Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State

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.

Additional indicators of out-of-state residency using non-PARIS data identified $509 million in premiums for members who may have resided outside New York based on data sources other than PARIS, including $323 million via NCOA.

eMedNY address data, Florida voter registry, and Medicare plan service areas identified $186 million in premiums for 338,483 premiums.

Unrecovered premiums: DOH did not recover $234 million in premiums where eligibility was ended due to PARIS matches; $198 million for NYSOH and $36 million for Local Districts remained unrecovered.

Totals: 5,723,432 premiums totaling $2.7 billion; 5,566,995 non-duplicated premiums totaling over $2.6 billion.

Rejected PARIS matches: 87,393 NYSOH records were rejected due to invalid Medicaid start dates; Medicaid paid 629,920 premiums totaling almost $325 million after PARIS match; about $143.8 million of these payments were for members who did not receive any NYS services after the match.

Local District closures misclassifications: 23,573 'Closed/Removed by Match' records; 4,837 not closed within 120 days; $65 million premiums paid after start dates in the other state.

Top out-of-state residencies: Florida, New Jersey, and Pennsylvania represented 35% of the premium payments.

NYSOH PARIS clock and residency verification issues: clocks not expiring as intended; 239 members potentially impacted; 2,314 clocks did not expire due to multiple NYSOH accounts; fixes implemented in July 2024 and September 2024.

NYSOH unverified SSN defect: 631,514 NYSOH members affected; fix implemented March 2024.

Using a risk-based approach, review NYSOH members identified by PARIS match between May 2017 and October 2019 (representing $1.5 billion in premiums paid through October 2024) and, as appropriate, determine residency, end Medicaid eligibility, and recover improper premium payments.

Correct NYSOH PARIS processing to ensure NYSOH verifies residency of all members identified by PARIS matches, including those with invalid Medicaid start dates, those who fail match validation (SSN/birth date mismatches, multiple identifiers), and those with Life Status Changes unrelated to residency; ensure all SSNs verified by SSA are included; ensure PARIS clock expires properly.

For NYSOH-enrolled members not properly processed due to NYSOH defects, review the consumers impacted and recover the $375 million in premium payments as appropriate; OMIG to pursue additional data sources for residency validation.

Develop a standard process that all Local Districts must follow for processing PARIS matches and notify all Local Districts of the process.

Review members marked 'Closed/Removed by Match' by Local Districts but whose eligibility was not closed and recover the $65 million in retroactive premium payments where appropriate.

Develop oversight processes to ensure resolutions of WMS and NYSOH PARIS matches are processed timely, including closing cases, retroactive disenrollments, and timely recoveries.

Review the $234 million in improper premiums paid for members whose eligibility was closed and make recoveries as appropriate.

Use NCOA and other data sources to identify members residing outside New York and recover improper premium payments as appropriate.

Engage with HHS to incorporate additional data sources (e.g., NCOA) into the federal PARIS match.

Review the $509 million in premiums identified via data sources other than PARIS and determine residency, end eligibility, and recover improper payments.

When OMIG identifies members with out-of-state MDW addresses and no in-state service claims, ensure retroactive recoveries of premiums.