The Medicaid ProgramState Medicaid managed care programs are intended to increase access to and improve the quality of health care for Medicaid beneficiaries. States contract with an MCO to make services available to enrolled Medicaid beneficiaries, usually in return for a periodic payment, known as a capitation payment. Federal Requirements States must generally provide notice when the State agency terminates a Medicaid beneficiary’s covered benefits or eligibility at least 10 days before the date of action (42 CFR § 431.211). However, if a State establishes that the beneficiary has been accepted for Medicaid services by another State, the original State must provide notice of the termination of the beneficiary’s benefits or eligibility no later than the date of the termination (42 CFR § 431.213(e)). Ohio’s Medicaid Managed Care ProgramDuring our audit period, approximately 90 percent of Ohio’s Medicaid population received benefits through MCOs under contract with the State agency. The contracts with the MCOs covered health care services to eligible Medicaid beneficiaries in exchange for a fixed per-member, per-month capitation payment. The Medicaid MCO contracts incorporate rules set forth in the Ohio Administrative Code (OAC) (State agency managed care contracts Article XIV), which requires the State agency to disenroll a beneficiary from an MCO plan when the beneficiary’s permanent residence moves outside the plan’s service area (OAC 5160-26-02.1(B)(1) and OAC 5160-58-02.1(A)(2)). Disenrollment must take effect on the last day of the month in which the beneficiary moves (OAC 5160-26-02.1(B)(1) and OAC 5160-58-02.1(A)(2)). Transformed Medicaid Statistical Information SystemThe Transformed Medicaid Statistical Information System (T-MSIS) is a critical data and systems component maintained by CMS. The primary purpose of T-MSIS is to establish an accurate, current, and comprehensive database containing standardized enrollment, eligibility, and paid claim data about Medicaid recipients to be used for the administration of Medicaid at the Federal level, and assist in the detection of fraud, waste, and abuse in Medicaid.Public Assistance Reporting Information SystemThe Public Assistance Reporting Information System (PARIS) is an information exchange system managed by the Administration for Children and Families. PARIS matches State and Federal data to provide State Public Assistance Agencies with beneficiary information that they can use to identify possible concurrent eligibility and erroneous payments. Ohio’s Medicaid eligibility verification plan describes the use of PARIS as a post-eligibility check for concurrent benefits received in another State while the individual is enrolled in Ohio Medicaid. The PARIS match information is added to Ohio’s eligibility system and generates an electronic alert (PARIS alert) for beneficiaries who were identified as having concurrent eligibility in another State. The State agency is required to contact the beneficiaries before eligibility may be terminated. If the State agency receives information that may affect a beneficiary’s Medicaid benefits, such as a PARIS alert, the State agency sends a PARIS Contact Notice to the beneficiary, and the beneficiary has 10 days to respond. If the beneficiary doesn’t respond, a county caseworker sends out a reminder letter. If there is no response from the beneficiary or if mail addressed to the beneficiary is returned from the post office with no forwarding address, the beneficiary’s eligibility may be terminated. If the State agency confirms that the beneficiary has been determined eligible for Medicaid in another State, the State agency is not required to provide advance notice and may send notice on the effective date of the beneficiary’s eligibility termination.
OH,
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