MassHealth's Eligibility Determination Process for Healthcare Services

This is a 2012 Massachusetts State Auditor report reviewing how MassHealth decided whether people qualified for healthcare benefits.

“This audit concerns public healthcare costs being borne by the Commonwealth’s Medicaid program that is administered in Massachusetts by an agency within the state’s Executive Office of Health and Human Services (EOHHS) called MassHealth.”

The Auditor looked at whether MassHealth had enough rules and controls to verify eligibility and possibly save taxpayer money by preventing improper benefits.

“The Office of the State Auditor (OSA) initiated an audit of MassHealth’s eligibility determination process to (1) assess the adequacy of the policies and internal controls MassHealth has established relative to this process and (2) if possible, identify opportunities for developing more effective policies and internal controls aimed at ensuring that only eligible applicants receive benefits, which could result in savings to the Commonwealth’s taxpayers.”

MassHealth covers many residents and costs billions, so weak eligibility checks can affect taxpayers and public trust.

“The effectiveness of the policy decisions and the internal controls that MassHealth establishes over its eligibility determination process are essential in addressing these concerns and maintaining the public’s confidence in the integrity of the administration of MassHealth programs.”

For an ordinary Massachusetts taxpayer or resident, the issue is whether public healthcare money is going only to people who qualify.

“In fiscal year 2011, MassHealth paid in excess of $12.2 billion to healthcare providers, of which approximately 35% was funded with Commonwealth funds.”

The Auditor found problems in how MassHealth checked income, residency, and conflicting information, creating a risk that ineligible people received benefits.

“As a result, MassHealth may be providing millions of dollars in benefits each year to individuals who are not entitled to receive these benefits.”

The Auditor recommended that MassHealth use data matches, request more documentation when needed, and formally document how conflicts are resolved.

“In order to address our concerns in this area, we recommend that MassHealth establish formal procedures on how to address conflicts in information provided by applicants/members, including a requirement to document in each case file the specific measures taken to address such conflicting information.”

The report says enrollment is a major driver of MassHealth costs, so eligibility errors can have a large financial impact.

“The evidence we have for the Commonwealth is that enrollment is the single most important cost driver for the program and that CMS expects enrollment to further drive costs after 2014, when PPACA is fully implemented.”