Audit finds Medicaid enrollment broker met most requirements but still found areas of concern

February 14, 2023

A recent audit on the state's Medicaid enrollment broker found that most requirements related to communicating and processing enrollment information were met; however, some processes had room for improvement.

The audit sought to determine if Maximus Inc. had complied with requirements involving communicating with eligible clients of the Texas State Medicaid program and the Children's Health Insurance Program (CHIP) in a timely and accurate manner, including receiving and processing information involving clients' selections of a health plan.

As the state's sole health plan enrollment broker, Maximus reported that they processed, on average, more than 103,000 new Medicaid enrollments monthly in Fiscal Year 21, with 35 percent of new clients enrolled in a managed care organization based on the member’s choice. An additional 6,924 children were enrolled in the CHIP program each month, with 70 percent based on a member's plan choice. If a member does not select a plan, the broker assigns the member to a plan through its default enrollment process, considering one or more factors, such as prior MCO coverage.

Auditors found that Maximus did not initiate its default enrollment process for CHIP members re-enrolling with the program in accordance with its procedures. The procedures outline that CHIP members who reenter the program within one year of leaving should be re-enrolled with their previous MCO, and those re-enrolling after a year should use the algorithm to select a plan. Auditors discovered that all previous CHIP clients were re-enrolled in their previous MCO regardless of their last coverage period.

Auditors recommended that Maximus work with HHS to update the process for initiating the default algorithm for CHIP clients to ensure the broker follows stated procedures.

Maximus is also responsible for communicating Medicaid enrollment transactions to HHS through the Texas Integrated Eligibility Redesign System (TIERS) and resolving transactions the system may deny. However, auditors found that Maximus had not resolved several types of transactions, specifically:

The daily report Maximus runs to capture TIERS-denied transactions did not include all TIERS-denied transactions.
On 12 of the daily reports reviewed by the OIG, Maximus did not include 68 percent of transactions in its tracking spreadsheet.
Maximus resolved all 25 tested transactions on its spreadsheet. However, 11 were not resolved timely, and one did not address the member's selection of MCO.

OIG auditors provided recommendations to the broker on how to address areas of concern, including strengthening the process used to resolve TIERS-denied transactions by developing a clear procedure that includes a process review. Auditors also suggested Maximus work with HHS to review prior TIERS-denied transactions not captured in its review process to ensure they were appropriately resolved.

Auditors also reviewed Maximus' communication with enrollees related to the process of joining Medicaid and CHIP, finding the broker had mostly shared accurate information with clients; however, there were several areas of improvement. For example, of the 27 Medicaid enrollment packets tested, 26 included an incorrect reply by date, which could lead to clients not being enrolled with their preferred MCO if deadlines are missed. Additionally, the broker failed to review the accuracy of its mailing contractor's self-reported information about the date client letters were delivered to the postal service.

The OIG made recommendations to Maximus aimed at improving communication with enrolling Medicaid clients, including the implementing process' that ensures enrollment packets provide accurate response deadlines and verify the accuracy of mail date information provided by its subcontractors.

Maximus agreed with the results of most of the audit's findings and has begun to develop or implement process changes based on the auditors' recommendations.