Objective

The objective of this audit was to determine whether the Department of Health (Department) made improper fee-for-service (FFS) payments for certain services covered by managed long-term care (MLTC) plans. The audit covered the period January 1, 2014 through June 30, 2019.

About the Program

The Department administers New York’s Medicaid program. Many of the State’s Medicaid recipients are enrolled in MLTC plans. MLTC plans provide long-term care services, such as home health care, nursing home care, and durable medical equipment, to people who are chronically ill or disabled. Medicaid pays MLTC plans monthly managed care premiums and, in return, MLTC plans pay for all MLTC covered services. The Medicaid program should not pay claims on a FFS basis for services covered by MLTC plans. Individuals are enrolled in MLTC through either Local Departments of Social Services (Local Districts) or a contractor that operates a statewide enrollment center for public health insurance programs. Enrollment information is ultimately communicated to eMedNY, the Medicaid claims processing and payment system.

Key Findings

The audit identified $16.4 million in improper Medicaid FFS payments for MLTC covered services. The improper payments resulted from the following:

• $15.6 million was paid because eMedNY did not identify certain MLTC services as the responsibility of the MLTC plan.
• Over $877,000 was paid because, at the time eMedNY adjudicated the claim, the recipient was not enrolled in MLTC, but was retroactively enrolled at a later date.

Key Recommendations

• Review the $16.4 million in improper Medicaid FFS payments and make recoveries, as appropriate.
• Correct eMedNY MLTC benefit package information and system edits to prevent FFS payments for MLTC covered services.
• Work with Local Districts and develop a process to identify and recover improper Medicaid FFS payments for MLTC services resulting from retroactive enrollments.