United States Government Accountability Office (GAO-25-106976)

Full Report: https://www.gao.gov/assets/gao-25-106976.pdf 

Highlights: https://www.gao.gov/assets/gao-25-106976-highlights.pdf

Federally funded health care programs are susceptible to improper payments and fraud.  For example, the United States Department of Health and Human Services (HHS) estimated $4.9 billion in Medicaid payments for ineligible people in FY 2024.  HHS oversees programs such as Medicaid and health insurance marketplaces.  These programs can generally detect when unauthorized people are enrolled in several programs at the same time within a state, but there are challenges across states.  We found about $1.6 billion in potential overpayments due to duplicate coverage across selected states.  Better data matching across states could help.  Our recommendations address this issue and more.

What GAO Found

For fiscal year 2023, the federal government and six selected states—California, Georgia, New York, Pennsylvania, Tennessee, and Texas—paid health insurance entities at least $1.6 billion in potential overpayments or fraud for duplicate health care coverage or benefits.  The payments were made on behalf of approximately 500,000 individuals who were simultaneously enrolled across multiple states in Medicaid or the Children’s Health Insurance Program (CHIP) or receiving an advance premium tax credit (APTC) across multiple states.  These payments were made on behalf of individuals to managed care organizations in the form of capitated payments for Medicaid and CHIP or to health insurance issuers through APTC.  The $1.6 billion in potential overpayments identified in GAO’s analyses may be relatively small compared to the total enrollment numbers, outlays, and expenditures.  However, they represent a significant amount of potential overpayments largely stemming from six selected states in GAO’s review.  It is also likely that the counts and dollar figures GAO identified were partially attributable to COVID-19-related continuous enrollment conditions for Medicaid and some CHIP enrollees.  Specifically, as a condition for receiving temporarily enhanced federal funding during the pandemic, states were required to keep Medicaid and some CHIP beneficiaries continuously enrolled unless an individual requested voluntary termination of eligibility, or the individual ceased to be a resident of the state.  Nonetheless, the conditions did not prevent states from disenrolling individuals who were confirmed to no longer be state residents, and duplication of Medicaid, CHIP, or APTC benefits across states for individuals should not have occurred.