Targeted
News Service (Press Releases) March 12, 2019
WASHINGTON, March
11 -- The office of Sen. Pat Toomey, R-Pennsylvania, issued the
following news release:
Senate Finance
Subcommittee on Health Care Chairman Pat
Toomey (R-Pa.) and Finance Committee Chairman Chuck
Grassley (R-Iowa) are pursuing stronger oversight and integrity of
Medicaid payments, of which nearly ten percent have been improper in recent
years. The entire budget for the National Institutes of Health is
smaller than the amount of erroneous payments made by Medicaid.
"To maintain
public confidence in such a large commitment of national resources, it is
essential to ensure these dollars are spent
as Congress intended-namely, to provide specified health and
long-term care services for low-income Americans, with a historical focus on
the aged, disabled, children, and families. Unfortunately governmental efforts
to ensure Medicaid payments are spent prudently have fallen short," the
senators wrote in a letter to Seema Verma, the administrator of
the Centers for Medicare and Medicaid Services (CMS).
Under the
traditional Medicaid program, the federal government pays roughly 58 percent of
the health care costs of low-income aged, disabled, children, and families.
States pick up the remaining amount. The Patient Protection and Affordable Care
Act expanded Medicaid to cover low-income adults without dependents, but at a
cost of 90-plus percent to federal taxpayers, giving states a huge financial
incentive to improperly categorize enrollees.
The federal
government is required by law to recoup any improper Medicaid
eligibility-related payments when they exceed a de minimis threshold, but CMS
has apparently made no efforts since 1992 to recover any of these improper
payments.
The senators asked
CMS for data on recoveries and eligibility error rates to better understand the
depth and breadth of the problem. They also asked CMS to identify any further
statutory authorities that could help enforcement and recovery efforts.
Full text of
Toomey's and Grassley's letter follows.
March 1, 2019
VIA ELECTRONIC
TRANSMISSION
The
Honorable Seema Verma
Administrator
Centers for
Medicare and Medicaid Services
Dear Administrator
Verma:
Section 1903(u) of
the Social Security Act requires, except in certain limited cases, that the
federal government recoup Medicaid eligibility-related improper payments in
excess of three percent made by states. A series of disturbing reports by
the Department of Health and Human Services Office of the
Inspector General (HHS OIG) and the Louisiana Auditor General suggest that
the government needs to do more to uphold Section 1903(u) and safeguard the
integrity of the Medicaid program.
Collectively, the
fifty-six Medicaid programs in our states and territories make up one of the
largest health insurance programs in the developed world, covering an estimated
97 million individuals in 2018, including an average of 76 million in any given
month. It represents a considerable investment on behalf of the American
taxpayer with an anticipated $7.8 trillion in spending over the next
decade, of which approximately $4.8 trillion will be paid by the
federal government. To maintain public confidence in such a large commitment of
national resources, it is essential to ensure these dollars are spent
as Congress intended-namely, to provide specified health and
long-term care services for low-income Americans, with a historical focus on
the aged, disabled, children, and families.
Unfortunately,
throughout its history, governmental efforts to ensure Medicaid payments are
spent prudently have fallen short. In 2018, the rolling national Medicaid
improper payment rate was 9.79 percent.[1] This stunning error rate actually
represented an improvement upon the prior year, which itself was an improvement
upon 2016. For context, Medicaid often makes more erroneous payments
than Congress appropriates for the entire budget of the National
Institutes of Health.[2]
Section 1903(u) of
the Social Security Act requires the government to "make no payment for
such period or fiscal year with respect to so much of erroneous excess payments
as exceed such allowable [eligibility] error rate of 0.03," but CMS
determined more than twenty years ago to focus "on prospective
improvements in eligibility determinations rather than disallowances" and
there have been no efforts made to recoup payments since 1992.[3] In fact,
on July 5, 2017, CMS finalized a rule on the Medicaid Eligibility Quality
Control and Payment Error Rate Measurement (PERM) programs that specifies
efforts to actually recoup funding in compliance with Section 1903(u) will not
even begin until next year, and even then only in limited circumstances when a
state has failed to even make vaguely defined "good faith" efforts to
improve eligibility determinations. Finally, in the exceptional circumstance
when a state does not make a "good faith" effort to improve eligibility
determinations, CMS has indicated it will at most pursue disallowances in one
out of every three years.[4]
The apparent lack
of effort in recouping misspent federal money is problematic. Recent reviews by
HHS OIG of beneficiaries made newly eligible by the Patient Protection and
Affordable Care Act (P.L. 111-148, as amended), also known as Obamacare, found
more than seven percent of beneficiaries were potentially ineligible in
Kentucky,[5] more than 25 percent were potentially ineligible in California,[6]
and more than 30 percent were potentially ineligible in New York.[7] In
Louisiana, a state Department of Health audit found an astounding 82
percent of recipients ineligible in a random sample.[8]
Diligent federal
oversight and legitimate threats of enforcement and disallowances like those
specified under Section 1903(u) are essential in Medicaid because the statutory
funding mechanism naturally reduces incentives for states to pursue rigorous
program integrity efforts. For every dollar saved by states on traditional beneficiaries,
the states on average only get to keep 43 cents.[9] For reducing one
dollar on waste, fraud, or legitimate errors in the expansion population
made eligible by Obamacare, the states save only 7 cents (10
cents starting in 2020).[10] Furthermore, if states accidentally enroll an
individual as an expansion enrollee instead of a traditional enrollee, states
are perversely, and significantly, rewarded for their error, unless the federal
government subsequently takes action to recoup those mistakenly paid funds.
Our offices would
like to work with you on our shared goal of ensuring that the government
complies with the intent and plain language of Section 1903(u) of the Social
Security Act by discouraging systematic and routine errors in Medicaid eligibility
determinations by states. We believe that CMS' past actions have ignored its
requirements under the law and are concerned that the July 5,
2017 final rule will perpetuate many of the weaknesses that characterized
the previous enforcement regime. Accordingly, please provide answers to the
following questions by March 15, 2019:
1. Has CMS
attempted to recoup any improper payments related to erroneous eligibility
determinations under Section 1903(u) of the Social Security Act since 1992? If
so, please identify the overpayment amount and the recoveries by state and
year.
2. What are the
state by state Medicaid eligibility error rates since the PERM program began
tracking this metric in 2008?
3. What are the
state by state Medicaid eligibility error rates for traditional eligibility
pathways versus the newly eligible pathway created by the Patient Protection
and Affordable Care Act since the expansion in 2014?
4. What additional
statutory authorities would be beneficial for the purpose of enforcing Section
1903(u)?
Thank you for your
attention to these important matters.
No comments:
Post a Comment