Objective

To assess the extent of implementation of the four recommendations included in our initial audit report, Excessive Premium Payments for Dual-Eligible Recipients Enrolled in Mainstream Managed Care and Health and Recovery Plans (Report 2021-S-37).

About the Program

DOH administers New York’s Medicaid program. Many Medicaid recipients are enrolled in Medicare and are referred to as “dual-eligibles.” Additionally, many Medicaid recipients receive their services through managed care, including Mainstream Managed Care (MMC), which provides comprehensive coverage, and Health and Recovery Plans (HARP), which provide specialized care to recipients aged 21 or older with serious mental illness and/or substance use disorders. Within MMC and HARP is the Integrated Benefits for Dually Eligible Enrollees Program (IB-Dual), which became effective April 1, 2021. IB-Dual pays lower MMC and HARP premium rates for Medicaid recipients in MMC or HARP who enroll in Medicare and do not need long-term services and support. However, recipients in MMC or HARP who enroll in Medicare but are not eligible for IB-Dual should be disenrolled from MMC and HARP and moved to Medicaid fee-for-service (FFS) because the cost of the managed care premiums generally exceeds the cost of deductibles and coinsurance that Medicaid would pay on FFS claims for dual-eligibles.

The objective of our initial audit, issued October 31, 2022, was to determine whether Medicaid overpaid MMC and HARP premiums on behalf of dual-eligible individuals. The audit covered the period from March 2021 through March 2022. The audit found over $190.6 million was paid on behalf of dual-eligible recipients who were ineligible for IB-Dual. These recipients should have been removed from their MMC or HARP plan and provided FFS coverage. Additionally, the audit found over $3.5 million was paid on behalf of dual-eligible recipients who appeared eligible for IB-Dual but were not enrolled in a timely manner. We found DOH’s rollout of IB-Dual did not initially include recipients who became dual-eligible prior to the date the new IB-Dual rate became effective.

Key Findings

DOH officials have made significant progress in addressing the problems we identified in the initial audit report. For example, DOH made adjustments to reduce MMC and HARP premiums to account for the presence of dual-eligibles enrolled in MMC and HARP plans. In addition, beginning in December 2023, DOH started disenrolling dual-eligible recipients from MMC and HARP as part of the COVID-19 public health emergency unwind process. Of the initial report’s four audit recommendations, two were implemented and two were partially implemented.

Key Recommendation

DOH officials are requested, but not required, to provide information about any actions planned to address the unresolved issues discussed in this follow-up within 30 days of the report’s issuance.