Objective

To determine whether NY State of Health (NYSOH, New York’s online health plan marketplace) properly sent accurate, complete, and timely Medicaid eligibility and enrollment information to the Medicaid claims payment system, and if it did not, determine the corresponding Medicaid overpayments. The audit covered the period January 1, 2014 through February 28, 2020.

About the Program

The Department of Health (Department) administers New York’s Medicaid program. Many of the State’s Medicaid recipients receive their services through managed care, whereby the Department pays managed care organizations (MCOs) a monthly premium for each enrolled recipient and, in turn, the MCOs pay health care providers for services their members require. Recipients can also receive services through fee-for-service, whereby the Department pays health care providers directly, through eMedNY, the Medicaid claims processing and payment system, for each eligible service rendered to Medicaid recipients.

NYSOH is the State-run health plan marketplace organized under the Department where individuals, families, and small businesses can search for and enroll in Medicaid and other health insurance plans. An individual’s Medicaid eligibility and enrollment information is transmitted from NYSOH to the Department’s eMedNY system. The eMedNY system relies on the information sent by NYSOH to update eligibility and enrollment data necessary to make appropriate claim payments. If this information is not sent in an accurate and timely manner, eMedNY is at risk of making improper payments for individuals who are ineligible or disenrolled from the Medicaid program.

Key Findings

The audit identified system processing weaknesses in NYSOH that caused improper transmissions of eligibility and enrollment information to eMedNY, and a lack of eligibility and enrollment data reconciliations between NYSOH and eMedNY that resulted in:

• $11.7 million in improper payments on behalf of 1,096 recipients who had terminated coverage in NYSOH, but continued coverage in eMedNY.
• $4.9 million in improper and questionable payments on behalf of 319 recipients who had a date of death in NYSOH, but continued eligibility in eMedNY.

Key Recommendations

• Review the $16.6 million in payments and make recoveries, as appropriate.
• Perform reconciliations of Medicaid program eligibility and enrollment, including dates of death, between NYSOH and eMedNY and resolve differences in a timely and accurate manner.
• Prioritize corrective actions to prevent Medicaid overpayments due to eligibility and enrollment processing weaknesses in the NYSOH and eMedNY systems.