Examining Washington’s Concurrent Medicaid Enrollments

Three agencies – two state, one federal – are involved in determining Medicaid eligibility. The two Washington state agencies administer almost all its Medicaid programs:

• HCA administers Medicaid programs for people who qualify based on their income (MAGI, from Modified Adjusted Gross Income). This includes about 95% of managed care recipients in Washington.
• DSHS administers Medicaid programs for people who receive long-term care or who are elderly or disabled. This represents about 5% of managed care recipients in Washington.

In most states, the federal Social Security Administration is responsible for determining Medicaid eligibility for people who are enrolled in Supplemental Security Income. (SSI provides monthly cash assistance for people who are blind, disabled or older than 65 and have limited resources.) In these states, a person receiving SSI is also qualified for Medicaid medical insurance. The Social Security Administration sends data confirming this to Washington’s systems, which automatically enroll clients in the state’s Medicaid program.

The federal government’s March 2020 declaration of the COVID-19 public health emergency required changes to the procedures states would usually take to address concurrent enrollments. HCA’s policies closely matched federal guidance. This meant Washington appropriately terminated coverage for some clients. However, Washington also retained many clients on Medicaid when it might have terminated their coverage in normal times. coverage for some clients. However, it also retained many clients on Medicaid when it might have terminated their coverage in normal times.

By contrast, according to auditors in other states, those states did not take several appropriate actions that were available to resolve concurrent enrollments. They did not do so because they were reluctant to risk the increased federal funding tied to continuous enrollment by inappropriately disenrolling someone. This greatly increased the number of dual enrollments across the nation.

Like most states, Washington enrolls people in Medicaid using the addresses applicants provide. Also, a lack of a fixed address does not impose a barrier to receiving health insurance. For example, acceptable addresses include homeless or domestic violence shelters. State agencies accept the applicant’s statement that they are a Washington resident, a policy called self-attestation.

Concurrent enrollment typically occurs when clients relocate from one state to another and, in the flurry of tasks involved in moving, forget to inform the state Medicaid agency they are leaving. They establish residency in their new state, and then enroll in its Medicaid program.

Two states thus find themselves paying for one person’s insurance premium to provide needed health care. The new state pays its MCO to insure its newly enrolled client, while the former state continues to pay its MCO for insurance the client no longer needs. The former state’s money could be spent on something else that provides a benefit to someone. The situation continues until one state or the other can confirm where the client actually resides. 

By the last year of the public health emergency, states spent about $135 million on unneeded premiums for clients concurrently enrolled with Washington Medicaid. More than 131,000 people were concurrently enrolled in Medicaid managed care programs in Washington and at least one other state during calendar years 2019-2022.

We began by analyzing the entire dataset of Medicaid enrollees we received from HHS-OIG. We identified seven states with the most concurrent enrollees. Listed in the order of most-to-least concurrent enrollees, they were: California, Oregon, Arizona, Idaho, Colorado, Nevada and Texas.

We closely reviewed a sample of concurrent enrollments in the seven states, including a large sample from Oregon. Our projections show Washington unnecessarily paid, on average, $8.6 million a year in premiums for long-term concurrent enrollees residing in these seven states.

• In the Oregon sample, five in 10 clients were resident in Oregon while Washington paid for their health insurance.
• In the sample of the other six states, four in 10 clients were resident in those states while Washington paid for their health insurance.

Both HCA and DSHS made premium payments for Medicaid clients who were resident in other states due to various factors. For example, some Oregon concurrent enrollees regularly visited providers in both states. This made it challenging to tell which state should pay for their coverage. Additionally, inaccurate information from the Social Security Administration resulted in clients being reenrolled into Washington’s Medicaid program. This was the case even after these clients informed DSHS they had left the state.

We also found that across states, clients’ challenging personal situations contributed to many concurrent enrollments. Adults in our sample were twice as likely to be homeless compared to the general Medicaid managed care population. Additionally, many concurrent enrollments reflected complex individual circumstances. These circumstances included fleeing from domestic violence and managing substance use disorders.

Limitations of federal processes hinder Washington in identifying and resolving concurrent enrollments. The federal Public Assistance Reporting Information System (PARIS) is a quarterly federal reporting process. Individual states send in information about recipients of Medicaid and other programs. These records are matched to find any clients who are enrolled in multiple states at the same time.  However, the PARIS system does not capture every case of concurrent enrollment, and results vary widely by state. In addition, inaccurate information from the Social Security Administration, together with a lack of clear guidance from federal partners, resulted in unwanted reenrollments. As a national program, Medicaid needs federal solutions for early identification of concurrent enrollments

The audit made a series of recommendations to HCA and DSHS to improve existing processes and to update the state’s contracts with managed care organizations.