Government Clamps Down on Duplicate Coverage to Cut Medicaid and ACA Fraud

By Kirk Anderson on October 11, 2016

Some Medicaid recipients end up picking up insurance coverage later on due to a change in their job situation. But some Medicaid beneficiaries who picked up coverage through the federal health insurance marketplace could be in position to lose their subsidies. Circumstances have come to light showing how people might face charges of Medicaid fraud. These situations involve people who enrolled in Medicaid but also received federal subsidies at the same time to pay for private health insurance under the Affordable Care Act. Those who fall have this duplicate coverage run the risk of losing financial support for their health insurance, according to The New York Times.

People who have duplicate health coverage were sent letters from the federal health exchange notifying them that they should end their marketplace coverage. The government order does not apply to consumers enrolled only in Medicaid. But any beneficiaries who enrolled in the Children’s Health Insurance Program, or CHIP, who are also receiving duplicate coverage must also end their marketplace plans.

Duplicate coverage is possible because Medicaid is administered at the state level, but the healthcare marketplaces for most states are overseen by the federal government. Sara Rosenbaum, a professor of health law and policy at George Washington University, told The New York Times that it can be difficult for the state and federal government to share information, in part because they use different computer systems.

The government’s concern is that duplicate coverage could lead to double payment.  Last year, Government Accountability Office investigators discovered the possibility of duplicate coverage leading to double payments if Medicaid beneficiaries switch between that coverage and subsidized private insurance as their circumstances change, The New York Times explained. Those changes could involve a new job or a new child. A government review comparing Medicaid records against federal marketplace records found 88,000 people who had this dual enrollment.

Medicaid fraud is not limited to knowingly receiving unauthorized benefits. Where government services are concerned, unnecessarily increasing government cost can also raise suspicion of fraud. If changing life circumstances meant that you held coverage from Medicaid and federally subsidized private insurance at different times, or at the same time, you could be affected by the government’s actions on duplicate coverage. To learn more about your legal options, contact us.