Key Issues > Medicaid Financing, Access, and Integrity
health icon, source: PhotoDisc

Medicaid Financing, Access, and Integrity

Medicaid plays an important role in providing health care coverage for over 60 million low-income people, including children, parents and individuals who are aged or disabled. The program is jointly financed by the federal government and the states and costs more than $400 billion a year. Under the Patient Protection and Affordable Care Act, federal expenditures are expected to increase significantly as millions of additional individuals are estimated to be covered by Medicaid beginning in 2014.

  1. Share with Facebook 
  2. Share with Twitter 
  3. Share with LinkedIn 
  4. Share with mail 

The Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS), the agency that oversees the program at the federal level, faces many challenges in overseeing payments and ensuring that children covered by Medicaid receive needed services. Because of concerns about inadequate federal oversight of the large and growing program, Medicaid has been designated as high risk.

  • CMS has not developed an effective program integrity strategy to identify and prevent fraud, waste, and abuse, despite estimated improper payments totaling more than $20 billion a year in federal funds. It currently uses different audit approaches with varying results.

Figure 1: Number of Audits and Potential NMAP Overpayments and through February 2012

Number of Audits and Potential NMAP Overpayments and through February 2012

  • Medicaid is the largest payer of long-term care and these services comprise over one-quarter of the total Medicaid expenditures. Variation in states’ policies and practices raises questions regarding how states determine Medicaid eligibility for long-term care and implement federal requirements to ensure that only eligible individuals receive Medicaid coverage.

Figure 2: Percentage of Nationwide Spending on Long-Term Care Services, by Payment Source (2009)

Percentage of Nationwide Spending on Long-Term Care Services, by Payment Source (2009)

  • Children in Medicaid receive basic preventive health care for some services at rates similar to those of children with private insurance. However, many families experience difficulties accessing some types of services, such as mental and oral health services. Although states are required to provide these services, millions of children do not receive them.

Figure 3: Percentage of Children in Medicaid Receiving Any Dental Service, Fiscal Year 2008

Percentage of Children in Medicaid Receiving Any Dental Service, Fiscal Year 2008

  • Gaps remain in federal oversight of supplemental Medicaid payments that states often make to certain providers as lump sum payments that are not based on claims for specific services, and can generate tens of billions of dollars in federal matching funds for states.
Looking for our recommendations? Click on any report to find each associated recommendation and its current implementation status.

Medicaid Long-Term Care:

Information Obtained by States about Applicants' Assets Varies and May Be Insufficient
GAO-12-749:
Published: Jul 26, 2012. Publicly Released: Aug 27, 2012.

Medicaid:

States Reported Billions More in Supplemental Payments in Recent Years
GAO-12-694:
Published: Jul 20, 2012. Publicly Released: Aug 20, 2012.

National Medicaid Audit Program:

CMS Should Improve Reporting and Focus on Audit Collaboration with States
GAO-12-627:
Published: Jun 14, 2012. Publicly Released: Jun 14, 2012.

Medicaid and CHIP:

Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care
GAO-11-624:
Published: Jun 30, 2011. Publicly Released: Jun 30, 2011.

Oral Health:

More Reports

Medicare Program Integrity:

Contractors Reported Generating Savings, but CMS Could Improve Its Oversight
GAO-14-111:
Published: Oct 25, 2013. Publicly Released: Nov 25, 2013.

Health Care Fraud and Abuse Control Program:

Medicare Program Integrity:

Increasing Consistency of Contractor Requirements May Improve Administrative Efficiency
GAO-13-522:
Published: Jul 23, 2013. Publicly Released: Aug 22, 2013.

Medicare Imaging Accreditation:

Medicare Program Integrity:

Health Care Fraud:

Types of Providers Involved in Medicare Cases, and CMS Efforts to Reduce Fraud
GAO-13-213T:
Published: Nov 28, 2012. Publicly Released: Nov 28, 2012.

Medicaid Integrity Program:

CMS Should Take Steps to Eliminate Duplication and Improve Efficiency
GAO-13-50:
Published: Nov 13, 2012. Publicly Released: Dec 10, 2012.

Medicare Program Integrity:

Greater Prepayment Control Efforts Could Increase Savings and Better Ensure Proper Payment
GAO-13-102:
Published: Nov 13, 2012. Publicly Released: Dec 10, 2012.

Medicare Fraud Prevention:

Health Care Fraud:

Types of Providers Involved in Medicare, Medicaid, and the Children's Health Insurance Program Cases
GAO-12-820:
Published: Sep 7, 2012. Publicly Released: Oct 9, 2012.
More...
There are no other materials currently linked to this content