The necessity of frequent and accurate Medicaid eligibility reviews is undeniable. American taxpayers spend more than $800 billion per year on this program that was intended to be a safety net for those in true need. The government should ensure those who are enrolled actually qualify for these taxpayer-funded benefits. But believe it or not, reviews haven’t happened for more than three years.

As part of the COVID public health emergency, states received additional Medicaid funding from the federal government . As a condition of the new funding, states were prohibited from performing routine eligibility checks on enrollees. States couldn’t remove virtually anyone from the program, including those who went back to work as the economy rebounded. This added close to 20 million new enrollees, most of whom are no longer eligible (assuming they were even eligible in the first place).

Thankfully, as of April 1, states have been allowed to start resuming regular eligibility checks, with 12 months to accomplish all reviews. The enhanced Medicaid funding will go away, albeit slowly, over the course of 2023. This gives states extra incentive to move as quickly as possible to clean up their Medicaid rolls, or else they’ll be on the hook for extra costs going into next year.

This process won’t be easy for states, given the magnitude of people who have been added to the program in recent years — and the roughly 65 million enrollees who were previously enrolled that also now need reviews. But thankfully, a few states are moving quickly to ensure that the truly eligible remain enrolled and that taxpayer dollars aren’t lost.

Paragon Health Institute recently unpacked these dynamics in a new paper , which also includes recommendations for how states should approach the renewal process.

We argue that reviewing eligibility once a year is the bare minimum needed to maintain integrity in the Medicaid system. States have an obligation to clean up their Medicaid rolls as quickly as possible in order to ensure that resources are available for the most vulnerable and to establish trust with taxpayers. This trust has been eroded since Medicaid’s improper payment rate rose to an extraordinary 22% in 2021.

Moreover, onerous Obama-Biden rules that make it easier for recipients to get on the program and stay on longer make the process more difficult for states. These rules expedite Medicaid enrollment by allowing applicants to self-attest many factors such as income , and they limit eligibility reviews to once every 12 months.

Many enrollees also gain access to Medicaid through presumptive eligibility where a recipient deemed ineligible can simply reapply at a hospital and receive temporary coverage without the state verifying information. These and other federal rules allow disenrolled recipients to get back on the program without verifying basic information.

This means that even if states move quickly, federal rules provide for protections such as retroactive eligibility so that even if individuals are incorrectly removed, they can re-enroll and, if found eligible, have up to three months of their expenses paid for.

Thankfully, a few states are taking smart and effective steps to ensure that the truly eligible remain enrolled and that taxpayer dollars aren’t squandered further.

Arkansas is one state taking such prudent steps. As of May 1, the Arkansas Department of Human Services reported that it had accomplished 133,000 reviews, with 72,000 removed for ineligibility . That’s slightly more than half of the reviewed recipients.

One of the reasons for this high percentage is that many enrollees who are now ineligible already had other sources of coverage. Indeed, as the left-leaning Urban Institute estimates, only 1% of those removed from Medicaid will not obtain coverage elsewhere.

With the public health emergency’s continuous eligibility policy coming to an end, the federal government should ensure that states act in a timely manner, penalizing those that lag behind the 12-month window and experience higher than normal error rates. Instead of coercing states with money to keep recipients on the program, Washington would do well to ensure that tax dollars are spent only on the truly eligible.

Gary D. Alexander, JD , is head of the Medicaid and Health Safety Net Initiative at the Paragon Health Institute and served as Pennsylvania’s Secretary of Human Services from 2011 to 2013 and Rhode Island’s Secretary of Health and Human Services and Medicaid Director from 2006 to 2011. Nic Horton is a research fellow for the Paragon Health Institute and the founder and CEO of Opportunity Arkansas Foundation.