Congress Moves to Address Medicaid Fraud and Program Integrity

Congress has taken steps to enhance the integrity of government health care programs, particularly in light of recent reports highlighting potential fraud in Medicaid and the Affordable Care Act (ACA) exchanges. The new measures aim to prevent taxpayer money from being misallocated, particularly to deceased individuals.

The Centers for Medicare and Medicaid Services (CMS) recently released data indicating a significant rise in the percentage of enrollees in Bronze and heavily subsidized Silver plans who did not file any claims. The figures show that from 2019 to last year, the percentage of these enrollees without claims increased from approximately 29% and 23% to 40%. This trend raises concerns about the effectiveness of enrollment processes and the potential for fraud.

Critics argue that the increase in zero-claims enrollees suggests that many individuals are being auto-enrolled into plans they do not need or want. “The data indicates a growing number of individuals receiving taxpayer-funded coverage without utilizing it, which raises questions about program integrity,” said Chris Jacobs, founder and CEO of Juniper Research Group.

The CMS data also revealed that states like Florida and Texas had the highest percentages of zero-claims enrollees, suggesting possible discrepancies in income reporting among applicants. Despite the data’s limitations, including potential overestimates of total enrollees, it underscores the need for reform in how health coverage is administered.

In response to these findings, Congress has enacted a reconciliation bill that includes provisions to enhance verification processes for applicants seeking subsidies. These changes are set to take effect at the end of this year, coinciding with the expiration of enhanced subsidies that have contributed to the current enrollment landscape.

Separately, a report from Louisiana’s legislative auditor highlighted another issue: the state’s Medicaid program has been paying for coverage for deceased beneficiaries. From February 2019 to March 2023, Louisiana disbursed at least $9.6 million for 1,072 individuals who were deceased. The report noted that insurers continued to receive payments for a median of 418 days after a beneficiary’s death, with some cases extending to 799 days.

“This situation illustrates a significant flaw in the system where payments continue despite the death of beneficiaries,” said the Louisiana legislative auditor. “We must ensure that taxpayer dollars are not wasted in this manner.”

The recently passed reconciliation measure mandates that states check the Social Security Death Master File quarterly starting in 2027 to prevent similar issues from recurring. This requirement aims to improve program integrity and ensure that only eligible individuals receive benefits.

Despite these reforms, some remain skeptical about their effectiveness. The Congressional Budget Office estimated that the changes would save less than $500,000 per year nationwide, prompting questions about the adequacy of the measures in addressing the scale of the problem.

As Congress moves forward with these initiatives, the focus remains on safeguarding taxpayer dollars and ensuring that government health care programs operate with greater accountability. The recent reports have prompted a renewed call for vigilance in monitoring enrollment processes and preventing fraud in Medicaid and ACA exchanges.