Improper Overlapping Medicaid and Essential Plan Enrollments (Follow-Up)

Issued Date
April 10, 2024
Health, Department of (Medicaid Program)


To assess the extent of implementation of the three recommendations included in our initial audit report, Improper Overlapping Medicaid and Essential Plan Enrollments (Report 2020-S-66).

About the Program

DOH administers the State’s Medicaid program and the Essential Plan. Medicaid provides a wide range of health care services to individuals who are economically disadvantaged and/or have special health care needs. The Essential Plan also provides health insurance to lower-income people who, generally, don’t qualify for Medicaid. As income, household makeup, and other factors change, individuals may transition between Medicaid and the Essential Plan.

NY State of Health (NYSOH) is the State-run health plan marketplace organized under DOH where individuals can apply for and enroll in health insurance plans, including Medicaid and the Essential Plan. Additionally, the State’s Welfare Management System (WMS) processes enrollments of certain Medicaid populations. Medicaid and Essential Plan enrollment data is transmitted from NYSOH and WMS to DOH’s eMedNY system, which uses the enrollment data to make Medicaid and Essential Plan payments.

The objective of our initial audit report, issued October 11, 2022, was to determine whether Medicaid and Essential Plan enrollments determined by NYSOH were accurately reflected in eMedNY when individuals transitioned between the Medicaid and Essential Plan programs and to identify overpayments resulting from inaccurate enrollments. The audit covered the period from January 2016 through May 2022. The audit identified system processing weaknesses in NYSOH and eMedNY that resulted in overlapping enrollments in Medicaid and the Essential Plan. During periods of duplicative enrollments, we identified $36.5 million in Medicaid payments and $16.2 million in Essential Plan payments on behalf of 4,422 recipients with the same Social Security number; and additional payments totaling $3.8 million by Medicaid and $2.2 million by the Essential Plan on behalf of 603 recipients who had other matching demographic data when Social Security numbers were not available, such as name, date of birth, and gender. Furthermore, DOH did not have a process to detect and correct these improper duplicative enrollments, nor did it have a process to recover improper payments caused by the overlapping enrollments.

Key Findings

DOH officials made some progress in addressing the problems we identified in the initial audit report; however, additional actions are needed. For example, while DOH established periodic reconciliations of certain enrollment overlaps, these reconciliations are only designed to detect one of three causes of overlaps identified in the original audit. Furthermore, DOH corrected overlapping Medicaid and Essential Plan enrollment periods for only seven of the 5,025 recipients identified in the initial audit and was unable to determine what, if any, recoveries had taken place. Of the initial report’s three audit recommendations, two were partially implemented and one was not implemented.

Key Recommendation

DOH 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