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NYS Comptroller

THOMAS P. DiNAPOLI

Taxpayers' Guide to State and Local Audits

Department of Health
Medicaid Program: Appropriateness of Medicaid Eligibility Determined by the New York State of Health System


Issued: October 28, 2015
Link to full audit report 2014-S-4
Link to 90-day response

Purpose
To determine if the Department of Health’s New York State of Health system has adequate controls to ensure accurate enrollments in the Medicaid program and to determine whether improper enrollments caused Medicaid overpayments. The audit covered the period October 1, 2013 through October 1, 2014.

Background
With the enactment of the federal Patient Protection and Affordable Care Act in 2010, the State developed the New York State of Health (NYSOH) as a new online marketplace for individuals to obtain health insurance coverage, including Medicaid. Individuals who apply for public assistance benefits, including Medicaid, are assigned a Client Identification Number (CIN) that uniquely identifies them. NYSOH is required to conduct various checks among data systems to verify applicants’ eligibility, ensure proper CIN assignment, and validate enrollees’ continued eligibility.

Key Findings

  • The Department did not provide auditors adequate access to the NYSOH system. Due to this limitation and other audit scope impairments, we were unable to fully assess the adequacy of NYSOH controls over Medicaid enrollments and fully determine the extent to which improper enrollments may have caused Medicaid overpayments. Consequently, readers of our audit report should consider the effect of the scope limitation on the conclusions presented in our report.
  • Using other Medicaid data sources, we determined that a range of design and process flaws in NYSOH’s eligibility process permitted inappropriate Medicaid enrollments that resulted in overpayments totaling about $3.4 million since NYSOH’s implementation. We determined:
    • NYSOH enrolled deceased individuals and continued Medicaid coverage for individuals who had died after enrollment, resulting in Medicaid overpayments of $325,030;
    • NYSOH issued multiple CINs to individual recipients, resulting in actual Medicaid overpayments of $2,852,210 and potential overpayments of $188,131; and
    • NYSOH issued unreasonably high numbers of CINs for expected multiple births per pregnancy – in some cases up to ten per pregnancy. In a single case, unnecessary CINs permitted eMedNY to make $4,796 in improper Medicaid payments for nine of ten improbable ‘unborn’ CINs issued for one pregnancy.

Key Recommendations

  • We made 14 recommendations to the Department to review and correct NYSOH eligibility system weaknesses, correct the improper Medicaid enrollments we identified, recover identified inappropriate payments, and ensure NYSOH system auditability.

Other Related Audits/Reports of Interest

Department of Health: Inappropriate Medicaid Payments for Recipients With Multiple Identification Numbers and No Social Security Numbers (2010-S-29)
Department of Health: Inappropriate Medicaid Payments for Recipients With Multiple Identification Numbers (2008-S-163)


State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: StateGovernmentAccountability@osc.state.ny.us
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236