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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

January 2015: 

Medicaid: 

Additional Federal Action Needed to Further Improve Third-Party 
Liability Efforts: 

GAO-15-208: 

GAO Highlights: 

Highlights of GAO-15-208, a report to congressional requesters. 

Why GAO Did This Study: 

In fiscal year 2013, Medicaid—jointly financed by states and the 
federal government-—provided health care coverage to over 70 million 
individuals at a total cost of about $460 billion. Congress generally 
established Medicaid as the health care payer of last resort, meaning 
that if enrollees have another source of health care coverage—-such as 
private insurance-—that source should pay, to the extent of its 
liability, before Medicaid does. This is referred to as third-party 
liability (TPL). There are known challenges to ensuring that Medicaid 
is the payer of last resort. GAO was asked to provide information on 
the prevalence of private insurance among Medicaid enrollees and on 
state and CMS efforts to ensure that Medicaid is the payer of last 
resort. 

This report examines (1) the extent to which Medicaid enrollees have 
private insurance, and (2) state and CMS initiatives to improve TPL 
efforts. GAO analyzed the 2012 ACS; interviewed Medicaid officials 
from eight states with high program spending or enrollment that used 
managed care; interviewed CMS officials and stakeholders; and reviewed 
relevant laws, regulations, and CMS guidance. 

What GAO Found: 

Based on responses to the 2012 U.S. Census Bureau’s American Community 
Survey (ACS)—-the most recent available at the time the work was 
conducted—-GAO estimates that 7.6 million Medicaid enrollees (13.4 
percent) had private health insurance in 2012. The estimated 
prevalence of private health insurance varied among Medicaid 
eligibility categories, which may differ with respect to Medicaid 
benefits and costs. The number of Medicaid enrollees with private 
health insurance is expected to increase with the expansion of 
Medicaid. 

Figure: Estimated Prevalence of Private Health Insurance among 
Medicaid Enrollees by Eligibility Category, 2012: 

[Refer to PDF for image: vertical bar graph] 

Medical eligibility category: Children; 
Estimated Prevalence of Private Health Insurance: 8.4%. 

Medical eligibility category: Adults; 
Estimated Prevalence of Private Health Insurance: 12.4%. 

Medical eligibility category: Disabled; 
Estimated Prevalence of Private Health Insurance: 13.2%. 

Medical eligibility category: Aged; 
Estimated Prevalence of Private Health Insurance: 34.6%. 

Medical eligibility category: All enrollees; 
Estimated Prevalence of Private Health Insurance: 13.4%. 

Source: GAO analysis of 2012 U.S. Census Bureau data. GAO-15-208. 

Note: GAO defined children as non-disabled individuals aged 0 through 
18; adults as non-disabled individuals aged 19 through 64; disabled as 
individuals aged 0 through 64 who reported a disability; and aged as 
individuals aged 65 and older. 

[End of figure] 

Selected states reported taking various steps to address challenges to 
ensuring that Medicaid is the payer of last resort and acknowledged 
recent Centers for Medicare & Medicaid Services (CMS) support, while 
also suggesting additional federal action. Four of the eight reviewed 
states reported various initiatives to improve coverage 
identification, such as arranging to participate in a data registry 
that allows participants to identify individuals with overlapping 
coverage. CMS has taken steps to issue TPL guidance and share some 
information on effective state practices, and such federal efforts 
should be ongoing to ensure that evolving approaches are captured and 
shared across states. In addition, officials in five states reported 
that enrollees with third-party coverage may be eligible to enroll in 
Medicaid managed care—in which states contract with health plans to 
provide services to enrollees and may delegate TPL activities such as 
payment recoveries to these plans. One of the five states had 
initiated a program to oversee plans’ TPL recoveries, while other 
states did not report similar oversight. The National Association of 
Medicaid Directors reported that, in the absence of explicit CMS 
guidance in this area, it can be difficult for states to work with 
plans to improve TPL oversight and has recommended CMS provide such 
guidance. 

What GAO Recommends: 

GAO recommends that the Secretary of the Department of Health and 
Human Services (HHS) direct CMS to (1) routinely monitor and share 
across all states information regarding key TPL efforts and 
challenges, and (2) provide guidance on state oversight of TPL efforts 
conducted by Medicaid managed care plans. HHS concurred with GAO’s 
recommendations and noted plans to address them. 

View [hyperlink, http://www.gao.gov/products/GAO-15-208]. For more 
information, contact Katherine M. Iritani at (202) 512-7114 or 
iritanik@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

An Estimated 7.6 Million Medicaid Enrollees Had Private Insurance in 
2012 and This Number Is Expected to Increase with the Medicaid 
Expansion: 

Selected States Reported Some Success Addressing Challenges to Their 
TPL Efforts and Additional CMS Action Could Improve Such Efforts 
Nationwide: 

Conclusions: 

Recommendations: 

Agency Comments: 

Appendix I: Scope and Methodology of the American Community Survey 
(ACS) Analysis: 

Appendix II: Detailed Estimates of Medicaid Enrollees with Other 
Sources of Health Coverage: 

Appendix III: Comments from the Department of Health and Human 
Services: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Examples of Initiatives in Selected States to Improve 
Coverage Identification: 

Table 2: Estimated Number and Percentage of Medicaid Enrollees with 
Other Private or Public Sources of Health Coverage in 2012, by 
Eligibility Category: 

Table 3: Estimated Number and Percentage of Medicaid Enrollees with 
Other Private or Public Health Coverage in 2012, by State: 

Figure: 

Figure 1: Estimated Prevalence of Private Health Insurance among 
Medicaid Enrollees by Eligibility Category, 2012: 

Abbreviations: 

ACS: American Community Survey: 

CHIP: State Children's Health Insurance Program: 

CMS: Centers for Medicare & Medicaid Services: 

COB: coordination of benefits: 

DRA: Deficit Reduction Act of 2005: 

ERISA: Employee Retirement Income Security Act of 1974: 

FAQ: Frequently Asked Questions: 

HHS: Department of Health and Human Services: 

MHPA: Medicaid Health Plans of America: 

OIG: Office of Inspector General: 

PIE: payer initiated eligibility/benefit: 

PPACA: Patient Protection and Affordable Care Act: 

PUMS: Public Use Microdata Sample: 

TAG: technical advisory group: 

TPL: third-party liability: 

VA: Department of Veterans Affairs: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

January 28, 2015: 

The Honorable Joseph R. Pitts: 
Chairman: 
Subcommittee on Health: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Michael C. Burgess, M.D. 
House of Representatives: 

In fiscal year 2013, Medicaid provided health care coverage to over 70 
million individuals at a total cost of about $460 billion.[Footnote 1] 
Congress generally established Medicaid as the health care payer of 
last resort, meaning that if Medicaid enrollees have another source of 
health care coverage, that source should pay, to the extent of its 
liability, before Medicaid does. Federal regulation refers to this 
requirement as third-party liability (TPL).[Footnote 2] In 
administering their Medicaid programs, states are required to take 
certain steps to identify sources of third-party coverage that 
Medicaid enrollees may have, and to ensure that these sources pay to 
the extent of their liability.[Footnote 3] When private third parties--
such as health insurers--pay for health care services instead of 
Medicaid, savings accrue not only to states, but also to the federal 
government, which historically has financed over half of the overall 
Medicaid program costs.[Footnote 4] In addition, federal financing of 
Medicaid is increasing with the implementation of the Patient 
Protection and Affordable Care Act (PPACA), under which states may 
expand Medicaid eligibility to certain low-income individuals and 
which specified that the federal government would pay 100 percent of 
costs for these individuals from 2014 through 2016, and a minimum of 
90 percent of such costs thereafter.[Footnote 5] Therefore, state 
efforts to ensure that health insurers pay to the extent of their 
liability, particularly for Medicaid enrollees who are newly eligible 
for the program, could lead to increased federal cost savings. 

States have substantially improved their TPL identification and 
recovery efforts (which we refer to hereafter as TPL efforts) in 
recent years, generating significant savings for the federal 
government as well as for themselves. A 2013 Department of Health and 
Human Services (HHS) Office of Inspector General (OIG) report 
indicated that states identified about $13.6 billion in combined 
federal-state cost savings from private health insurers in 2011, 
compared to about $3.7 billion in 2001--with states largely crediting 
increased cost savings to enhanced use of available technology to 
identify Medicaid enrollees with other insurance.[Footnote 6] However, 
the report also found that states commonly face challenges to their 
TPL efforts, such as health insurers refusing to provide coverage 
information to states or denying liability for procedural reasons, 
that pose potential barriers to realizing cost savings. Furthermore, 
state Medicaid agencies face administrative capacity constraints that 
may limit their ability to go beyond basic program requirements to 
further improve cost savings.[Footnote 7] 

Given the PPACA Medicaid expansion and the importance of ensuring that 
Medicaid appropriately pays only after other liable third parties have 
done so, you asked us to examine the prevalence of private sources of 
health insurance among Medicaid enrollees, and state and Centers for 
Medicare & Medicaid Services (CMS) efforts to ensure that Medicaid is 
the payer of last resort. In this report, we examine (1) the extent to 
which Medicaid enrollees have private health insurance and (2) state 
and CMS initiatives to improve TPL efforts. 

