Objective

To determine if improper Medicaid payments were made on behalf of recipients with multiple Client Identification Numbers (CINs) where at least one CIN was enrolled in fee-for-service. The audit covered the period from January 1, 2014 to March 31, 2019.

About the Program

The Department of Health (Department) uses two methods to pay for Medicaid services: fee-for-service (FFS) and managed care. Under the FFS method, the Department pays health care providers directly, through eMedNY, the Department’s claims processing system. Under managed care, the Department pays managed care organizations (MCOs) monthly premiums and the MCOs arrange for the provision of health care services for Medicaid recipients and reimburse providers.

Each individual who applies for Medicaid benefits is assigned a CIN, a unique identifier. However, recipients may have more than one CIN assigned during the time they are in receipt of benefits, such as one CIN under FFS enrollment and a different CIN under managed care enrollment. Only one CIN should have active eligibility at a time to prevent duplication of payments.

Individuals have several options for enrolling in Medicaid, including through Local Departments of Social Services (Local Districts) and the NY State of Health (NYSOH, the State’s online health insurance marketplace). Local Districts use the State’s downstate Welfare Management System (WMS) to process enrollment data for individuals in New York City and the upstate WMS for individuals in the rest of the State. The NYSOH system processes its own enrollment data. Additionally, the New York City Administration for Children’s Services processes Medicaid enrollments for individuals in foster care in New York City, but must use the upstate WMS. The eMedNY system relies on the information sent by the WMS and NYSOH systems to update its enrollment data, which is necessary to make accurate payments. When an individual is assigned multiple CINs, each with its own record of eligibility, Medicaid is at risk of making improper payments for the duplication of benefits.

Key Findings

• Medicaid made $47.8 million in payments on behalf of recipients with multiple CINs for the period January 1, 2014 through March 31, 2019, which included:
  • $32.6 million in improper premiums for inappropriate managed care enrollments of recipients concurrently enrolled in FFS foster care under different CINs;
  • $12.7 million in improper premiums for managed care enrollments of recipients concurrently enrolled in FFS under different CINs (in each case, one of the concurrent enrollments was improper; the circumstances identified provide a basis for recovering premiums);
  • $2.5 million in potential duplicate FFS payments made on behalf of recipients with concurrent FFS enrollments under different CINs.
• Multiple CINs are often the result of incorrect/missing recipient demographic information, use of multiple eligibility systems during enrollment (e.g., upstate WMS, downstate WMS, NYSOH), and limitations in the enrollment process for foster care recipients.
• The Office of the Medicaid Inspector General (OMIG) recovers improper premium payments for foster care recipients with multiple CINs. By the end of our fieldwork, $16.6 million of the improper payments identified were voided. However, OMIG does not have a process to recover improper premium payments for non-foster care recipients with concurrent FFS enrollment or improper FFS payments for recipients with multiple FFS enrollments.

Key Recommendations

• Review the improper payments identified and make recoveries, as appropriate.
• Correct the multiple CIN cases identified to prevent future improper payments.
• Evaluate controls to prevent the creation of multiple CINs for recipients in foster care.
• Begin recovering improper premiums for non-foster care recipients with concurrent FFS enrollment and improper FFS payments for recipients with concurrent FFS enrollments.