Department of Health
Oversight of the Family Health Plus Program The Family Health Plus Program provides health insurance to low-income individuals with no other health insurance who are not eligible for Medicaid. The Program is overseen by the Department of Health and administered by local social services districts (57 counties and New York City). Program recipients must enroll in local managed care organizations (plans). The plans provide recipients with access to covered health services and pay the service providers. The Department pays the plans a monthly premium for each Program recipient enrolled in the plans by the local districts.
We found that certain actions need to be taken by the Department to improve coordination among the local districts and provide the districts with more reliable information for their determinations of applicants’ Program eligibility. We identified a number of instances in which duplicate monthly premiums were paid because recipients were enrolled in two different plans in two different local districts. We also found indications that many ineligible individuals may have been enrolled in the Program. We identified an estimated $1.9 million in overpayments during our 30-month testing period, and found indications that a significant portion of another $32.5 million in monthly premiums and another $1.5 million in fee-for-service payments may also have been overpaid. We recommended that all overpayments be recovered and improvements be made in the Department’s oversight and in the automated information system containing Program data.
For a complete copy of Report 2004-S-17 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.