Objective

To determine whether Medicaid and Essential Plan enrollments determined by NY State of Health were accurately reflected in eMedNY when individuals transitioned between the Medicaid and Essential Plan programs and to identify overpayments resulting from inaccurate enrollments. The audit covered the period January 2016 through May 2022.

About the Program

The New York State Medicaid program, administered by the Department of Health (Department), provides a wide range of health care services to individuals who are economically disadvantaged and/or have special health care needs. New York’s Essential Plan (EP) provides health insurance to lower-income people who, generally, don’t otherwise qualify for Medicaid. As income, household makeup, and other factors change, individuals may transition between Medicaid and EP.

NY State of Health (NYSOH) is the State-run health plan marketplace organized under the Department where individuals can apply for and enroll in health insurance plans, including Medicaid and EP. An individual’s Medicaid and EP enrollment data is transmitted from NYSOH to eMedNY, the Department’s Medicaid claims processing and payment system. The eMedNY system relies on information from NYSOH to accurately make payments for the Medicaid and EP programs.

Key Findings

The audit identified system processing weaknesses in NYSOH and eMedNY that resulted in recipients having duplicative Medicaid and EP enrollments, which led to improper Medicaid and EP payments.

• We identified 4,784 overlapping Medicaid and EP enrollment periods for 4,422 recipients who had the same Social Security number and combinations of the same first name, last name, and/or date of birth. During these overlapping enrollment periods, the Department made Medicaid payments totaling $36.5 million and EP payments totaling $16.2 million.
• We identified 651 overlapping Medicaid and EP enrollment periods for 603 recipients using the Department’s probabilistic matching criteria (first name, last name, date of birth, and gender) when recipient Social Security numbers were not listed in one or both programs. During these overlapping enrollment periods, the Department made Medicaid payments totaling $3.8 million and EP payments totaling $2.2 million.
• We concluded weaknesses in the Department’s automated processes caused overlapping enrollments in Medicaid and EP. Further, the Department does not have a process to detect and correct these improper duplicative enrollments, nor does it have a process to recover improper payments caused by the overlapping enrollments. Case reviews are necessary to determine which program made improper payments.

Key Recommendations

• Review and correct the identified enrollment overlaps and recover overpayments, as warranted.
• Strengthen controls to prevent overlapping enrollment periods, including: Force Closure processing weaknesses, NYSOH flaws with assigning multiple recipient identification numbers, and 834 transactions not being processed as intended.
• Develop and implement reconciliations between the Medicaid and EP programs to detect duplicative enrollments, and take corrective actions.