To examine the extent to which Medicaid enrollees have private health 
insurance, we analyzed 2012 data--the most recent data available at 
the time we conducted the work--from the American Community Survey 
(ACS), a nationally representative annual survey conducted by the U.S. 
Census Bureau. The ACS collects self-reported information, such as 
each individual's type of health coverage (if any) as of the date of 
the survey, disability status, age, and state of residence. For the 
ACS question regarding each individual's type of health coverage, 
Medicaid is grouped with other types of means-tested public coverage 
as a single response option.[Footnote 8] Therefore, for purposes of 
the report, we refer to these groups collectively as Medicaid 
enrollees. We further divided Medicaid enrollees into four broad 
Medicaid eligibility categories--children, adults, disabled, and 
aged.[Footnote 9] For all Medicaid enrollees, and for each Medicaid 
eligibility category, we estimated the number and percentage with 
private health insurance and other sources of health coverage. We 
defined individuals as having private health insurance if they 
reported health insurance provided through an employer or union, or 
health insurance purchased individually. Unless noted otherwise, 
estimates presented in this report have a relative standard error of 
less than 15 percent. To determine the reliability of the ACS data, we 
reviewed related documentation and compared our results to other 
published estimates and determined that the ACS data were sufficiently 
reliable for our purposes. (A more detailed description of our 
methodology is provided in appendix I.) 

To examine CMS and state initiatives to improve TPL efforts, we 
reviewed relevant federal laws, regulations, and related documents, 
and interviewed officials from CMS and a sample of 8 states. To select 
the sample of states, we began by identifying states that: (1) were 
among the top 15 states with respect to either Medicaid enrollment or 
spending; and (2) used capitated managed care--in which states pay 
health plans a monthly fee per Medicaid enrollee in exchange for 
services provided--to deliver services to some or all Medicaid 
enrollees.[Footnote 10] We then reviewed challenges states reported in 
the 2013 HHS OIG report and obtained input from federal officials and 
stakeholders about related state legislation or practices and selected 
8 of these states to include in our review: Georgia, Massachusetts, 
Michigan, Minnesota, Missouri, New York, Ohio, and Washington. In 
several cases, officials in these states asked the contractor 
responsible for aspects of TPL work in their state to respond to our 
questions or included contractor representatives in the interviews. To 
supplement information from the selected states, we also interviewed 
or reviewed information provided by representatives of HMS--a firm 
that conducts various TPL services on behalf of over 30 states and 
about 160 Medicaid managed care plans--national associations 
representing Medicaid directors and Medicaid managed care plans, and 
other stakeholders. 

We conducted this performance audit from December 2013 through January 
2015 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

Medicaid enrollees across various eligibility categories may have 
access to private health insurance for a number of reasons. For 
example, some adults may be covered by employer-sponsored private 
health insurance even though they also qualify for Medicaid. Children 
similarly may be eligible for Medicaid while also being covered as a 
dependent on a parent's private health plan. Individuals age 65 and 
older may receive private coverage from a former employer or purchase 
such coverage to supplement their Medicare coverage. Medicaid benefits 
and costs may vary depending on an enrollee's eligibility 
category.[Footnote 11] CMS requires states to provide for the 
identification of Medicaid enrollees' other sources of health 
coverage, verification of the extent of the other sources' liability 
for services, avoidance of payment for services in most circumstances 
where the state believes a third party is liable, and recovery of 
reimbursement from liable third parties after Medicaid payment, if the 
state can reasonably expect to recover more than it spends in seeking 
reimbursement.[Footnote 12] Specifically, states must provide that the 
following steps are taken: 

1. Coverage identification. To identify enrollees with third-party 
health coverage, states are required to request coverage information 
from potential Medicaid enrollees at the time of any determination or 
redetermination of eligibility for Medicaid. States are also required 
to obtain and use information pertaining to third-party liability, for 
example by conducting data matches with state wage information 
agencies, Social Security Administration wage and earning files, state 
motor vehicle accident report files, or state workers compensation 
files. 

2. Coverage verification. When other health coverage is identified, 
states need to verify the information, including the services covered 
through the other insurance and the dates of eligibility. 

3. Cost avoidance. Cost avoidance occurs when states do not pay 
providers for services until any other coverage has paid to the extent 
of its liability, rather than paying up front and recovering costs 
later. After a state has verified other coverage, it must generally 
seek to ensure that health care providers' claims are directed to the 
responsible party.[Footnote 13] The cost-avoidance process accounts 
for the bulk of the cost savings associated with third-party liability. 

4. Payment recovery. When states have already paid providers for 
submitted claims for which a third party is liable, they must seek 
reimbursement from the third party, if it is cost effective to do so. 

States have flexibility in determining specific approaches to achieve 
these ends. For example, states are increasingly contracting with 
managed care plans to deliver services to Medicaid enrollees (such 
plans are hereafter referred to as Medicaid managed care plans), and 
may delegate TPL responsibilities to such plans.[Footnote 14] Both 
states and Medicaid managed care plans may obtain the services of a 
contractor to identify third-party coverage by conducting electronic 
data matches and to conduct other TPL responsibilities, such as 
payment recovery. 

Ensuring compliance with Medicaid TPL requirements has long been 
challenging for states. The McCarran-Ferguson Act affirms the 
authority of states to regulate the business of insurance in the 
state, without interference from federal regulation, unless federal 
law specifically provides otherwise.[Footnote 15] Thus, states 
generally regulate private health insurers operating in the state. 
However, states may not have authority over private insurers that are 
not licensed to do business in the state but still provide coverage to 
state residents. For example, some individuals work and receive health 
insurance through employment in one state but live in a neighboring 
state. In addition, states are preempted by the Employee Retirement 
Income Security Act of 1974 (ERISA) from regulating employer-sponsored 
health benefit plans that self-insure coverage rather than purchase 
coverage from an insurer.[Footnote 16] 

Due to the bifurcated nature of private health insurance regulation, 
both federal and state legislation has been required to allow states 
to enforce TPL requirements. For example, the Omnibus Budget 
Reconciliation Act of 1993 required all states to enact laws 
prohibiting insurers from taking Medicaid status into account in 
enrollment or payment for benefits and to enact laws giving the state 
rights to payments by liable third parties.[Footnote 17] In addition, 
the Deficit Reduction Act of 2005 (DRA) contained provisions affecting 
state authority to verify coverage and recoup payments from liable 
health insurers. Under the DRA, states must attest that they have laws 
in place to require health insurers to, among other requirements, 
provide information necessary to identify Medicaid enrollees with 
third-party coverage and, within specified time limits, respond to 
inquiries from the state regarding claims, as well as to agree not to 
deny claims solely because of the date the claim was submitted, the 
form that was used, or the failure to properly document coverage at 
the point of service.[Footnote 18] 

The 2013 HHS OIG report on TPL cost savings and challenges concluded 
that the DRA provisions likely had a positive effect on states' 
ability to avoid costs and recover payments from private health 
insurers, in part through improvements in states' identification of 
enrollees with insurance. States also credited process improvements, 
such as online verification of coverage and electronic data matching 
agreements with private insurers, as well as contractor assistance. 
However, the study reported that states continue to face key 
challenges working with private insurers, including the following: 

* 96 percent of states reported challenges with insurers denying 
claims for procedural reasons. 

* 90 percent of states reported challenges with insurer willingness to 
release coverage information to states. 

* 86 percent of states reported challenges with insurers providing 
incomplete or confusing information in response to attempts to verify 
coverage. 

* 84 percent of states reported problems with pharmacy benefit 
managers--entities which administer pharmacy benefits on behalf of 
insurers or employers--such as pharmacy benefit managers not providing 
coverage information or claiming a lack of authority to pay claims to 
Medicaid agencies.[Footnote 19] 

An Estimated 7.6 Million Medicaid Enrollees Had Private Insurance in 
2012 and This Number Is Expected to Increase with the Medicaid 
Expansion: 

Based on responses to the U.S. Census Bureau's ACS, we estimate that 
7.6 million Medicaid enrollees--13.4 percent--also had a private 
source of health insurance in 2012.[Footnote 20] However, the 
prevalence of private health insurance varied among four Medicaid 
eligibility categories that we analyzed--children, adults, disabled, 
and aged. For example, according to our estimates, 34.6 percent of 
aged Medicaid enrollees also had private health insurance, compared to 
12.4 percent of adult Medicaid enrollees and 8.4 percent of children. 
[Footnote 21] (See figure 1 and see appendix II, table 1, for more 
detailed estimates). 

