Summary of Section 6034: Medicaid Integrity Program

Establishes a Medicaid Integrity Program Directs the HHS Inspector General to enter into contracts with eligible entities to carry out the program’s activities, which would include: (1) review of the actions of individuals or entities furnishing items or services for which a Medicaid payment may be made, (2) audit of claims for payment for items or services furnished or for administrative services rendered, (2) audit of claims for payment for items or services furnished or for administrative services rendered, and (3) education of service providers, managed care entities, beneficiaries, and other individuals with respect to payment integrity and benefit quality assurance issues. Beginning in FY 2006 and every five years thereafter, the Secretary, in consultation with the Attorney General, the Director of the Federal Bureau of Investigation, the Comptroller General of the United States, the Inspector General of HHS, and state officials with responsibility for controlling provider fraud and abuse under Medicaid, would establish a comprehensive plan for ensuring Medicaid program integrity by combating fraud, waste, and abuse. Appropriations for the Medicaid Integrity Program would total $5 million in FY 2006, $50 million in FY 2007 and in Y 2008, and $75 million in FY 2009 and in each fiscal year hereafter. Amounts appropriated remain available until expended. Requires the Secretary, no later than 180 days after the end of each fiscal year (beginning with FY 2006), to submit a report to Congress that identifies the use and effectiveness of the use of funds appropriated for the program. State Requirement to Cooperate with Integrity Program Efforts Requires states to comply with any requirements determined by the Secretary to be necessary for carrying out the Medicaid Integrity Program. Increased Funding for Medicaid Fraud and Abuse Control Activities In each of FY 2006 - FY 2010, $25 million would be appropriated for Medicaid activities of the HHS Office of Inspector General (in addition to any other amounts appropriated or made available for its Medicaid activities, to remain available until expended). Increase in CMS Staffing Devoted to Ensuring Medicaid Program Integrity Directs the Secretary to significantly increase the number of full-time equivalent employees whose duties consist solely of ensuring the integrity of the Medicaid program by providing states with support and assistance to combat provider fraud and abuse. Expansion of the Medicare-Medicaid Date Match Program (Medi-Medi Program) Establishes a national expansion of the Medicare- Medicaid data match project. Requires the HHS Secretary to enter into contracts with eligible entities to ensure that the Medi-Medi Program is conducted for the purpose of: (1) identifying program vulnerabilities in Medicare and Medicaid through the use of computer algorithms to look for payment anomalies, (2) working with states, the Attorney General, and the Inspector General of HHS to coordinate appropriate actions to protect Medicare and Medicaid expenditures, and (3) increasing the effectiveness and efficiency of both programs through cost avoidance, savings, and recoupment of fraudulent, wasteful, or abuse expenditures.  At least quarterly, the HHS Secretary is required to make available in a timely manner any data and statistical information collected by the Medi-Medi Program to the Attorney General, the Director of the Federal Bureau of Investigation, the Inspector General of HHS, and the states.  In addition to Health Care Fraud and Abuse Control (HCFAC) program appropriations for the Medicare Integrity Program (which have a statutory floor and ceiling), the Medi- Medi Program would receive $12 million in FY 2006, $24 million in FY 2007, $36 million in FY 2008, $48 million in FY 2009, and $60 million in FY 2010 and in each fiscal year thereafter. Delayed Effective Date In the case of a state whose legislative calendar does not allow for timely passage of state laws necessary for compliance with the Medicaid state plan requirements of this chapter, the plan would not be regarded as failing to comply solely on the basis of its failure to meet the requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the state legislature that begins after the date of enactment of this act. (Federal costs - $528 million over five years/$1.2 billion over ten years)

For further information, please call NCSL staff Joy Johnson Wilson, Health Policy Director at 202-624-8689 or Rachel Morgan RN, BSN, Senior Health Policy Specialist at 202-624-3569.