Medicaid Recovery Investigations, LLC (MRI), is a company formed to recover Life Insurance and Annuity proceeds on behalf of states participating in the Medicaid program (1993 Omnibus Act Sec.13612. Medicaid Estate Recoveries.) MRI sees the opportunity to implement its proprietary program in all fifty states through the CMS System.
In 1993, Congress enacted the “Reconciliation Act” (Sec. 13612 Medicaid Estates Recoveries.) This federal law requires states to recover from the estates of Medicaid recipients to reimburse the taxpayers for services provided through Medicaid. States have not even minimally complied with the law due to lack of resources, funding, technology, and applicable knowhow. Today, states are under even greater financial constraints and unable to subsidize a program that would return hundreds of millions of lost dollars annually into their Medicaid budgets. MRI offers a turnkey solution to recover these uncollected monies to the state without the state having to create or fund a new program.
The purpose of MRIS is to act as an interface bridge between the life insurance companies and Federal and State Medicaid bringing states in compliance with "1993 Omnibus Act Sec. 1361." The purpose of MRI is to act as an interface bridge between the Insurance companies and Federal and State Medicaid bringing states in compliance with “1993 Omnibus Act Sec.1361.” MRI identifies and recovers all in‐force policies and annuities within the mandated 5-year look‐back period, including Known Policies, Manipulated Policies, and Orphaned Policies. MRI represents the State in collection of these types of assets for reimbursements into the State Medicaid Program. All recovered proceeds are returned to the State, less a fee retained by Medicaid Recovery Investigations.
The technology of the proposed system includes:
- Python
- Git Version Control
- SQL Server
- PostgreSQL Server
Medicaid Recovery Investigations is designed to assist the Federal, State and Local governments in recovering life Insurance and Annuity proceeds on the life of Medicaid recipients, in compliance with the 1993 “Reconciliation Act”. States have large deficits, especially in the Medicaid area and are delinquent in instituting effective procedures and/or efficiently carrying out the intent of the “1993 Reconciliation Act, Sec.13612, Medicaid Estates Recoveries.” MRI will comply with all Federal and State requirements such as HIPAA, SAS 70, and all other safety regulations.
MRI’s program will help offset the staggering costs of Medicaid programs and ensure that life insurance proceeds are not subject to fraud and abuse. The MRI program will have a direct impact on every taxpayer in the United States of America. The MRI system is designed not to add any additional budgetary constraints, costs, or labor to existing Federal, State, and local programs.
MRI’s proprietary software, extensive insurance industry knowledge, and strategic marketing plan provide state governments with a method to recover costs, comply with Federal law and help reduce their Medicaid outlay.
The proposed system works as follows:
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Data exchange between State Medicaid and MRI.
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State Medicaid will provide approved recipient information to MRI from existing Medicaid data.
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MRI specialists will assist the State Medicaid office in compiling this data.
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Interface between MRI and all licensed life insurance companies
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MRI will work with insurance companies to locate in-force policies and annuities.
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MRI will securely manage and maintain policy information.
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MRI will research policy status and submit claims on behalf of the State.
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MRI will accomplish this using a proprietary process.
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MRI will recover funds from in-force policies.
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Recovered funds are disbursed to the State.
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MRI will provide periodic reports or recovery activities to the State.
MRI’s software will offer several benefits, including:
- Recovery of funds to offset staggering costs of the current Medicaid program.
- Brings State Medicaid programs into compliance with federal regulation: The Reconciliation ACT.
- Financially strengthens the State’s Medicaid program to maintain the quality-of-care Medicaid recipients are entitled.
- Lowers the burden put on all taxpayers supporting the Medicaid program.
- Assists States to detect fraud and abuse in the Medicaid system, and more importantly,
- No cost to state governments for this program.
Title 19 of the “Social Security Act of 1965” created the program, commonly known as Medicaid, to provide health care services for the poor. It is available in all fifty states and is jointly funded by federal, state, and local governments. This “Entitlement Program” is a very expensive social service program to administer. The burden of this, as well as many other social programs, falls on very taxpayer in the United States. The program allows people to receive medical benefits automatically upon qualification. State governments have little control over the number of participants and can restrain the cost of the program only by tightening eligibility requirements, withdrawing benefits, or reducing reimbursements to the health care providers. As the population ages, the number of Medicaid applicants will continue to rise based on several social and economic influences. With baby boomers beginning their retirement, applications to this program will significantly increase dramatically impacting every state’s budget.
Eligibility requirements for Medicaid benefits vary from state to state. Each state is empowered to administer the program based on federal and state-established guidelines. The process to qualify for Medicaid is known as an “asset buy down” and is subject to a five-year look-back period. Applicants must divest themselves of all assets, with certain exceptions, to qualify for Medicaid. When qualified, they are considered indigent and a ward of the state. Their “estate” becomes that of the state of jurisdiction or residence. Life Insurance and Annuity is the only asset an individual owns that is guaranteed by contract. However, certain Medicaid recipients who make use of “Medicaid Estate Planning” have found a way to assign or transfer ownership of their life insurance policies to third parties, thus diverting funds that would be available to the state for Medicaid reimbursement.
Loopholes of this type are carried out effectively due to the inability of state governments to detect and recover these assets. This is primarily because most states lack the resources and industry expertise necessary to research, track and recover life insurance and Annuity payouts.
