30 Jul CMS REPORTS SURGE IN DUAL ENROLLMENT: MEDICAID PLANS REQUIRE REAL-TIME ELIGIBILITY TOOLS
A recent report from the Centers for Medicare & Medicaid Services (CMS) has revealed that millions of individuals were enrolled in overlapping public health programs in 2024, a situation that continues to strain Medicaid budgets and expose vulnerabilities in eligibility tracking systems. These duplicate Medicaid enrollments are costing the program approximately $14 billion annually.
Through a detailed review of national enrollment data—conducted in partnership with software engineers—CMS found that 1.2 million beneficiaries were enrolled in Medicaid or CHIP in more than one state, while 1.6 million others were covered by both Medicaid and an ACA Marketplace plan receiving federal subsidies. These findings highlight a systemic issue that has significant financial and operational implications for the Medicaid program. Medicaid is losing billions in improper payments.
For Managed Care Organizations (MCOs) across the country, particularly those overseeing the Coordination of Benefits (COB) and Third-Party Liability (TPL) functions, this news reinforces a long-standing challenge. These teams are deeply engaged in identifying additional coverage and ensuring Medicaid acts as the payer of last resort. But despite their persistence, gaps in data access, outdated infrastructure, and fragmented systems make it nearly impossible to prevent duplicate enrollment proactively.
Too often, these cases are uncovered only after claims have been paid, pushing plans into recovery mode. This pay-and-chase model is not only inefficient—it’s costly and unsustainable.
“Plans aren’t failing to do the work. They’re being asked to manage a national-scale eligibility challenge without the modern tools required to solve it,” noted one industry expert.
Overlapping enrollment doesn’t just waste taxpayer dollars—it creates administrative burdens for providers, confusion for members, and delays in care. While MCOs have adopted internal processes to catch red flags, the lack of real-time, standardized, and nationwide data integration remains a significant barrier to effective cost avoidance.
CMS’s findings echo a message Medicaid plans have consistently delivered: program integrity requires more than compliance—it involves technology and data. COB and TPL professionals are doing all they can, but they need better tools to identify coverage conflicts before they result in improper payment.
To safeguard Medicaid’s future, both federal and state partners must commit to building interoperable, modernized eligibility systems, along with policies that promote smarter data exchange. These changes will enable MCOs to transition from reactive recovery to proactive prevention, thereby improving outcomes while protecting vital public resources.