Pennsylvania Did Not Refund the Full Federal Share of Recouped Excess Capitation Payments from the Medicaid Behavioral HealthChoices Program.

摘要

Under Pennsylvania's PA-25 section 1915(b) waiver, the Behavioral HealthChoices program provides mental health services to beneficiaries in 25 of Pennsylvania's counties. A second waiver, PA-42, provides similar services to the remaining 42 counties (we did not review the PA-42 waiver for this report). Under the PA-25 waiver, the State agency contracts with 24 counties for the Behavioral HealthChoices program and pays the counties a monthly capitation payment for behavioral health services for each enrolled beneficiary. Counties subcontract with managed care organizations that coordinate service delivery through providers. For one county, the State agency contracts directly with the managed care organization. The State agency uses risk-based contracts under which the counties incur a risk if the cost of providing the program exceeds the capitation payments. When capitation payments exceed the cost of the program, counties are permitted to set aside in restricted Reinvestment accounts capitation revenues and investment income that were not expended during the contract year for use in approved plans in subsequent years. Counties may also seek approval from the State agency to designate funds as Risk and Contingency to fund in-plan services when costs exceed capitation payments, to pay managed care entities when capitation payments from the State agency are delayed, and to meet the requirements of insolvency agreements, if necessary. A past audit identified some Pennsylvania counties with excess capitation payments that appeared to be unreasonable, including one county that received excess capitation payments of 38 percent. Subsequent to that audit, the State agency established procedures to recoup unreasonable excess capitation payments. Our objective was to determine whether the State agency refunded the Federal share of excess capitation payments recouped from the Risk and Contingency and Reinvestment funds in accordance with Federal requirements.