OIG Audit Reveals NY Medicaid Eligibility Errors

July 25, 2019 | Margarita Christoforou | Affordable Care Act | Legislation and Public Policy | Medicare and Medicaid

Based on a recent audit of payments under New York’s Medicaid program, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) estimated in a report that the state made hundreds of millions of dollars in payments to ineligible or “potentially ineligible” beneficiaries.

The audit examined payments to “non-newly eligible” beneficiaries, meaning individuals who were already eligible for Medicaid before the Affordable Care Act (ACA) expanded coverage in 2010. The OIG included New York among the states audited because New York’s pre-ACA eligibility guidelines were so broad that more than 90% of post-ACA Medicaid beneficiaries fell into the non-newly eligible category.

The audit covered 5,351,560 non-newly eligible beneficiaries for whom New York made Medicaid payments totaling $24.6 billion for services provided from October 2014 to March 2015. From this group, the OIG selected a random sample of 130 beneficiaries, which included six people who were determined to be ineligible and 14 for whom the state failed to provide supporting documentation. Based on an extrapolation, the OIG’s very rough estimates were that 383,893 ineligible beneficiaries received Medicaid payments of $520.3 million and 618,057 potentially ineligible beneficiaries received $1.3 billion during the six-month audit period.

The OIG report recommended that New York tighten its procedures for determining Medicaid eligibility. The state disagreed with the audit results but agreed to take steps to ensure that Medicaid determination and enrollment policies are adhered to.

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