The Centers for Medicare and Medicaid Services has proposed a new rule that would reduce the burden on states for deciding Medicaid eligibility and continue the reduction of improper payments.
Improper payment rates are based on the review of fee-for-service, managed care, and and the eligibility of Medicaid and the Children's Health Insurance Program.
Under the new rule, a payment would be determined to be improper if the federal share amount is incorrect, even if the total amount adds up to the correct amount, CMS said.
This is a change from the current rule that cites improper payments only by the total computable amount, which is based on the federal share plus the state share.
Under the proposed rule, CMS will change the dates of review from October through September to July through June of a given year.
States are currently required to conduct eligibility reviews and report the results to CMS. The new rule would change that responsibility by having a federal contractor conduct eligibility reviews with support from each state, CMS said.
The eligibility review, along with medical and data processing reviews, will be conducted on the beneficiary associated with a claim sample for fee for service and managed care payments. This is a change from the current rule, in which states have separate sample claims.
Under the new rule, a national sample size would be calculated and then distributed across states. State-specific sample sizes would be based on factors such as each state's expenditures and previous improper payment rate, CMS said.
The current rule builds the sample size from the states on up, based on each's previous improper payment rate and its level of precision combined to total the national sample size.
States will continue to implement corrective action plans for all errors and deficiencies, CMS said
However, there would be more stringent requirements, and the possibility of reductions and disallowances, for states that have consecutive improper payment rates over the 3 percent national standard established by law.
CMS will only pursue disallowances if a state does not try to meet the national standard, it said.
The eligibility program requires states to report the ratio of their erroneous excess payments for medical assistance.
States review Medicaid cases to determine whether the sampled cases meet Medicaid eligibility requirements. Payments would be withheld by the amount of the improper payments that exceed the 3 percent threshold.
Twitter: @SusanJMorse