An audit by State Comptroller Thomas P. DiNapoli has identified significant problems in New York’s process for verifying the residency of Medicaid members, leading to nearly $1.2 billion in managed care premiums paid for individuals who may have lived outside the state. The report also found that the Department of Health (DOH) delayed efforts to recover improper payments.
“Medicaid is a vital program and the single biggest expense in the state budget. We cannot afford any wasteful spending,” DiNapoli said. “If a person is enrolled in more than one state at the same time, both states may end up paying premiums to his or her managed care plans. Responsibility for preventing enrollment in more than one state lies at both the federal and state levels, and stronger coordination is needed to reduce improper payments, protect the program’s integrity, and ensure New York is only paying Medicaid costs for its residents.”
Most Medicaid recipients are enrolled through either the New York State of Health (NYSOH) or local departments of social services. These members are typically placed into managed care plans that receive monthly premium payments from DOH to cover health services. If a member moves out of New York, they should be disenrolled and any excess premiums returned.
The audit reviewed activity from July 2017 through October 2024 and found that DOH did not begin submitting NYSOH member data to the federal Public Assistance Reporting Information System (PARIS)—which matches public assistance enrollments across all states—until May 2017, almost three years after NYSOH began operations. Furthermore, DOH did not start reviewing PARIS match results until October 2019, resulting in $1.5 billion in premium payments between 2017 and 2019 for unreviewed members.
Additional findings showed that even when eligibility was closed based on PARIS matches indicating out-of-state residency, DOH and the Office of the Medicaid Inspector General (OMIG) often failed to recover premium payments made during those periods. OMIG officials reported they might have missed recovering up to $11.4 million due to regulatory limits on how far back they could recoup funds.
DiNapoli urged OMIG to expedite reviews of these findings so improper payments can be recovered where possible.
All U.S. states, along with Washington D.C. and Puerto Rico, participate in PARIS matching; however, not every jurisdiction participates each quarter, which affects how well out-of-state members are identified.
In response to recommendations from DiNapoli’s office, DOH agreed with most suggestions and stated it is taking action—including considering additional data sources such as NCOA—to better identify non-resident members and working with federal agencies on improving residency verification within PARIS.
“Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State” is available from DiNapoli’s office.
