Appendix A

Health Care Services’ Payments for Beneficiaries with Questionable Eligibility by County

Health Care Services’ Payments for Beneficiaries with Questionable Eligibility by County Health Care Services paid at least $4 billion in questionable Medi‑Cal premiums and claims from January 2014 through December 2017 because it failed to ensure that it was providing benefits only to eligible beneficiaries. As the Audit Results discusses and Table A shows, we found more than 453,000 beneficiaries with eligibility discrepancies in Health Care Services’ eligibility system when compared to the three systems counties use to track beneficiaries—CalWIN, Consortium IV system (C‑IV), and the LEADER Replacement System (LRS). Further, our analysis identified questionable payments in all 58 counties and across both managed care and fee for service.

Table A
Health Care Services’ Questionable Payments by County
January 2014 Through December 2017
			QUESTIONABLE PAYMENTS
COUNTY	COUNTY ELIGIBILITY SYSTEM	NUMBER OF BENEFICIARIES WITH QUESTIONABLE ELIGIBILITY	MANAGED CARE PREMIUMS	FEE-FOR-SERVICE CLAIMS	TOTAL	PERCENTAGE OF TOTAL QUESTIONABLE PAYMENTS
Alameda	CalWIN	16,576	$102,076,949	$39,202,592	$141,279,541	3.5%
Alpine	C-IV	18	111,776	3,198	114,974	0
Amador	C-IV	17	150,769	91,505	242,274	0
Butte	C-IV	1,269	8,674,341	1,885,072	10,559,413	0.3
Calaveras	C-IV	311	2,429,671	899,317	3,328,988	0.1
Colusa	C-IV	36	87,892	20,999	108,891	0
Contra Costa	CalWIN	7,920	49,935,252	33,879,863	83,815,115	2.1
Del Norte	C-IV	211	1,577,960	140,628	1,718,588	0
El Dorado	C-IV	105	616,193	87,021	703,214	0
Fresno	CalWIN	5,297	18,709,439	5,568,238	24,277,677	0.6
Glenn	C-IV	40	294,679	45,276	339,955	0
Humboldt	C-IV	79	318,614	231,436	550,050	0
Imperial	C-IV	550	3,353,730	710,360	4,064,090	0.1
Inyo	C-IV	16	43,300	181,053	224,353	0
Kern	C-IV	2,357	10,421,757	2,854,656	13,276,413	0.3
Kings	C-IV	163	779,034	327,911	1,106,945	0
Lake	C-IV	463	3,273,444	855,301	4,128,745	0.1
Lassen	C-IV	69	387,951	58,094	446,045	0
Los Angeles	LRS	229,248	1,532,680,994	585,660,939	2,118,341,933	52.4
Madera	C-IV	119	864,046	1,989,151	2,853,197	0.1
Marin	C-IV	827	8,859,327	627,725	9,487,052	0.2
Mariposa	C-IV	67	299,716	285,105	584,821	0
Mendocino	C-IV	748	3,748,953	2,149,447	5,898,400	0.1
Merced	C-IV	86	341,869	152,196	494,065	0
Modoc	C-IV	20	47,371	16,239	63,610	0
Mono	C-IV	112	504,847	399,282	904,129	0
Monterey	C-IV	2,563	18,387,622	3,430,382	21,818,004	0.5
Napa	C-IV	595	6,741,645	3,225,622	9,967,267	0.2
Nevada	C-IV	396	1,311,998	407,463	1,719,461	0
Orange	CalWIN	34,891	323,964,900	34,352,740	358,317,640	8.9
Placer	CalWIN	1,393	7,298,676	1,648,104	8,946,780	0.2
Plumas	C-IV	162	660,807	121,101	781,908	0
Riverside	C-IV	29,018	180,213,715	60,838,585	241,052,300	6
Sacramento	CalWIN	11,251	68,144,496	9,930,744	78,075,240	1.9
San Benito	C-IV	495	1,536,023	1,210,685	2,746,708	0.1
San Bernardino	C-IV	5,907	27,007,104	13,326,250	40,333,354	1
San Diego	CalWIN	70,080	474,787,181	130,309,308	605,096,489	15
San Francisco	CalWIN	366	1,377,952	1,496,221	2,874,173	0.1
San Joaquin	C-IV	1,747	6,954,016	985,090	7,939,106	0.2
San Luis Obispo	CalWIN	982	5,244,684	1,614,122	6,858,806	0.2
San Mateo	CalWIN	4,015	38,392,429	2,351,471	40,743,900	1
Santa Barbara	CalWIN	3,507	21,179,178	3,601,565	24,780,743	0.6
Santa Clara	CalWIN	3,931	32,825,284	8,542,892	41,368,176	1
Santa Cruz	CalWIN	1,240	9,838,597	5,370,235	15,208,832	0.4
Shasta	C-IV	70	420,248	1,960,819	2,381,067	0.1
Sierra	C-IV	24	122,038	24,143	146,181	0
Siskiyou	C-IV	400	2,047,409	570,499	2,617,908	0.1
Solano	CalWIN	3,784	36,185,927	3,590,391	39,776,318	1
Sonoma	CalWIN	2,009	8,882,768	4,753,208	13,635,976	0.3
Stanislaus	C-IV	768	4,558,082	1,247,585	5,805,667	0.1
Sutter	C-IV	555	3,193,302	312,170	3,505,472	0.1
Tehama	C-IV	65	171,574	35,906	207,480	0
Trinity	C-IV	33	161,649	76,513	238,162	0
Tulare	CalWIN	4,016	15,727,846	5,214,699	20,942,545	0.5
Tuolumne	C-IV	49	256,429	80,509	336,938	0
Ventura	CalWIN	901	5,596,056	1,954,286	7,550,342	0.2
Yolo	CalWIN	809	6,254,162	714,797	6,968,959	0.2
Yuba	C-IV	645	3,325,283	746,105	4,071,388	0.1
Totals*		453,391	$3,063,358,954	$982,366,814	$4,045,725,768	100%

Source: Analysis of the counties’ and Health Care Services’ eligibility data, and Health Care Services’ payment data.

* The percentage of total questionable payments does not total 100 percent due to rounding.