Objective

To assess the extent of implementation of the five recommendations included in our initial audit report, Improper Payments of Medicare Buy-In Premiums for Ineligible Recipients (Report 2020-S-35).

About the Program

The Department of Health (Department) administers New York’s Medicaid program. Many Medicaid recipients are also enrolled in Medicare. Under the Medicare buy-in program (Buy-in Program), administered by the Centers for Medicare & Medicaid Services (CMS), Medicaid pays Medicare premiums for individuals who meet Buy-in Program eligibility requirements. The State’s Local Departments of Social Services determine eligibility and authorize and process enrollment in the Buy-in Program. In addition, CMS automatically enrolls certain individuals. Medicaid should not pay premiums for Buy-in Program coverage on behalf of individuals who do not have a benefit eligibility period – a date range for which the individual has Medicaid eligibility or Buy-in Program only eligibility – established in eMedNY, the Department’s Medicaid claims processing system.

The objective of our initial audit report, issued November 29, 2021, was to determine if Medicaid made improper Medicare premium payments on behalf of recipients enrolled in the Buy-in Program. The audit covered Medicaid payments for individuals enrolled in the Buy-in Program for the period from January 1, 2015 through December 31, 2019 and associated Medicare Buy-in Program credits from January 1, 2015 to November 30, 2020. We determined the Department had not established sufficient controls to ensure timely Buy-in Program eligibility determinations and prevent improper premium payments. We found that Medicaid made $31.7 million in improper Medicare premium payments for individuals who did not have a benefit eligibility period established in eMedNY. We also determined Medicaid paid $23.6 million in premiums for individuals who were automatically added to the Buy-in Program by CMS with coverage beginning more than 2 years retroactively, despite limitations on premium liability beyond 2 years. Accordingly, the State may have been eligible for equitable relief from CMS for its share of $13 million in premiums paid beyond the 2 years. Furthermore, Medicaid paid $372,716 in Medicare premiums for 282 individuals identified as deceased.

Key Findings

Department officials have made some progress in addressing the problems we identified in the initial audit report; however, additional actions are needed. In particular, the Department had not yet reviewed the individuals identified by our audit who had active Buy-in Program coverage but did not have a benefit eligibility period in eMedNY. Of the initial report’s five audit recommendations, two had been implemented, two had been partially implemented, and one had not yet been implemented.

Key Recommendation

Officials are given 30 days after the issuance of this report to provide information on any actions planned to address the unresolved issues discussed in this follow-up.