Figure 1: Estimated Prevalence of Private Health Insurance among 
Medicaid Enrollees by Eligibility Category, 2012: 

[Refer to PDF for image: vertical bar graph] 

Medical eligibility category: Children; 
Estimated Prevalence of Private Health Insurance: 8.4%. 

Medical eligibility category: Adults; 
Estimated Prevalence of Private Health Insurance: 12.4%. 

Medical eligibility category: Disabled; 
Estimated Prevalence of Private Health Insurance: 13.2%. 

Medical eligibility category: Aged; 
Estimated Prevalence of Private Health Insurance: 34.6%. 

Medical eligibility category: All enrollees; 
Estimated Prevalence of Private Health Insurance: 13.4%. 

Source: GAO analysis of 2012 U.S. Census Bureau data. GAO-15-208. 

Notes: Estimates are based on responses to the 2012 American Community 
Survey (ACS), and have relative standard errors of less than 15 
percent. For purposes of this report, the child eligibility category 
included individuals aged 0 through 18 who did not report a 
disability; the adult eligibility category included individuals aged 
19 through 64 who did not report a disability; the disabled 
eligibility category included individuals aged 0 through 64 who 
reported a disability; the aged eligibility category included 
individuals aged 65 and older. 

[End of figure] 

The number of Medicaid enrollees who also have private health 
insurance is expected to increase beyond the estimated 7.6 million 
with the expansion of Medicaid; however, the extent of the increase is 
uncertain. The Congressional Budget Office projected that 
approximately 7 million nonelderly individuals would enroll in 
Medicaid in 2014 as a result of the Medicaid expansion and other PPACA 
provisions.[Footnote 22] While some newly Medicaid eligible 
individuals can be expected to have access to private sources of 
health insurance, the extent to which they will participate in 
Medicaid, or maintain private insurance once enrolled in Medicaid, is 
unknown. If these individuals' rates of private insurance are similar 
to the 12.4 percent of adult Medicaid enrollees whom we estimated had 
private insurance in 2012, about 868,000 of the projected 7 million 
new enrollees in 2014 would be expected to have private insurance. 

Selected States Reported Some Success Addressing Challenges to Their 
TPL Efforts and Additional CMS Action Could Improve Such Efforts 
Nationwide: 

States face multiple challenges in ensuring that Medicaid is the payer 
of last resort for enrollees that have private health insurance. 
Selected states and CMS have taken various steps to address some of 
these challenges; however, selected states and stakeholders suggested 
that further CMS guidance and efforts to facilitate information 
sharing among states could improve TPL efforts nationwide. 

Selected States Have Taken Various Actions to Address Challenges with 
Coverage Identification, Managed Care Plan TPL Activities, and 
Coverage Denials: 

State Actions to Address Challenges with and Improve Coverage 
Identification: 

As the identification of Medicaid enrollees with private health 
insurance is a critical first step for achieving TPL cost savings, 
many states nationwide conduct electronic data matches of Medicaid 
enrollment files with insurer files themselves or through a contract 
with a vendor that conducts matches on the state's behalf. While not 
required, such state efforts to independently identify enrollees with 
private insurance can lead to significant cost savings.[Footnote 23] 
For example, Minnesota officials reported that by contracting with a 
vendor for electronic data matching, the state nearly doubled 
identified cases of TPL in a 5-year period, saving the state an 
estimated $50 million over this period.[Footnote 24] Despite such 
efforts, states we included in our review reported experiencing the 
following challenges to their coverage identification efforts: 

* Challenges obtaining out-of-state coverage data. Medicaid enrollees 
in one state may have coverage from a health insurer that is licensed 
in a different state--for example, some enrollees work and participate 
in employer-sponsored insurance in one state while living and 
enrolling in Medicaid in a neighboring state. State laws requiring 
insurers to provide coverage data may not apply if insurers are not 
licensed in the state, and officials from two of the states we 
reviewed noted that insurers sometimes refuse to provide coverage data 
to Medicaid agencies outside the state in which they are licensed. HMS 
representatives reported that, while HMS advocates that insurers 
provide coverage data to Medicaid agencies outside the state in which 
the insurers are licensed, many insurers refuse to do so. According to 
CMS, there is a significant amount of third-party coverage derived 
from insurers licensed in a different state from where the Medicaid 
enrollee resides.[Footnote 25] 

* Challenges with insurers conducting data matches. State and HMS 
representatives reported that, rather than providing coverage data to 
the state (or its contractor, as applicable), some insurers request 
the Medicaid data and perform the data match themselves. HMS 
representatives reported that, in such cases, states only have access 
to matches identified by the insurer, which may understate the number 
of individuals with overlapping coverage. One state reported 
estimating that insurers missed the identification of about 7 percent 
of the individuals with private insurance when insurers conducted the 
match instead of the state's contractor. 

* Challenges with obtaining key data elements. Insurers may not 
maintain or provide states or their contractors access to key data 
elements, such as Social Security numbers, and not having access to 
these data can reduce the efficiency or usefulness of data matches, 
according to officials in several states we reviewed. For example, 
officials from two selected states noted that data matches are more 
difficult and error-prone when Social Security numbers are not 
available. Similarly, officials from two other states we reviewed 
reported that their ability to verify identified coverage would be 
assisted if employer identification numbers were included in insurer 
coverage data. 

* Challenges with timeliness of data matches. Most selected states 
reported that there is a time lag, typically up to 15 to 30 days, 
between an individual's enrollment in Medicaid and when the individual 
is included in a data match with private insurers. As a result, states 
may not be able to identify other coverage until after enrollees have 
already begun using services. States would generally then seek 
reimbursement for paid claims. 

States in our review reported taking various steps to address these 
and other coverage identification challenges. Four of the eight 
selected states reported initiatives underway or completed to improve 
data-matching strategies to identify private coverage, some of which 
focused on nationally coordinated approaches. For example, Minnesota 
officials reported that Minnesota law allows the state Medicaid agency 
and Medicaid managed care plans to participate in a national coverage 
data registry, launched in late 2013 by CAQH, an association of health 
plans and trade associations.[Footnote 26] The data registry allows 
participating insurers and states to submit coverage data files for 
comparison with files of other participants in order to identify 
individuals with overlapping coverage. Minnesota officials commented 
that the registry was at an early stage but expected that 
participation of private insurers would increase over time because of 
benefits to private insurers of coordinating with one another. Table 1 
describes a variety of initiatives underway or completed to improve 
coverage data in selected states. 

Table 1: Examples of Initiatives in Selected States to Improve 
Coverage Identification: 

State: Massachusetts; 
Description of initiative: The state is in the process of arranging 
for its vendor to conduct real time data matches--that is, to check 
for additional insurance at the point that an individual enrolls in 
Medicaid--which will allow for earlier identification of overlapping 
coverage. Officials reported aiming for implementation at the end of 
calendar 2015. 

State: Michigan; 
Description of initiative: The state obtained national coverage data 
from insurers and developed an in-house, third-party liability (TPL) 
tracking and billing system, which was implemented in 2006. Officials 
reported that as a result, cost savings related to TPL had increased 
exponentially in recent years, and the state was able to reduce its 
reliance on a vendor to conduct data matches. 

State: Minnesota; 
Description of initiative: The state and Medicaid managed care plans 
with which it contracts plan to participate in a registry launched by 
CAQH in late 2013 that allows participating insurers and states to 
identify individuals with overlapping coverage. Participating insurers 
submit full national coverage data to be matched against data 
submitted by all other participants in the registry on a weekly basis. 
State officials anticipated that the registry could possibly be 
leveraged to permit identification of TPL at the point of enrollment. 
State officials anticipated that participation in this registry would 
begin in early 2015. 

State: Washington; 
Description of initiative: The state implemented a nationally 
standardized format for receiving coverage data developed by the 
Centers for Medicare & Medicaid Services (CMS), called the Payer 
Initiated Eligibility/Benefit (PIE) Transaction. The PIE Transaction 
allows states that elect to adopt it to obtain eligibility information 
from insurers automatically and allows insurers to set up one standard 
file to share with any state that had implemented it. 

Source: GAO analysis of interviews with selected state officials. 
GAO-15-208. 

