New York Medicaid Managed Care Capitation Payments for Incarcerated Enrollees
Learn how the AI-generated research projects were createdOverall Conclusion
New York made unallowable managed care capitation payments totaling $7,551,670 ($6,164,734 Federal share) on behalf of 1,375 incarcerated Medicaid enrollees and did not consistently disenroll incarcerated enrollees; recommendations include refunding the Federal share and strengthening enrollment matching controls.
Source Document
Audit Scope
Audit covered January 1, 2021 through December 31, 2024; $7.6 million in capitation payments to MCOs for 1,375 incarcerated enrollees; matched DOCCS prison data to T-MSIS/WMS; evaluated internal controls and policies for disenrollment.
Key Findings Summary
The State agency made unallowable managed care capitation payments totaling $7,551,670 ($6,164,734 Federal share) on behalf of all 1,375 incarcerated Medicaid enrollees.
The State agency did not always disenroll incarcerated enrollees from Medicaid managed care after notification of incarceration, due to system limitations and overrides during the COVID-19 Public Health Emergency (PHE).
In some cases, minor differences in enrollees' demographic information prevented identification of incarcerated individuals, leading to continued capitation payments.
AI-Assisted
AI Scope Summary
This audit examined whether New York's Department of Health made unallowable capitation payments to Medicaid managed care organizations for incarcerated enrollees during 2021–2024, identified the total unallowable amounts not recovered, and concluded with recommendations to refund the federal share and strengthen disenrollment and data-matching controls to inform future audits of incarcerated populations in Medicaid.
AI-Generated Insight
The report highlights risks from prolonged continuous enrollment during the PHE and data-matching gaps between prison incarceration data and Medicaid enrollment data, suggesting automated disenrollment triggers and enhanced, tolerance-based matching to prevent future unallowable capitation payments.
Audit Objectives
Determine whether the State agency made unallowable capitation payments to Medicaid MCOs on behalf of individuals incarcerated in State prisons.
Identify the dollar amount of any unallowable capitation payments made on behalf of incarcerated enrollees that were not recovered.
Audit Findings (3)
The State agency made unallowable managed care capitation payments totaling $7,551,670 ($6,164,734 Federal share) on behalf of all 1,375 incarcerated Medicaid enrollees.
The State agency did not always disenroll incarcerated enrollees from Medicaid managed care after notification of incarceration, due to system limitations and overrides during the COVID-19 Public Health Emergency (PHE).
In some cases, minor differences in enrollees' demographic information prevented identification of incarcerated individuals, leading to continued capitation payments.
Recommendations (2)
Refund $6,164,734 (Federal share) for unallowable capitation payments.
Strengthen policies and procedures to prevent system limitations that may lead to Medicaid capitation payments for incarcerated enrollees and to account for minor differences in enrollees' demographic information when matching DOCCS prison data to Medicaid enrollment data in the Welfare Management System (WMS).