State Audit Finds Oregon Health Plan Spent Millions on Ineligible Members

A state audit of the Oregon Health Plan, the state's Medicaid expansion program for low-income residents, has concluded that "thousands" of people have received benefits for which they were not eligible, costing the state $4.3 million per year, the Portland Oregonian reports. A review of benefits awarded in 2000 and 2001 by the Oregon Secretary of State showed that "in some instances," caseworkers either signed up people they knew did not meet eligibility requirements, did not verify wage information, failed to ask for a Social Security number or did not ask for proof of citizenship. In one in four cases in 2000 the auditors sampled, enrollees in the health plan earned at least 25% more than the maximum income limit; their participation in the health plan cost the state an estimated $2.1 million. Between Jan. 1, 2000, and April 30, 2001, workers for the health plan failed to ask for a Social Security number in approximately 15,000 cases, costing the state an estimated $1.6 million. While Social Security numbers are not required when applying for family coverage, requesting the information would have helped health officials check on the applicants' wages. In addition, the report concluded that the state lost $1.7 million a year by awarding benefits to undocumented immigrants. According to the report, because health officials rely on applicants to mail in a form stating their citizenship, there is a "risk that applicants would lie about their citizenship status." Finally, the audit said caseworkers improperly waived monthly premiums for about 1,260 enrollees who claimed not to be earning any money but who were in fact working full time. The health plan is open to Oregon residents who earn up to 100% of the federal poverty level, or $17,650 for a family of four. Beneficiaries pay a premium of between $6 and $23 per month and must re-apply every six months.

Jeopardizing Waiver?
While the cases of ineligible people receiving benefits represent a "small percentage" of the 17,000 applicants the state processes each month, the Oregonian reports that the audit's findings come after the state Legislature approved $2.3 million in funding in 1999 to improve applicant screening. In addition, the Department of Human Services, which administers the Oregon Health Plan, faces large budget cuts as lawmakers look for ways to reduce the state's estimated $850 million shortfall. Aides for Gov. John Kitzhaber (D), who helped create the health plan as a member of the Oregon Senate and who is in favor of expanding coverage, said they would evaluate the audit's findings. "If our eligibility workers are not doing a good job, we'll take whatever steps we can to get the work done appropriately," Mark Gibson, Kitzhaber's health care policy adviser, said. State Rep. Jeff Kruse (R) said he was concerned that the audit findings could jeopardize the state's attempt to obtain a federal waiver to expand the Oregon Health Plan to more residents. "We are getting Medicaid dollars based on a certain set of standards as to eligibility. If they're including people who don't fit the categories, the feds would have right to say, 'We're not going to play that game anymore,'" he said (Lednicer, Portland Oregonian, 1/4). The full audit is available online. Note: You will need Adobe Acrobat to view the audit.