[End of table] 

In addition, at least two of the eight states had laws that addressed 
challenges with obtaining private insurer compliance with TPL 
requirements, including requirements to provide coverage data. For 
example, Michigan law authorizes the state to collect coverage data 
from insurers to determine TPL and to assess penalties on insurers for 
noncompliance.[Footnote 27] Michigan officials reported that the state 
was successful in obtaining national coverage data from insurers. In 
addition, Minnesota law requires that all insurers that cover state 
Medicaid enrollees must comply with TPL requirements irrespective of 
where they are licensed.[Footnote 28] 

State Actions to Support and Oversee Medicaid Managed Care Plan TPL 
Activities: 

Selected states have taken various actions that support or increase 
oversight of Medicaid managed care plan TPL activities, as applicable. 
For example, in five of the eight states in our review, individuals 
with third-party coverage may be eligible to enroll in Medicaid 
managed care plans and certain TPL responsibilities are delegated to 
these plans.[Footnote 29] The laws of two selected states--Ohio and 
Minnesota--specifically authorize Medicaid managed care plans to 
recover TPL payments on the state's behalf.[Footnote 30] Ohio 
officials in particular credited the legislation as effective in 
improving insurer cooperation with the state's Medicaid managed care 
plans. While the DRA required states to have laws in effect compelling 
insurers to provide states with access to data and recognize the 
states right to recoup payments, it did not provide that those laws 
specifically require insurers to similarly cooperate with Medicaid 
managed care plans conducting such work on behalf of states. CMS 
provided guidance that, when states delegate TPL responsibilities to a 
Medicaid managed care plan, third-parties should treat the plan as if 
it were the state.[Footnote 31] HMS representatives reported that this 
guidance has been effective in garnering cooperation from insurers 
that previously refused to provide coverage data or pay claims to 
Medicaid managed care plans in various states without legislation 
specifically requiring them to do so. However, a few insurers continue 
to refuse to cooperate with such plans despite this guidance, 
according to information provided by representatives of HMS and 
Medicaid Health Plans of America (MHPA)--an association of Medicaid 
managed care plans. 

In addition, Minnesota sought to improve its oversight of Medicaid 
managed care TPL activities by initiating a program to allow the state 
to review Medicaid managed care plan TPL payment recoveries and to 
arrange for conducting supplemental recoveries when the plans had not 
recouped payment within a set time.[Footnote 32] However, according to 
a representative of the National Association of Medicaid Directors, it 
can be difficult for states to work with Medicaid managed care plans 
and insurers as needed to strengthen state oversight. The other states 
included in our review that delegate TPL work to Medicaid managed care 
plans did not report conducting this type of oversight, which is 
consistent with information provided by MHPA in which plans indicated 
that some states that contract with Medicaid managed care plans to 
perform TPL activities do not specifically review these activities. We 
have previously found that some Medicaid managed care plans may have a 
conflict of interest in conducting payment recoveries. Specifically, 
Medicaid managed care plans may not have appropriate incentives to 
identify and recover improper payments--which include payments made 
for treatments or services that were not covered by program rules, 
that were not medically necessary, or that were billed for but never 
provided--because doing so could reduce future capitation rates. 
[Footnote 33] 

State Actions to Reduce Denials by Insurers for Procedural Reasons: 

Most selected states reported challenges with denials from private 
insurers for procedural reasons, such as for not obtaining prior 
authorization before receiving services or not using in-network 
providers.[Footnote 34] HMS representatives estimated that in 2013, 
insurers had denied about $120 million in claims for failure to obtain 
prior authorization, and about $30 million for failure to use an in-
network provider, for states and for Medicaid managed care plans with 
which HMS contracted. Selected states reported various methods to 
reduce such denials: 

* Ohio and Missouri laws explicitly prohibit denials due solely to a 
lack of prior authorization for services.[Footnote 35] 

* Massachusetts, Georgia, and New York officials reported that they 
contest denials due solely to a lack of prior authorization for 
services based on general state legislation passed in accordance with 
the DRA, which requires states to prohibit insurers from denying 
claims based solely on the date the claim was submitted, the form that 
was used, or the failure to properly document coverage at the point of 
service.[Footnote 36] 

* Michigan and Minnesota, through their Medicaid provider manuals, 
require providers to check for third-party coverage and specify that 
providers are not to be paid by Medicaid for services provided to 
enrollees if rules of the third-party coverage were not followed. 
[Footnote 37] For example, Michigan's Medicaid provider manual states 
that Medicaid will not cover charges incurred when enrollees elect to 
go out of their third-party insurer's preferred provider network. 
Michigan and Minnesota officials reported that these types of denials 
were generally not problems for the state. 

While CMS Has Taken Action to Support State TPL Efforts, Additional 
Federal Action Could Benefit TPL Efforts Nationwide: 

CMS has taken steps, including issuing additional guidance, to address 
certain challenges that states face in ensuring that Medicaid is the 
payer of last resort. For example, CMS published a set of frequently 
asked questions (FAQ) in September 2014 that clarified the parameters 
under which health insurers are permitted to release coverage 
information to states in light of Health Insurance Portability and 
Accountability Act of 1996 privacy restrictions, and emphasized the 
role of state legislation in specifying the scope of information 
required to be submitted by health insurers.[Footnote 38] The guidance 
also reiterated previously published information, such as clarifying 
that when states delegate TPL responsibilities to a Medicaid managed 
care plan, third parties are required to treat the plan as if it were 
the state.[Footnote 39] CMS officials also noted that the agency is 
available to provide technical assistance relating to TPL at the 
request of states or other entities. 

In addition, CMS has also taken steps to foster collaboration among 
states. For example, CMS solicited effective TPL practices that had 
been implemented as of 2013 from states and published the responses. 
[Footnote 40] On a related note, CMS officials highlighted the role of 
the Coordination of Benefits (COB)-TPL Technical Advisory Group (TAG) 
in providing states with opportunities to coordinate and share 
information on TPL challenges and effective practices.[Footnote 41] 
Specifically, CMS officials said that COB-TPL TAG representatives are 
responsible for canvassing states about problems that may be occurring 
and reporting these back to CMS. However, officials from one state 
suggested that COB-TPL TAG representatives need to do more to 
proactively survey states and share information about problems that 
states not directly represented on the COB-TPL TAG are experiencing. 

While acknowledging CMS's efforts, stakeholders and officials from 
selected states suggested a need for additional federal action, 
commenting on how, for example, additional or clarified guidance could 
facilitate state efforts to conduct certain TPL activities. 

* The National Association of Medicaid Directors recommended, given 
the growth in states' use of managed care, that CMS require states to 
share available insurance coverage information with Medicaid managed 
care plans and provide an approved approach for conducting oversight 
of such plans' TPL activities. According to a representative of this 
association, several states indicated that explicit CMS guidance in 
this area would provide states leverage to strengthen their Medicaid 
managed care plan contracts and oversight related to TPL. 

* HMS representatives recommended that CMS strengthen its statements 
encouraging insurers to share coverage information with out-of-state 
Medicaid agencies, and further clarify through regulations existing 
CMS guidance regarding insurer cooperation with Medicaid managed care 
plans that conduct TPL activities on behalf of states. 

* State officials suggested that CMS could provide information to 
ensure all states are aware of promising available data-matching 
strategies. 

CMS, however, may have incomplete information to inform such guidance 
as, according to CMS, the agency does not actively track all states' 
coverage-identification strategies on an ongoing basis, and in some 
cases, may not be aware of promising state initiatives. While the 
effective state practices CMS solicited and shared with states 
included information on initiatives implemented as of 2013, other 
state initiatives underway were not included. For example, Minnesota 
officials said they had submitted information about the CAQH data 
registry; however, the state's submission did not meet the criteria 
for inclusion in the effective practices document because the state 
had not yet implemented the registry. In addition, while CMS suggests 
that states should oversee Medicaid managed care plan TPL activities, 
as applicable, the agency does not track which states delegate TPL 
responsibilities to Medicaid managed care plans, nor the problems with 
or oversight of related Medicaid managed care plan TPL activities in 
states that do. 

Officials from selected states also emphasized efficiencies and other 
benefits that could be gained from state collaboration and information 
sharing, which CMS could support. For example, Michigan officials 
noted that the state wanted to explore sharing the national coverage 
data it obtained from insurers, as well as the TPL tracking and 
billing system it developed, with other states, noting the cost-
effectiveness of states using its system and data rather than each 
developing their own. In addition, officials in multiple states noted 
the value of CMS-facilitated national TPL conferences that provide 
states with opportunities to discuss emerging problems and share 
expertise regarding solutions.[Footnote 42] CMS officials indicated 
that the last conference occurred when there were significant changes 
under the DRA and that CMS has no specific plans to facilitate future 
TPL conferences, but officials noted that discussions were underway 
regarding additional conferences or other training opportunities. 

Conclusions: 

National survey data suggest that a substantial number of Medicaid 
enrollees--7.6 million--had private health insurance in 2012 and that 
many of these enrollees were in eligibility groups that incur, 
traditionally, higher medical costs. Furthermore, this number is 
expected to increase because of the Medicaid expansion. States have 
front-line responsibility for ensuring that Medicaid is the payer of 
last resort and are required to take steps to identify individuals 
with other health insurance and ensure that other insurance pays to 
the extent of its liability. Substantial increases in TPL cost savings 
in recent years highlight that improvements to TPL efforts, such as 
heightened attention to coverage identification, can substantially 
improve TPL cost avoidance and recoveries. The scale of the cost 
savings to Medicaid at both federal and state levels through the 
identification of coverage through, and payment of services by, 
private health insurance--reportedly nearly $14 billion in 2011--
underscores the potentially significant return on investment that may 
be gained from continued TPL improvement efforts and attention to 
resolving remaining gaps in state access to available coverage data. 

