Objective

To assess the extent of implementation of the four recommendations included in our initial audit report, New York State Health Insurance Program – Payments by Beacon Health Options for Mental Health and Substance Use Services for Ineligible Members (Report 2021-S-18).

About the Program

The New York State Health Insurance Program (NYSHIP), administered by the Department of Civil Service (Civil Service), provides health insurance coverage to over 1.2 million active and retired State, local government, and school district employees, and their dependents. The Empire Plan is the primary health insurance plan for NYSHIP, covering 1.1 million members. Civil Service contracts with Carelon Behavioral Health (Carelon), formerly Beacon Health Options, to administer the mental health and substance use (MHSU) program for the Empire Plan.

Civil Service is responsible for maintaining the New York Benefits Eligibility and Accounting System (NYBEAS), the system of record for member enrollment and eligibility information. Eligibility information is entered into NYBEAS by a participating employer’s health benefits administrator (HBA) as well as by Civil Service. If a NYBEAS disenrollment is entered after the date the change in eligibility takes effect, it is considered a retroactive disenrollment. Civil Service provides Carelon with a daily update file of NYBEAS changes, and Carelon also has access to NYBEAS to confirm eligibility information.

The objective of our initial audit report, issued on May 13, 2022, was to determine whether Carelon paid MHSU claims for Empire Plan members who were not eligible for coverage. The audit covered the period January 2015 through December 2020. We identified $3.21 million in overpayments for services, which resulted primarily from retroactive disenrollments.

Key Findings

Civil Service and Carelon have made significant progress in addressing the issues identified in the initial audit. Carelon had recovered nearly $726,000 of the $3.21 million in overpaid claims we identified. In addition, Civil Service and Carelon have implemented quarterly reconciliations of eligibility information between NYBEAS and Carelon’s system to help ensure claims are paid only for eligible members. Civil Service continues to provide training programs to remind HBAs of their responsibilities. Of the initial report’s four audit recommendations, three were implemented and one was partially implemented.

Key Recommendation

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