and weed out inefficiencies:

Indiana has ended self-attestation for Medicaid eligibility and now mandates ongoing cross-checks against federal and state databases. The state has also implemented quarterly reporting on fraud prevention and payment accuracy.

Texas has upgraded its eligibility verification systems to include IRS and third-party data checks, automating what were previously manual processes.

Florida and Missouri are conducting more frequent eligibility redeterminations and increasing scrutiny of Medicaid Managed Care Organizations (MCOs).

Arkansas and Georgia are utilizing data-driven redetermination strategies to streamline enrollment and prevent ongoing eligibility lapses.

States are no longer waiting for federal intervention. They’re proactively tightening controls to reduce errors, cut unnecessary costs, and better target assistance.

MODERN TECH: THE MISSING PIECE IN MEDICAID REFORM

While legislative reforms are a step in the right direction, they won’t succeed without modern infrastructure to support them. Technology is key to implementing oversight at scale, in real time.

That’s why more Medicaid plans are turning to platforms like ProTPL from Syrtis Solutions.

ProTPL is a real-time, automated system that identifies third-party liability (TPL) before Medicaid pays a claim—ensuring Medicaid acts as the payer of last resort. It enables state plans to:

Block improper payments before they happen, rather than recovering them later,

Automatically detect commercial coverage on pharmacy and medical claims,

Reduce manual eligibility checks to improve efficiency and accuracy.

Comply with federal cost avoidance and COB mandates with minimal effort.

ProTPL enables Medicaid plans to respond more quickly, operate more efficiently, and prevent losses at the source.

THE PATH FORWARD: STRONG POLICY + SMART TECHNOLOGY

As the fiscal burden of Medicaid grows heavier, one thing is clear: status quo systems won’t cut it. States that combine aggressive policy reform with smart, proven technology will be best positioned to rein in spending, reduce fraud, and protect coverage for the people who need it most.

Click here to learn more.

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MEDICAID NEWS IN JANUARY

Syrtis Solutions sends out a monthly Medicaid news roundup to help you stay up-to-date. The monthly recap focuses on developments, analysis, and legislation that pertains to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid developments.

Learn more here.

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THREE DECADES OF MEDI-CAL: GROWTH, EXPANSION, AND IMPACT

Over the last three decades, Medi-Cal, California's Medicaid program, has gone through considerable changes and expansion. By 2016, the program provided coverage to more than one in three Californians, and as of January 2024, eligibility has been expanded to include all residents with incomes below specific thresholds.

In 1990, Medi-Cal served about one in eight Californians, with eligibility limited to specific low-income groups like children, parents or caretakers of dependent children, and people with disabilities. Enrollment increased incrementally throughout the 1990s and 2000s, influenced by economic shifts and minor expansions in eligibility for children and pregnant women. The ACA brought a substantial change in 2014, allowing states to extend Medicaid coverage to most low-income adults without children or disabilities, with the federal government covering the majority of the costs. This resulted in more than a 60% increase in Medi-Cal enrollment by 2016, adding over 5 million Californians to the program. At present, 46% of Medi-Cal enrollees are children and their caregivers, 34% are adults who gained coverage through the ACA, and around 15% are seniors and individuals with disabilities. Since the ACA expansion, the number of uninsured Californians has been cut in half, with improvements noted in various health and economic areas. Having said that, nearly 3 million state residents remain without comprehensive health insurance, many of whom are noncitizens excluded by federal policies. California has taken steps to address this gap.

As the state with the largest immigrant population, California has worked to close eligibility gaps created by federal requirements on Medicaid access for some immigrants. When welfare reform in the 1990s separated Medi-Cal from cash assistance and limited eligibility to documented immigrants with green cards for at least five years, California chose to cover these individuals before they reached the five-year mark. Furthermore, California extended coverage to several groups of low-income immigrants, including those with Deferred Action for Childhood Arrivals (DACA) status.

In the last few years, California has steadily expanded Medi-Cal eligibility, beginning with undocumented children. This was followed by expansions to include undocumented young adults, older adults, and, as of January 2024, all remaining adults who meet the income criteria.

Medi-Cal's massive expansion has made it the largest single expenditure in California's state budget, with total costs projected to approach $160 billion this fiscal year. This includes $98 billion in federal funds, $36 billion from the state General Fund, and $25 billion from other sources, including local governments and provider taxes such as the Managed Care Organization (MCO) Tax. The MCO tax was increased in both 2023 and 2024, with some of the revenue intended to raise payment rates for Medi-Cal providers to improve access to care-- an ongoing priority for healthcare stakeholders. However, concerns about the state budget have put this plan in jeopardy. In November, voters will decide whether the revenue from the MCO tax should be dedicated to increasing provider rates or if more of it should be used to balance the state budget.

Medi-Cal has been at the forefront of Medicaid expansion, and studies indicate that this growth has resulted in better insurance coverage, improved health outcomes, and a reduction in poverty. As the program continues to be a lifeline for millions, preserving and responsibly managing its resources is important. One effective approach is for plans administering the program to make use of modern technology solutions to enhance the coordination of care, improving efficiency and reducing costs. By maintaining and strengthening this vital program, California can continue to provide critical healthcare services to their most vulnerable residents.

Learn more here.

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APRIL MEDICAID RECAP

Syrtis Solutions sends out a monthly Medicaid news summary to help you stay informed. The monthly recap focuses on developments, research, and legislation that relates to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Here is a summary of last month's important Medicaid news.

Find out more here.

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OCTOBER MEDICAID RECAP

Syrtis Solutions sends out a monthly Medicaid news recap to help you stay up-to-date. The monthly roundup highlights developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's significant Medicaid news. Click here to open the news.

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SEPTEMBER MEDICAID NEWS

Syrtis Solutions delivers a monthly Medicaid news roundup to help you stay informed. The monthly recap concentrates on developments, analysis, and legislation that pertains to Medicaid program integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a list of last month's Medicaid developments. See the news here. 

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MEDICAID NEWS IN APRIL

Syrtis Solutions issues a monthly Medicaid news recap to help you stay up-to-date. The monthly recap highlights developments, research, and legislation that relates to Medicaid integrity, cost avoidance, coordination of benefits, third party liability, improper payments, fraud, waste, and abuse. Below is a summary of last month's significant Medicaid developments. Click here to open.