Selected states have taken a variety of steps to further improve TPL 
efforts, and other states may also be implementing initiatives to 
address persistent challenges states report in ensuring Medicaid pays 
after other liable third parties. The various initiatives that 
selected states have undertaken--such as initiatives to improve 
identification of enrollees with private health insurance through data 
matches or to ensure that TPL efforts are maintained in an 
increasingly managed care environment--highlight options that other 
states could consider to improve their respective TPL savings. Other 
states may also have initiatives that could be adopted more broadly. 
CMS has taken steps to support states and publicize effective state 
practices. However, as new strategies emerge over time, a robust 
ongoing effort to collect and share information about state 
initiatives would ensure that states--particularly any states that may 
not conduct data matches with private insurers--are aware of available 
data matching strategies and solutions to challenges states or 
Medicaid managed care plans may face in conducting TPL activities. 
Given the significant federal Medicaid outlays, which are increasing 
as Medicaid expands under PPACA, the federal government has a vested 
financial interest in further increasing states' TPL cost savings, and 
CMS should play a more active leadership role in monitoring, 
understanding, supporting and promoting state TPL efforts. 

Recommendations: 

In light of the federal interest in ensuring that Medicaid should pay 
only after other liable third parties; state initiatives to improve 
TPL efforts, such as coverage identification strategies; and states' 
increasing use of managed care, we recommend that the Secretary of 
Health and Human Services direct CMS to take the following two 
additional actions to oversee and support state TPL efforts: 

* Routinely monitor and share across all states information regarding 
key TPL efforts and challenges. 

* Provide guidance to states on their oversight of TPL efforts 
conducted by Medicaid managed care plans. 

Agency Comments: 

We provided a draft of this report to HHS for comment. In its written 
comments--reproduced in appendix III--HHS concurred with our 
recommendations. HHS stated that it will continue to look at ways to 
provide guidance to states to allow for sharing of effective practices 
and to increase awareness of initiatives under development in states. 
HHS also stated that it will explore the need for additional guidance 
regarding state oversight of TPL efforts conducted by Medicaid managed 
care plans. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies to the 
Secretary of Health and Human Services, the Administrator of the 
Centers for Medicare & Medicaid Services, and other interested 
parties. In addition, the report will be available at no charge on the 
GAO website at [hyperlink, http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix IV. 

Signed by: 

Katherine M. Iritani: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology of the American Community Survey 
(ACS) Analysis: 

To assess the extent to which Medicaid enrollees have private health 
insurance, we utilized the ACS, an annual survey conducted by the U.S. 
Census Bureau. The ACS includes representative samples of households 
from each state and also includes individuals residing in institutions 
such as nursing homes. The ACS collects self-reported information, 
such as the type of health insurance coverage as of the date of the 
survey (if any), disability status, age, and state of residence. We 
analyzed data from the most recent ACS Public Use Microdata Sample 
(PUMS) that was available at the time we conducted our work, which 
covered calendar year 2012.[Footnote 43] 

Our analysis of ACS PUMS data is subject to limitations. The analysis 
uses 2012 data and therefore does not include individuals who were 
newly eligible for Medicaid in 2014 as a result of the optional 
program expansion under the Patient Protection and Affordable Care 
Act. In addition, our estimates are based on responses from the ACS 
PUMS sample and may differ from actual figures that would be obtained 
if the full population had been surveyed using the same methods. 
Similarly, as the ACS collects self-reported information, errors may 
exist due to factors such as differing interpretations of survey 
questions, the inability or unwillingness of survey participants to 
provide correct information, or data processing errors. The Census 
Bureau reported that quality control and edit procedures were used to 
reduce such errors. For example, an eligibility edit was applied to 
assign Medicaid, Medicare, and TRICARE coverage to individuals based 
on program eligibility rules.[Footnote 44] To determine the 
reliability of the ACS PUMS data, we reviewed related documentation 
and compared the results to estimates based on data from another 
Census Bureau survey, the Current Population Survey. We determined 
that the ACS PUMS data were sufficiently reliable for the purposes of 
our engagement. 

Key Analysis Variables: 

From the available ACS PUMS data, we constructed the following 
variables for our analysis: 

* Medicaid coverage and eligibility category. We defined individuals 
as having Medicaid if they reported health coverage through Medicaid, 
medical assistance, or any kind of government assistance plan for 
individuals with low incomes or a disability. These sources of 
coverage are combined in one question in the ACS PUMS.[Footnote 45] 
For purposes of the report, we refer to these individuals collectively 
as Medicaid enrollees. 

We further categorized Medicaid enrollees into four broad Medicaid 
eligibility categories--children, adults, disabled, and aged: 

- We defined the child eligibility category as individuals aged 0 
through 18 who did not report a disability. 

- We defined adult eligibility category as individuals aged 19 through 
64 who did not report a disability. 

- We defined the disabled eligibility category as individuals aged 0 
through 64 who reported one or more of the 6 disability indicators 
included in the ACS data.[Footnote 46] 

- We defined the aged eligibility category as individuals aged 65 and 
older. 

* Third-party private and public health coverage. We defined 
individuals as having private insurance coverage if they reported 
having health insurance through a current or former employer or union, 
insurance purchased directly from an insurance company, or both. We 
defined individuals as having public coverage other than Medicaid if 
they reported coverage through Medicare or TRICARE, or having ever 
used or enrolled in health care provided through the Department of 
Veterans Affairs (VA).[Footnote 47] 

Methodology: 

Based on the variables defined above, we used calendar year 2012 ACS 
PUMS data to estimate the number and percentage of Medicaid enrollees 
with private and other sources of health coverage. We produced 
separate estimates by Medicaid eligibility group and state of 
residence. To generate our estimates, we applied the appropriate 
weights contained in the ACS PUMS data files in order to expand the 
sample to represent the total population and to account for the 
complex sample design. Specifically, we used the person weights to 
generate estimated numbers and percentages.[Footnote 48] We used the 
person replicate weights to generate standard errors. 

To assess the precision of our estimates, we calculated a relative 
standard error for each estimate. A relative standard error is 
calculated by dividing the standard error of the estimate by the 
estimate itself. For example, if an estimate has a mean of 100 and a 
standard error of 20, the relative standard error would be 20/100, 
which would be 20 percent. Estimates with small relative standard 
errors are considered more reliable than estimates with large relative 
standard errors. A small relative standard error is a more precise 
measurement since there is less variance around the mean. Unless 
otherwise noted, estimates included in this report have relative 
standard errors of less than 15 percent. 

[End of section] 

Appendix II: Detailed Estimates of Medicaid Enrollees with Other 
Sources of Health Coverage: 

The following tables provide more detailed information about the 
estimates derived from of our analysis of the 2012 American Community 
Survey (ACS) Public Use Microdata Sample (PUMS). Specifically, tables 
1 and 2 provide estimates of the number and percentage of Medicaid 
enrollees with other sources of health coverage by Medicaid 
eligibility category and by state. 

Table 2: Estimated Number and Percentage of Medicaid Enrollees with 
Other Private or Public Sources of Health Coverage in 2012, by 
Eligibility Category: 

Source of coverage: Private[B]; 
Medicaid eligibility category[A]: 
Children: 2,254,373 (8.44%); 
Adults: 1,664,062 (12.39%); 
Disabled: 1,276,605 (13.23%); 
Aged: 2,363,891 (34.60%); 
All categories: 7,558,931 (13.35%). 

Source of coverage: Medicare[C]; 
Medicaid eligibility category[A]: 
Children: 178,071 (0.67%); 
Adults: 855,302 (6.37%); 
Disabled: 2,646,272 (27.42%); 
Aged: 6,831,506 (100%); 
All categories: 10,511,151 (18.56%). 

Source of coverage: TRICARE[D]; 
Medicaid eligibility category[A]: 
Children: 156,862 (0.59%); 
Adults: 135,644 (1.01%); 
Disabled: 123,540 (1.28%); 
Aged: 319,184 (4.67%); 
All categories: 735,230 (1.30%). 

Source of coverage: Department of Veterans Affairs (VA)[E]; 
Medicaid eligibility category[A]: 
Children: 23,948 (0.09%); 
Adults: 155,347 (1.16%); 
Disabled: 190,109 (1.97%); 
Aged: 471,094 (6.90%); 
All categories: 840,498 (1.48%). 

Source of coverage: No other coverage; 
Medicaid eligibility category[A]: 
Children: 24,203,047 (90.58%); 
Adults: 10,952,795 (81.56%); 
Disabled: 6,040,083 (62.59%); 
Aged: 0 (0.00%); 
All categories: 41,195,925 (72.75%). 

Source: GAO analysis of 2012 U.S. Census Bureau data. GAO-15-208. 

