Purpose

To determine the implementation status of the 14 recommendations made in our initial audit report, Appropriateness of Medicaid Eligibility Determined by the New York State of Health System (Report 2014-S-4).

Background

The Department of Health (Department) administers the State’s Medicaid program, which provides a wide range of health care services to individuals who are economically disadvantaged and/or have special health care needs. Following enactment of the Affordable Care Act in 2010, the State developed the New York State of Health (NYSOH) as a new online marketplace for individuals to obtain health insurance coverage, including Medicaid. Individuals who apply for Medicaid are assigned a Client Identification Number (CIN) that uniquely identifies them. NYSOH is required to conduct real-time checks among various data systems to verify applicants’ eligibility, ensure proper CIN assignment, and validate enrollees’ continued eligibility.

We issued our initial audit report on October 28, 2015. The objectives were to determine if the Department’s NYSOH system had adequate controls to ensure accurate enrollments in the Medicaid program and to determine whether improper enrollments caused Medicaid overpayments. The audit covered the period October 1, 2013 through October 1, 2014. We were unable to fully assess NYSOH controls over Medicaid enrollments and fully determine the extent that improper enrollments may have caused Medicaid overpayments because the Department did not provide auditors adequate access to the NYSOH system. Using other Medicaid data sources, we found flaws in NYSOH’s eligibility process that resulted in overpayments totaling about $3.4 million due to enrollments of deceased individuals and continued coverage for individuals who died after enrollment; multiple CINs issued to individual recipients; and unreasonably high numbers of CINs issued for expected multiple births per pregnancy.

We recommended that the Department recover approximately $3.4 million in overpayments, review and correct NYSOH eligibility system weaknesses and improper Medicaid enrollments, and ensure NYSOH system auditability.

Key Finding

Department officials made progress addressing the problems we identified in the initial audit report. The Department made certain improvements to NYSOH and most of the overpayments caused by the enrollment of deceased individuals were recouped. However, further actions are still needed. The Department did not recover most of the identified overpayments caused by multiple CINs issued to individual recipients. We also determined the Department did not terminate the corresponding Medicaid eligibility of all of these CINs, which caused additional overpayments totaling up to $801,759 to continue between January 1, 2016 and August 1, 2017. During our follow-up, we informed Department officials of the additional overpayments and they ended the eligibility for the remaining improper CINs we identified. However, the Department has not completed steps to “link together” each recipient’s multiple improper CINs to prevent potential overpayments from occurring again. Of the initial report’s 14 recommendations, 12 were implemented and two were partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Appropriateness of Medicaid Eligibility Determined by the New York State of Health System (2014-S-4)