Currently, the Centers for Medicare and Medicaid Services (CMS) are looking for ways to standardize the Medicaid program to reduce fraud and abuse, and to close loopholes in the system. In an effort to mitigate the rising costs of this program, Congress required states to recover the cost of benefits from the estate of Medicaid recipients (Age 55 and older) by including a provision in the 1993 Law, referred to as the “Reconciliation Act”.
- MRI - Medicaid Recovery Investigations
- MRIS - Medicaid Recovery Investigations System
- CMS - Centers for Medicare & Medicaid Services
- NAIC - National Association of Insurance Commissioners
- ACORD - Association for Cooperative Operations Research and Development
- B2G - Business to Government
- CMS
- Private life/annuity insurance companies
- NAIC
- MRI Administrator
MRI will work on behalf of state governments to recover life insurance policy payouts on Medicaid recipients, in conformity and compliance with the 1993 “Reconciliation Act.” As reported in The Wall Street Journal many state governments have been ineffective in their attempts to effectively identify policies and recoup from abusers. This is largely due to the lack of synergism between states, Centers for Medicare, and Medicaid Services (CMS) and the life insurance industry.
MRI creates a bridge between these entities by employing its proprietary processes software program to identify, evaluate and track in-force life insurance and Annuity policies including lost or forgotten policies on Medicaid recipients.
MRI estimates, based on CMS and insurance industry data that billions of dollars in life insurance and Annuity benefits paid annually are available for recovery and put back into Medicaid system (see exhibit 2).
MRI has developed a proprietary process to identify efficiently and comprehensively all in-force Life Insurance and Annuity policies on Medicaid recipients throughout the country. Our system recovers the life insurance and Annuity assets that have been assigned, irrevocably, as a requirement of eligibility, to the state’s Medicaid program. MRI will utilize a fee based “Direct Service Agreement” with all states for the recovery of these assets.
The user stories of this MRI system will be:
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MRIS-1: As an administrator, I would like to automatically receive Medicaid recipients from CMS.
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MRIS-2: As an administrator, I would like to see which recipients need to be reviewed or edited.
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MRIS-3: As an administrator, I would like to automatically send recipients to NAIC.
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MRIS-4: As an administrator, I would like to automatically receive recipient data from NAIC.
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MRIS-5: As an administrator, I would like to automatically send recipients to CMS.
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MRIS-6: As an administrator I would like to automatically create and edit reports on positive recipients from NAIC.
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MRIS-7: As an administrator, I would like to automatically send reports to CMS.
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MRIS-8: As an administrator, I would like to have all approved recipient data saved in a database.
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MRIS-9: As an administrator, I would like to access database data.
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MRIS-10: When CMS receives a new recipient, CMS shall forward recipient data to MRI.
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MRIS-11: When MRI receives new approved recipient data from CMS, MRI system shall store the approved recipient immediately into the MRI’s database.
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MRIS-12: When recipient data is saved, MRI system shall send recipient data to NAIC.
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MRIS-13: When the NAIC return positive recipient match, MRI system shall change the status of recipient in the database.
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MRIS-14: When positive recipient data is saved, MRI shall notify CMS of potential beneficiaries with in-force policies.
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MRIS-15: MRI shall send CMS updates on recipients with positive results once a week.
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MRIS-16: MRI database system shall be compatible with NAIC database system.
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MRIS-17: The system shall not be shut down for maintenance more than once in a 24hour period.
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MRIS-18: The system restart cycle shall execute completely in less than 60 seconds.
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MRIS-19: Unless the system is non-operational, the system shall present a user with a notification informing them that the system is unavailable.
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MRIS-20: The system shall follow HIPAA regulations.
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MRIS-21: The system shall follow SAS-70 regulations.
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MRIS-22: The system shall follow CMS regulations.
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MRIS-23: The system shall be compatible with CMS systems.
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MRIS-24: The system shall be compatible with NAIC systems.
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MRIS-25: The software license used by MRI shall comply with approved licenses for Florida Department of Health.
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MRIS-26: The system shall follow SORN regulations.
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MRIS-27: The system database shall be transferable to CMS database.
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MRIS-28: The system database shall be transferable to NAIC database.
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MRIS-29: The system shall have secure internet connection to host cloud servers.
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MRIS-30: The application response time for any keypress or button press shall be 0.1 second or less.
MRI system shall use pipe and filter design to bridge the State’s Medicaid Recovery system and the NAIC Insurance Companies’ list of Known, Manipulated and Orphan policies. The purpose of MRI is to act as an interface bridge between the Insurance companies and Federal and State Medicaid bringing states in compliance with “1993 Omnibus Act Sec.1361.” MRI identifies and recovers all in‐force policies and annuities within the mandated 5-year look‐back period, including Known Policies, Manipulated Policies, and Orphaned Policies. To complete all the diagram details, we must learn from CMS what is the exact way our system will be able to receive data from their system. Rules and regulations may change the system diagrams and are subject to change.
Mr. Terry Gilbert has congressional permission by Congressman Donalds U.S. representative for Florida's 19th congressional district.
- Jaysson Balbuena
- Jamie Parra
- Billy Jean Baptiste
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