Notes: Estimates are based on self-reported information from the 
American Community Survey (ACS) Public Use Microdata Sample (PUMS) 
dataset. Individuals may report multiple sources of health coverage. 
For example, an enrollee may report Medicaid, Medicare, and private 
coverage. Therefore, estimated numbers for each eligibility category 
may sum to greater than the total number of enrollees, and estimated 
percentages may sum to greater than 100 percent. All estimates shown 
have relative standard errors of less than 15 percent. 

[A] We categorized Medicaid enrollees into four broad Medicaid 
eligibility categories--children (individuals aged 0 through 18 who 
did not report a disability), adults (individuals aged 19 through 64 
who did not report a disability), disabled (individuals aged 0 through 
64 who reported a disability), and aged (individuals aged 65 and 
older). 

[B] We defined private sources of health insurance to include 
employer- or union-sponsored and individually purchased health 
insurance. 

[C] Medicare is a federal health insurance program for individuals 
aged 65 and older or with certain disabilities and individuals with 
end-stage renal disease. 

[D] TRICARE is a health program operated by the Department of Defense 
generally for active duty personnel and their dependents, and retirees 
and their dependents and survivors. 

[E] VA provides health care generally for persons who served in active 
military duty and who were discharged or released under conditions 
other than dishonorable. In the ACS PUMS, individuals who have ever 
used or enrolled in VA health care are included in this category. 

[End of table] 

Table 3: Estimated Number and Percentage of Medicaid Enrollees with 
Other Private or Public Health Coverage in 2012, by State: 

Type of additional coverage: 

State: Alabama; 
Private[A]: 148,707; 15.93%; 
Public[B]: 221,293; 23.71%. 

State: Alaska; 
Private[A]: 15,418[C]; 13.87%; 
Public[B]: 21,307; 19.17%. 

State: Arizona; 
Private[A]: 145,995; 11.37%; 
Public[B]: 196,618; 15.31%. 

State: Arkansas; 
Private[A]: 73,411; 11.69%; 
Public[B]: 138,000; 21.97%. 

State: California; 
Private[A]: 808,909; 10.56%; 
Public[B]: 1,384,444; 18.07%. 

State: Colorado; 
Private[A]: 101,233; 12.93%; 
Public[B]: 138,385; 17.68%. 

State: Connecticut; 
Private[A]: 91,340; 14.30%; 
Public[B]: 127,763; 20.00%. 

State: Delaware; 
Private[A]: 34,832; 18.36%; 
Public[B]: 33,802; 17.81%. 

State: District of Columbia; 
Private[A]: 26,258; 15.62%; 
Public[B]: 29,433; 17.50%. 

State: Florida; 
Private[A]: 381,354; 11.23%; 
Public[B]: 801,696; 23.60%. 

State: Georgia; 
Private[A]: 214,039; 12.52%; 
Public[B]: 339,391; 19.85%. 

State: Hawaii; 
Private[A]: 33,903; 14.30%; 
Public[B]: 43,251; 18.25%. 

State: Idaho; 
Private[A]: 43,127; 17.11%; 
Public[B]: 46,407; 18.41%. 

State: Illinois; 
Private[A]: 275,647; 11.87%; 
Public[B]: 357,409; 15.39%. 

State: Indiana; 
Private[A]: 154,077; 14.98%; 
Public[B]: 191,184; 18.59%. 

State: Iowa; 
Private[A]: 116,280; 22.54%; 
Public[B]: 121,483; 23.55%. 

State: Kansas; 
Private[A]: 68,438; 17.41%; 
Public[B]: 82,946; 21.10%. 

State: Kentucky; 
Private[A]: 111,051; 13.51%; 
Public[B]: 188,333; 22.91%. 

State: Louisiana; 
Private[A]: 120,964; 11.70%; 
Public[B]: 197,423; 19.10%. 

State: Maine; 
Private[A]: 48,732; 15.53%; 
Public[B]: 77,923; 24.83%. 

State: Maryland; 
Private[A]: 133,520; 14.81%; 
Public[B]: 162,353; 18.01%. 

State: Massachusetts; 
Private[A]: 241,265; 16.38%; 
Public[B]: 298,749; 20.29%. 

State: Michigan; 
Private[A]: 332,911; 17.11%; 
Public[B]: 368,583; 18.95%. 

State: Minnesota; 
Private[A]: 118,720; 15.05%; 
Public[B]: 141,811; 17.98%. 

State: Mississippi; 
Private[A]: 76,244; 10.47%; 
Public[B]: 157,527; 21.63%. 

State: Missouri; 
Private[A]: 115,410; 12.17%; 
Public[B]: 196,883; 20.76%. 

State: Montana; 
Private[A]: 23,543; 15.24%; 
Public[B]: 33,277; 21.55%. 

State: Nebraska; 
Private[A]: 38,139; 15.86%; 
Public[B]: 55,229; 22.97%. 

State: Nevada; 
Private[A]: 54,776; 16.31%; 
Public[B]: 68,847; 20.50%. 

State: New Hampshire; 
Private[A]: 28,746; 17.85%; 
Public[B]: 38,175; 23.71%. 

State: New Jersey; 
Private[A]: 184,708; 14.48%; 
Public[B]: 282,584; 22.16%. 

State: New Mexico; 
Private[A]: 52,755; 11.11%; 
Public[B]: 79,717; 16.79%. 

State: New York; 
Private[A]: 599,711; 13.46%; 
Public[B]: 817,949; 18.36%. 

State: North Carolina; 
Private[A]: 211,977; 12.13%; 
Public[B]: 357,624; 20.47%. 

State: North Dakota; 
Private[A]: 13,232; 20.59%; 
Public[B]: 20,226; 31.47%. 

State: Ohio; 
Private[A]: 298,374; 14.76%; 
Public[B]: 371,395; 18.37%. 

State: Oklahoma; 
Private[A]: 84,954; 12.78%; 
Public[B]: 118,692; 17.86%. 

State: Oregon; 
Private[A]: 115,430; 16.84%; 
Public[B]: 128,846; 18.79%. 

State: Pennsylvania; 
Private[A]: 390,012; 17.83%; 
Public[B]: 461,480; 21.09%. 

State: Rhode Island; 
Private[A]: 33,356; 17.78%; 
Public[B]: 50,650; 27.01%. 

State: South Carolina; 
Private[A]: 112,300; 12.85%; 
Public[B]: 184,120; 21.08%. 

State: South Dakota; 
Private[A]: 20,869; 16.80%; 
Public[B]: 29,197; 23.51%. 

State: Tennessee; 
Private[A]: 164,825; 13.46%; 
Public[B]: 251,776; 20.55%. 

State: Texas; 
Private[A]: 466,512; 9.99%; 
Public[B]: 779,806; 16.69%. 

State: Utah; 
Private[A]: 64,392; 19.55%; 
Public[B]: 55,008; 16.70%. 

State: Vermont; 
Private[A]: 24,169; 15.88%; 
Public[B]: 31,576; 20.74%. 

State: Virginia; 
Private[A]: 130,910; 14.38%; 
Public[B]: 200,777; 22.06%. 

State: Washington; 
Private[A]: 174,679; 16.09%; 
Public[B]: 217,385; 20.03%. 

State: West Virginia; 
Private[A]: 46,548; 13.94%; 
Public[B]: 79,360; 23.77%. 

State: Wisconsin; 
Private[A]: 176,384; 17.99%; 
Public[B]: 195,305; 19.92%. 

State: Wyoming; 
Private[A]: 15,845; 20.60%; 
Public[B]: 20,019; 26.02%. 

Source: GAO analysis of 2012 U.S. Census Bureau data. GAO-15-208. 

Notes: Estimates are based on self-reported information from the 
American Community Survey (ACS) Public Use Microdata Sample (PUMS) 
dataset. Individuals may report multiple sources of health coverage. 
For example, an enrollee may report Medicaid, Medicare, and private 
coverage. Therefore, estimated numbers for each state may sum to 
greater than the total number of enrollees in the state, and estimated 
percentages may sum to greater than 100 percent. Estimates shown have 
relative standard errors of less than 15 percent unless otherwise 
noted. 

[A] We defined private sources of health insurance to include 
employer- or union-sponsored and individually purchased health 
insurance. 

[B] We defined public sources of coverage to include coverage through 
Medicare, TRICARE, or the Department of Veterans Affairs (VA). 
Medicare is a federal health insurance program for individuals aged 65 
and older or with certain disabilities and individuals with end-stage 
renal disease. TRICARE is a health program operated by the Department 
of Defense generally for active duty military personnel and their 
dependents and retirees and their dependents and survivors. VA 
provides health care generally for persons who served in active 
military duty and who were discharged or released under conditions 
other than dishonorable. In the ACS PUMS, individuals who have ever 
used or enrolled in VA health care are included in this category. 

[C] The relative standard error of the estimate is 15.6 percent. 

