Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State
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Source Document
Audit Scope
The audit covered the period July 2017 through October 2024. It examined PARIS matching for NYSOH and Local Districts, data sources including NCOA, Florida Voter Registry, Medicare plan service areas, and MDW address data to identify members who may reside outside New York; it also analyzed premium payments and recoveries.
Key Findings Summary
DOH did not begin reviewing NYSOH PARIS matches for NYSOH-enrolled members until October 2019—over five years after NYSOH enrollments began—resulting in $1.5 billion in premiums paid for members who may have resided outside New York.
NYSOH PARIS matches were not fully included in PARIS processing, and NYSOH inappropriately rejected certain PARIS matches, totaling $375 million.
Local District PARIS Processing deficiencies: 75,254 premiums paid for members whose eligibility was designated as closed but not officially closed, totaling $65 million.
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AI-Assisted
AI Scope Summary
This audit examined whether DOH properly restricted Medicaid managed care premium payments to New York residents by evaluating PARIS matches, NYSOH data, Local District PARIS processing, and additional residency indicators (NCOA, Florida voter registry, Medicare service areas). It found significant deficiencies in timing, data quality, and recoveries that resulted in billions of dollars in potentially improper premiums, and it recommends standardized processes, broader data-source usage, and enhanced recoveries to strengthen controls for future Medicaid audits.
AI-Generated Insight
DOH relied on PARIS to identify out-of-state residency but faced data gaps and processing flaws, leading to potentially billions in improper managed-care premium payments. The audit highlights multiple corrective actions, including expanding data sources (NCOA, Florida voter registry), standardizing Local District PARIS processing, and strengthening recoveries through OMIG and OMIG oversight. Implementing these changes should reduce improper payments and improve residency verification going forward.