Department of Health

Medicaid Recipients Enrolled in Medicare HMO Risk Plans

Medicare is a federal health insurance program for the aged and the disabled; Medicaid is a joint state and federal health insurance program for the needy. If an individual is eligible for both Medicare and Medicaid, the individual's eligible medical costs should generally be paid by Medicare. We examined the controls established by the Department of Health for ensuring that such costs are paid by Medicare when dual eligible individuals are enrolled in Medicare managed care plans (HMO risk plans). We found that the controls need to be strengthened, as the Medicare eligibility of most of the dual eligible individuals in our sample was not identified by the Department's records. As a result, there is less assurance that the eligible medical costs of these individuals will be paid by Medicare. We also determined that, contrary to Department policy, a number of individuals were enrolled in Medicaid managed care plans at the same time they were enrolled in Medicare HMO risk plans. We recommend that certain improvements be made to prevent Medicaid overpayments for costs that should be paid by Medicare.

For a complete copy of Report 98-S-5 click here.
For a copy of the 90-day response click here.