[End of table] 

Appendix III: Comments from the Department of Health and Human 
Services: 

Department of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

January 5, 2015: 

Katherine Iritani: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Iritani: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled, "Medicaid: Additional Federal Action Needed to 
Further Improve Third-Party Liability Efforts" (GA0-15-208). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled: 
Medicaid: Additional Federal Action Needed To Further Improve Third-
Party Liability Efforts (GAO-15-208): 

The U.S. Department of Health and Human Services (1411S) appreciates 
the opportunity to review and comment on this draft report. 

GAO Recommendation: 

The Government Accountability Office (GAO) recommends that the 
Secretary of HHS direct the Centers for Medicare & Medicaid Services 
(CMS) to take additional actions to oversee and support state Third 
Party Liability (TPL) efforts, including: 

* Routinely monitoring and sharing across all states information 
regarding key TPL, efforts and challenges. 

* Provide guidance on state oversight of TPL, efforts conducted by 
Medicaid managed care plans. 

HHS Response: 

HHS concurs with GAO's recommendations. HHS will continue to look at 
ways to provide guidance to states, to allow for continued sharing of 
proven effective practices and to increase awareness of initiatives 
under development among the states, HH.S will consider the collection 
and publication of effective state practices that are working and 
proposed practices that are scheduled for implementation within the 
submitting states. HHS will remind the states that they may request 
technical assistance in resolving general or specific Medicaid 
Coordination of Benefits and Third Party Liability (COB/TPL) issues by 
contacting the CMS Regional Office staff or CMS Central Office COB/TPL 
staff, and that any state may raise an issue for discussion by the 
COB/TPL Technical Advisory Group (TAG) by contacting the TAG State 
Representative for its region. 

HHS is pleased that the GAO acknowledged several effective measures 
that HHS has taken to assist states to meet TPL challenges, such as 
issuing guidance through the Frequently Asked Questions posted on the 
Medicaid.gov web site in September 2014 ("FAQs: Identification of 
Medicaid Beneficiaries' Third Party Resources and Coordination of 
Benefits with Medicaid") and fostering collaboration among states by 
publishing effective state practices on Medicaid.gov in July 2014 
("Coordination of Benefits and Third Party Liability in the Medicaid 
Program: A Guide to Effective State Agency Practices"[Footnote l). 

Additionally, HHS is pleased that GAO acknowledged the guidance HHS 
recently published to clarify that, when states delegate TPL 
responsibilities to the Medicaid managed care organizations (MCOs), 
third parties are required to treat the MCOs as if they were the 
state. 11115 will remind state Medicaid agencies of the availability 
of this guidance, and explore the need for additional guidance 
regarding state oversight of TPL efforts conducted by Medicaid MCOs. 

Footnote: 

[1] This guide was developed in response to a recommendation by the 
office of the Inspector General, U.S. Department of Health and Human 
Services, in its study "Medicaid Third-Party Liability Savings 
Increased, but Challenges Remain", OEI-05-11-00130, issued January 
2013. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Katherine M. Iritani, Director, Health Care, (202) 512-7114, 
iritanik@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Susan Anthony, Assistant 
Director; Emily Beller; George Bogart; Britt Carlson; Laurie Pachter; 
and Ying Long made key contributions to this report. 

[End of section] 

Footnotes: 

[1] See Medicaid and State Children's Health Insurance Program (CHIP) 
Payment and Access Commission, Report to the Congress on Medicaid and 
CHIP, March 2014 (Washington, D.C.: March 14, 2014). Medicaid is 
jointly financed by the federal government and states. 

[2] See 42 C.F.R. §§ 433.135 et seq. (2013). 

[3] States administer their individual Medicaid programs subject to 
approval and oversight by the Centers for Medicare & Medicaid Services 
(CMS), a federal agency within the Department of Health and Human 
Services (HHS). 

[4] This report focuses on private health insurance. Under federal 
regulations, private insurance includes commercial insurance companies 
offering insurance to individuals or groups, prepaid plans offering 
medical services or payment for services covered by Medicaid, and 
organizations administering insurance plans for professional 
organizations, unions, fraternal groups, employer-employee benefit 
plans, and other similar organizations, including self-insured and 
self-funded plans. See 42 C.F.R. § 433.136 (2013). Besides private 
health insurance, other sources of third-party payment include 
Medicare, which provides health coverage for individuals aged 65 and 
over or with certain disabilities and individuals with end-stage renal 
disease; TRICARE, the health care program generally for active duty 
military personnel and their dependents, and retirees and their 
dependents and survivors; and the Department of Veterans Affairs (VA), 
which provides health care generally for qualifying veterans. 

[5] Pub. L. No. 111-148, §§ 2001 and 10201(c), 124 Stat. 119, 271, 918 
(2010), as amended by the Health Care and Education Reconciliation 
Act, Pub. L. No. 111-152, § 1201, 124 Stat. 1029, 1051 (2010). Under 
PPACA, states may expand Medicaid eligibility under their state plans 
to nonpregnant, nonelderly adults who are not eligible for Medicare 
and whose income does not exceed 133 percent of the federal poverty 
level. PPACA also imposes a 5 percent income disregard when 
calculating modified adjusted gross income, which in effect, raises 
this income limit to 138 percent of the federal poverty level. We 
refer to state expansion under this authority as the Medicaid 
expansion. As of July 2014, 26 states and the District of Columbia had 
opted to expand their Medicaid programs. 

[6] HHS Office of Inspector General, Medicaid Third-Party Liability 
Savings Increased, but Challenges Remain, OEI-05-11-00130 (January 
2013). State-reported, inflation-adjusted cost savings increased from 
about $34 billion in 2001 to about $72 billion in 2011, with the 
majority of the overall cost savings attributable to cost avoidance 
and payment recoveries from Medicare. However, there are 
methodological limitations of the cost savings figures reported by 
states. For example, states may use various methods to calculate cost 
savings, and some forms of cost avoidance, such as when a provider 
directly bills a third party rather than Medicaid, are not possible 
for states to capture or report. 

[7] Limitations in states' administrative capacities are discussed in 
more detail in a recent Medicaid and CHIP Payment and Access 
Commission report. For example, see Medicaid and CHIP Payment and 
Access Commission, Report to the Congress on Medicaid and CHIP, June 
2014 (Washington, D.C.: June 13, 2014). 

[8] The ACS question combines Medicaid coverage with other types of 
means-tested public coverage, such as health coverage through any kind 
of government assistance plan for individuals with low incomes or a 
disability. Therefore, some individuals we identified as Medicaid 
enrollees may have other types of means-tested coverage, such as CHIP 
coverage. While it is not possible to differentiate these groups in 
ACS data, Medicaid is the largest means-tested program, with over 70 
million individuals enrolled during fiscal year 2012. 

[9] We defined the child eligibility category as individuals aged 0 
through 18 who did not report a disability, we defined the adult 
eligibility category as individuals aged 19 through 64 who did not 
report a disability, we defined the disabled eligibility category as 
individuals aged 0 through 64 who reported a disability, and we 
defined the aged eligibility category as individuals aged 65 and older. 

[10] We included state use of managed care as part of our selection 
criteria to ensure our review included specific considerations related 
to conducting TPL efforts in a managed care environment. 

[11] For example, we previously estimated that, in 2008, average state 
per enrollee Medicaid spending varied across eligibility categories, 
ranging from $2,973 for the child category to $17,609 for the aged 
category and $19,135 for the disabled category. See GAO, Medicaid: 
Assessment of Variation among States in Per-Enrollee Spending, 
[hyperlink, http://www.gao.gov/products/GAO-14-456] (Washington, D.C.: 
June 16, 2014). 

[12] See 42 C.F.R. §§ 433.137--433.139 (2013). 

[13] Exceptions include claims for prenatal or pediatric services or 
when coverage is through a parent whose obligation to pay for medical 
support is enforced by the state's child enforcement agency. See 42 
C.F.R. § 433.139(b)(2),(3) (2013). 

[14] Alternatively, states may retain TPL responsibilities for 
individuals in managed care, or they may elect not to enroll 
individuals with identified TPL in managed care, among other options. 

[15] Pub. L. No. 79-15, ch. 20, § 2, 59 Stat. 33, 34 (1945) (codified 
as amended at 15 U.S.C. § 1012). 

[16] 29 U.S.C. § 1144(a). This ERISA preemption therefore results in a 
different regulatory framework depending on whether the employer 
purchases its health care coverage from an insurer, which the state 
regulates, or self-funds its health plan, avoiding many state 
regulations. 

[17] Pub. L. No. 103-66, § 13622, 107 Stat. 312, 632. 

[18] Pub. L. No. 109-171, § 6035, 120 Stat. 4, 78 (2006). 

[19] See OEI-05-11-00130. Prior GAO and HHS-OIG reports also 
identified similar challenges. See GAO, Medicaid Third-Party 
Liability: Federal Guidance Needed to Help States Address Continuing 
Problems. [hyperlink, http://www.gao.gov/products/GAO-06-862] 
(Washington, D.C.: Sept. 15, 2006) and HHS OIG, Medicaid Recovery of 
Pharmacy Payments From Liable Third Parties, OEI-03-00-00030 (August 
2001). 

