Oversight of Managed Long-Term Care Member Eligibility (Follow-Up)

Issued Date
March 13, 2024
Health, Department of (Medicaid Program)


To assess the extent of implementation of the four recommendations included in our initial audit report, Medicaid Program: Oversight of Managed Long-Term Care Member Eligibility (Report 2020-S-52).

About the Program

The Department of Health (Department) administers New York’s Medicaid program. Many of the State's Medicaid recipients are enrolled in managed long-term care (MLTC) plans, which provide long-term care services, such as home health care and nursing home care, for people who are chronically ill or disabled. For the year ended December 31, 2022, Medicaid paid MLTC plans $15.7 billion in premiums for 338,186 recipients enrolled in MLTC. The Department contracts with Maximus Health Services, Inc. (Maximus) to conduct initial eligibility assessments for individuals who choose to voluntarily enroll in MLTC (other individuals meeting certain criteria are automatically enrolled). To be eligible, all individuals must be assessed as needing community-based long-term care (CBLTC) for more than 120 days. After the initial assessment, MLTC plans were responsible for performing semi-annual assessments of their own members to determine whether the members should remain in their plans. MLTC plans are responsible for initiating disenrollment of enrollees when it is determined they are no longer MLTC eligible (e.g., enrollees who did not receive any CBLTC services in a month or deceased recipients), and Maximus is responsible for processing the disenrollments. The Department can recover premium payments made to MLTC plans for ineligible enrollees.

The objective of our initial audit report, issued on August 5, 2022, was to determine whether the Department made improper MLTC premium payments on behalf of ineligible enrollees. The audit covered the period from January 2015 through March 2021. The audit identified $701 million in improper Medicaid MLTC premiums on behalf of 52,397 recipients who were no longer eligible for MLTC. Additionally, we determined Medicaid paid $2.8 billion in MLTC premium payments on behalf of 51,947 recipients who received a limited number of CBLTC services, and the Department did not have a process to monitor that enrollees were properly assessed or had access to the care they needed.

Key Findings

Department officials made some progress in addressing the problems we identified in the initial audit report; however, additional actions are still needed. For example, less than 5% of the $701 million in improper MLTC payments had been recovered. Furthermore, the Department needs to develop a process to identify and monitor ineligible enrollees in between assessments. Of the initial report’s four audit recommendations, one was implemented, two were partially implemented, and one was not implemented.

Key Recommendation

Department officials are requested, but not required, to provide information about any actions planned to address the unresolved issues discussed in this follow-up within 30 days of the report’s issuance.

Andrea Inman

State Government Accountability Contact Information:
Audit Director: Andrea Inman
Phone: (518) 474-3271; Email: [email protected]
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236