Objective

To determine the extent of implementation of the six recommendations included in our initial audit report, Accuracy of Medicaid Eligibility Determined by NY State of Health (Report 2019-S-43).

About the Program

NY State of Health (NYSOH) is the online health plan marketplace organized under the Department of Health (Department) where people can enroll in Medicaid. An individual’s Medicaid eligibility and enrollment information is transmitted from NYSOH to the Department’s Medicaid claims processing and payment system (eMedNY). The eMedNY system relies on accurate and timely information from NYSOH to update eligibility and enrollment data necessary to make appropriate claim payments.

We issued our initial audit report on September 17, 2020. The audit objective was to determine whether NYSOH properly sent accurate, complete, and timely Medicaid eligibility and enrollment information to eMedNY and, if it did not, to determine the corresponding Medicaid overpayments. For the period January 1, 2014 through February 28, 2020, our 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 which led to recipients, including some who were deceased, remaining eligible beyond their actual eligibility period. As a result, the Department made $16.6 million in improper and questionable Medicaid payments during the audit period.

Key Finding

Department officials made some progress in addressing the problems we identified in the initial audit report, such as correcting certain deficiencies in NYSOH data processing. However, further actions are required. For example, very little of the overpayments from the initial report have been recovered. Department officials stated that federal restrictions and the ongoing public health emergency adversely affected their ability to disenroll recipients and recoup improper payments in a timely manner. In addition, the Department needs to perform timely, periodic reconciliations of death data between NYSOH and eMedNY to prevent additional improper payments, as well as to address the causes that allow differences to continue. Of the initial report’s six audit recommendations, four were partially implemented and two were 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.