[20] Our estimates of the extent to which individuals with Medicaid 
have private insurance are relatively consistent with older available 
estimates. For example, we estimated, based on responses to the 2010 
ACS, that about 14 percent of individuals with Medicaid had private 
insurance in 2010. Similarly, we reported in 2006 that 13 percent of 
individuals enrolled in Medicaid for an entire year had private 
insurance at some point during the year, based on an analysis of a 
separate data source that covered 2002 to 2004. See [hyperlink, 
http://www.gao.gov/products/GAO-06-862]. 

[21] In addition to private insurance, Medicaid enrollees may also 
have public health coverage through federal programs such as Medicare 
or veterans health programs. For example, we estimate that about 18.6 
percent of Medicaid enrollees in 2012 also had coverage through 
Medicare. This report focuses on private sources of third-party 
coverage, but we provide more detailed estimates of various additional 
sources of coverage in appendix II. 

[22] See Congressional Budget Office, Updated Estimates of the Effects 
of the Insurance Coverage Provisions of the Affordable Care Act, April 
2014. This number includes CHIP enrollees, and was projected to 
increase to approximately 13 million by 2018. These estimates reflect 
that states are permitted but not required to expand Medicaid. 

[23] Such efforts can be important because Medicaid applicants may not 
be aware of or report other insurance. Additionally, Medicaid 
enrollees who do not have other insurance when they first enroll may 
obtain it later. Some state officials also noted potential concerns 
about the completeness of self-reported insurance information obtained 
during new online application procedures--underscoring that the 
importance of independently obtaining coverage information may be 
increasing. 

[24] While contracting with a vendor to conduct data matches can be 
beneficial, some states noted limitations with this approach. For 
example, Minnesota officials noted that the national coverage database 
maintained by its vendor does not necessarily contain information on 
all insurers in the state. 

[25] CMS guidance highlights the need for states to request that 
insurers provide coverage data on individuals covered in other states. 
See CMS, Medicaid and CHIP FAQs: Identification of Medicaid 
Beneficiaries' Third-Party Resources and Coordination of Benefits with 
Medicaid (Baltimore, Md.: Sept. 11, 2014). HMS representatives 
reported that when insurers do not share this data with out-of-state 
Medicaid agencies or Medicaid managed care plans, it is difficult for 
HMS to reliably identify or bill for otherwise recoverable out-of-
state TPL recoveries on behalf of those state Medicaid agencies or 
plans. 

[26] See Minn. Stat. § 256.01, subdivision 18a (2014). 

[27] Mich. Comp. Laws §§ 550.283, 550.287 (2014). 

[28] Specifically, the statute imposes these requirements "as a 
condition of doing business in Minnesota or providing coverage to 
residents of Minnesota" who are enrollees in state medical programs. 
See Minn. Stat. § 62A.045 (2014). Although Minnesota officials were 
not aware of their contractor experiencing significant problems 
accessing coverage data from insurers licensed in other states, they 
reported difficulty in collecting payments from a large out-of-state 
insurer under this statute. Officials said they had asked their 
contractor to begin providing reports of insurers that refuse to 
cooperate with either providing data or paying claims. 

[29] Officials in the other three selected states said that the state 
generally does not enroll Medicaid enrollees with known private 
insurance in Medicaid managed care plans. 

[30] See Ohio Rev. Code § 5160.40(B) (2014) and Minn. Stat. § 
62A.045(c) (2014). 

[31] CMS had provided this clarification on its website and also 
included the information in a set of frequently asked questions (FAQ) 
published in September 2014. See CMS, Medicaid and CHIP FAQs: 
Identification of Medicaid Beneficiaries' Third-Party Resources. 

[32] Minn. Stat. § 256B.69, subdivision 34 (2014). 

[33] We recommended that CMS increase its oversight of program 
integrity efforts, in part through updating its guidance on Medicaid 
managed care plan program integrity. See GAO, Medicaid Program 
Integrity: Increased Oversight Needed to Ensure Integrity of Growing 
Managed Care Expenditures, [hyperlink, 
http://www.gao.gov/products/GAO-14-341]. (Washington, D.C.: May 19, 
2014). These concerns about incentives could similarly apply to 
identifying and recovering payments for services from liable third-
parties. 

[34] Private health plans may place certain conditions on their 
coverage of services. For example, an insurer may require enrollees to 
obtain services from providers that are within its provider network, 
and it may require enrollees to obtain prior authorization before 
obtaining covered services. When enrollees do not follow these 
procedures, insurers may deny payment for services that would have 
been covered had the conditions been met. 

[35] See Ohio Rev. Code § 5160.40(A) (2014) and Mo. Rev. Stat. § 
208.215.1(1) (2013). 

[36] We did not independently assess whether denials due to lack of 
prior authorization for services are prohibited under the DRA. HMS 
representatives, however, commented that it is difficult and 
inefficient to address such denials in states without more specific 
statutory prohibitions against them. 

[37] See Michigan Medicaid Provider Manual, Coordination of Benefits, 
§§ 1.3, 2.1 (October 2014) and Minnesota Medicaid Provider Manual, 
Billing Policy (Overview), Section on Coordination of Services 
(September 2014) and Medicare and Other Insurance, Section on Third-
Party Liability (TPL) (December 2013). 

[38] See CMS, Medicaid and CHIP FAQs: Identification of Medicaid 
Beneficiaries' Third-Party Resources. 

[39] These CMS FAQs also provided guidance on additional issues noted 
in the 2013 HHS OIG report on TPL. For example, CMS clarified that 
states must require insurers to either authorize pharmacy benefit 
managers or other entities with which they contract to provide 
coverage information to states, or to provide coverage information 
directly to states without such entities' assistance. 

[40] See CMS, Coordination of Benefits and Third-Party Liability (COB/ 
TPL) in the Medicaid Program: A Guide to Effective State Agency 
Practices, (Baltimore, Md.: July 2014). Ten states submitted 
responses, including some of our selected states. For example, 
Washington officials submitted information about implementation of the 
PIE Transaction, and Ohio officials submitted information about a 
state law prohibiting denials based on lack of prior authorization for 
services. 

[41] The COB-TPL TAG includes CMS officials, a state chair, and 10 
state representatives, which represent the other states in their 
respective CMS regions (CMS divides the United States into 10 
geographic regions). CMS and state officials also reported that a 
listserv run by states without CMS involvement is a channel for state 
communication and collaboration. 

[42] States may share TPL information though other avenues that are 
not necessarily specifically focused on TPL. For example, New York 
officials reported sharing TPL-related information with other states 
at a Medicaid program integrity conference, and at the Medicaid 
Integrity Institute--a national Medicaid program integrity training 
program. While federal program integrity efforts center on combating 
provider fraud, waste, and abuse, some states include TPL under the 
umbrella of program integrity activities. 

[43] The ACS PUMS dataset contains a sample of actual responses to the 
ACS, as well as variables that were constructed based on responses. 
The ACS PUMS file for 2012 contains data on approximately one percent 
of the U.S. population. 

[44] Medicare is a federal health insurance program for individuals 
aged 65 and older or with certain disabilities and individuals with 
end-stage renal disease. TRICARE is a federal health program generally 
for active-duty military personnel and their dependents, and retirees 
and their dependents and survivors. 

Medicaid coverage was assigned to foster children, certain individuals 
receiving Supplementary Security Income or Public Assistance, and the 
spouses and children of certain Medicaid beneficiaries. Medicare 
coverage was assigned to individuals aged 65 and older who received 
Social Security or Medicaid benefits. TRICARE was assigned to active-
duty military personnel and their spouses and children. 

[45] Because the ACS PUMS variable combines Medicaid coverage with 
other types of public coverage, some individuals we identified as 
Medicaid enrollees may have other types of means-tested coverage, such 
as Children's Health Insurance Program coverage. 

[46] These indicators were (1) self-care difficulty, (2) hearing 
difficulty, (3) vision difficulty, (4) independent living difficulty, 
(5) ambulatory difficulty, and (6) cognitive difficulty. 

[47] VA provides health care generally for veterans who served in 
active military duty and who were discharged or released under 
conditions other than dishonorable. We did not include Indian Health 
Service coverage as a third-party source of coverage because when 
individuals have both Medicaid and Indian Health Service coverage, 
Indian Health Service is the payer of last resort. See 42 C.F.R. § 
136.61. 

[48] The ACS PUMS data includes survey weights in order to allow users 
to generate accurate estimates and standard errors from the sample 
data. The ACS PUMS contains person weights and household weights; 
person weights are used to generate estimates that pertain to 
individuals, and household weights are used to generate estimates 
pertaining to housing units and households. Person and household 
replicate weights are used to generate accurate standard errors for 
estimates pertaining to individuals or households respectively. 

[End of section] 

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