In addition, it also touched on the major issues surrounding state Medicaid plan programs, specifically:

The inability to assess standards and success among states

Even though the federal government requires states to establish quality standards for Medicaid programs and monitor quality and reporting compliance, there is practically no uniformity for these standards across the states. Shortfalls in contract requirements and data collection make it difficult to compare state-to-state data and assess whether beneficiary health has actually improved throughout the country.

Staff cuts and questions of accountability

Some states have cut back on staffing of their Medicaid offices. This not only raises concerns about the states’ ability to hold health plans accountable, but also has resulted in the federal government being criticized for failing to ensure the states properly oversee the plans.

Inconsistencies in practices

States are required to set rates, monitor contracts and enrollment practices, and oversee operational functions and compliance programs of their Medicaid plans, but how each state complies differs. This, unfortunately, leads to operational and reporting inconsistencies and prevents the ability to share and compare best practices, data and other important information.

Lack of CMS state oversight

Each state is required to audit health plans providing Medicaid services. CMS monitors that state oversight. However, CMS has been accused of having problems with such oversight, according to reports from the Department of Health and Human Services Inspector General’s office and the U.S. Government Accountability Office.

To alleviate these challenges, CMS is moving to exert more direct control and oversight of these programs, which will ultimately benefit Medicaid plans. However, preparing compliance efforts will be key. To find out how Medicaid plans can prepare for increased CMS oversight, see our previous blog post on this topic.

We excel in providing consulting and software solutions to help government-sponsored health plans significantly mitigate compliance risk. If you’d like to learn more, please contact us today.