Half of Illinois Medicaid enrollees reviewed found ineligible

In January, the Illinois Department of Healthcare and Family Services, or HFS, began a new project verifying eligibility for Illinois’ 2.7 million Medicaid enrollees. For years, state workers had failed to take adequate steps to ensure the people receiving Medicaid benefits were actually eligible for the program. As an Auditor General report noted, state workers failed to...

In January, the Illinois Department of Healthcare and Family Services, or HFS, began a new project verifying eligibility for Illinois’ 2.7 million Medicaid enrollees. For years, state workers had failed to take adequate steps to ensure the people receiving Medicaid benefits were actually eligible for the program. As an Auditor General report noted, state workers failed to verify basic eligibility criteria, such as income, residency and citizenship status. Worse yet, some of the annual eligibility checks had been delayed for more than five years.

So state lawmakers pushed HFS to hire an independent vendor who specializes in this kind of work to review Medicaid eligibility. Since January, the independent vendor has reviewed nearly 419,000 case files of individuals currently enrolled in Medicaid. Of those, the vendor identified more than 210,000 that were ineligible for benefits, which amounts to more than 50 percent of all cases reviewed so far. Another 47,000 cases reviewed so far this year were eligible for some benefits, but enrolled in the wrong program. For example, some individuals enrolled in Medicaid may only qualify for programs with greater cost-sharing. Overall, the review has yielded an eligibility error rate of more than 61 percent.

When HFS receives a recommendation from Maximus to cancel benefits for a particular case, the state gives the enrollee an additional 20 days to submit documentation showing they are still eligible for benefits. The state then removes individuals from the program after verifying that they are no longer eligible.

Unfortunately, the American Federation of State, Municipal and County Employees has initiated a legal challenge which may slow or halt this progress. AFSCME wants the state to terminate its contract with the expert vendor reviewing eligibility and instead hire new dues-paying state workers to do the job. Never mind the fact that state workers’ failure to do the job adequately prompted the state to hire an independent vendor in the first place. With another 347,000 cases currently pending review, and thousands more on the way, this challenge becomes all the more worrisome.

Gov. Quinn recently announced that he intended to fight the legal challenge, but one has to wonder whether his heart is really in that fight. After all, the gubernatorial campaign season is heating up and AFSCME has donated more than $304,000 to Quinn since 2002. Is Gov. Quinn simply going through the motions on fighting this challenge? Will the General Assembly have to finally step in amend the law to make explicitly clear that this contract and the project can move forward despite AFSCME’s protests?