Nearly 72 percent of Illinois Medicaid cases reviewed last week had eligibility errors

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 eligibility for nearly 327,000 individuals currently enrolled in Medicaid. That means that more than 10 percent of the state’s Medicaid program has been audited by the vendor.

Of those, the vendor identified nearly 165,000 who were ineligible for benefits. Another 36,000 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.

And it’s only getting worse. This was the second week in a row that the error rate actually increased. In just the last week, the independent vendor found more than 13,000 individuals on Medicaid who were ineligible for benefits. This is the single largest weekly find since the state began seriously checking eligibility earlier this year. In fact, nearly 72 percent of the cases reviewed just last week had serious eligibility errors.

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 376,000 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. Indeed, Scott Reeder wondered in a recent column whether this is a “thrown fight.” After all, the gubernatorial campaign season is heating up and AFSCME has donated more than $304,000 to Quinn since 2002. Indeed, AFSCME was one of Quinn’s largest backers in the last election.

So, is it a thrown fight? Is Gov. Quinn simply going through the motions? 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?