Objective

To determine the extent of implementation of the five recommendations made in our initial audit report, Inappropriate Premium Payments for Recipients No Longer Enrolled in Mainstream Managed Care and Family Health Plus (Report 2015-S-47).

About the Program

Most Medicaid recipients are enrolled into mainstream managed care, which provides comprehensive medical coverage. During the initial audit period, Family Health Plus (FHP) was a publicly funded managed care program for individuals whose income was too high to qualify for Medicaid. This program was eliminated effective January 1, 2015 and the majority of FHP enrollees transitioned to the Medicaid program. Managed care plans (Plans) receive monthly premium payments for individuals enrolled in their plans. The Department of Health (Department) has the right to recover premium payments from Plans for inappropriately enrolled recipients.

We issued our initial audit report on July 11, 2017. The audit objective was to determine whether the Department made improper premium payments to Medicaid mainstream managed care plans and FHP managed care plans for recipients who were no longer enrolled. The audit covered the period October 1, 2010 through September 30, 2016. We found the Department made improper and questionable premium payments totaling $122.4 million ($103.9 million in improper premiums and $18.5 million in questionable premiums) for 171,936 recipients who were retroactively disenrolled from a Plan. We provided the claim data to the Office of the Medicaid Inspector General (OMIG), and it recovered about $7.4 million from the Plans by the end of the audit. We also found the New York City Human Resources Administration misinterpreted guidelines, leaving many improper premiums uncollected. We recommended the Department review the remaining $115 million in premiums and recover all overpayments, and strengthen controls to prevent the types of improper payments we identified.

Key Finding

Department officials made progress in addressing the problems we identified in the initial audit report; however, additional action is needed. In particular, OMIG recovered about $20 million of the identified improper premiums; however, $84 million still needed to be reviewed and recovered from the Plans. Of the initial report’s five audit recommendations, one was implemented and four 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 the follow-up report.