Sneak Preview: N.Y. Urged To Better Assess Medicaid Eligibility

January 26, 2018 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) New York health officials are providing extra training for staff and making system modifications to ensure that Medicaid beneficiaries in a specific “newly eligible” category actually meet federal and state eligibility requirements, in response to recommendations in a recent Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit.

The Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148) gave states the option to expand Medicaid coverage to low-income adults without dependent children, and established a higher federal reimbursement rate for services provided to these newly eligible beneficiaries. In order to qualify as newly eligible, these individuals also must be no younger than 19 and no older than 64, not pregnant, not eligible for or enrolled in Medicare, and meet established income threshold levels. As of Jan. 1, 2017, New York was one of 31 states and the District of Columbia that had chosen to expand Medicaid to include the newly eligible beneficiaries.

OIG reviewed a sample of 130 newly eligible beneficiaries from October 2014 through March 2015 to assess whether the New York Department of Health accurately determined the applicants’ eligibility. It found that the state agency correctly determined eligibility for 90 of the 130 sampled beneficiaries. However, it did not appropriately determine eligibility for 37 beneficiaries in accordance with federal and state requirements, and did not provide supporting documentation to verify the eligibility of the remaining beneficiaries. OIG explained that the determination problems stemmed from human or system errors related to new eligibility determination processes and the lack of documentation supporting determinations. Overall, OIG estimated that the state agency made about $26 million in payments to about 47,000 ineligible beneficiaries during the audit period.

OIG found that eight beneficiaries that were inaccurately determined as eligible were above the maximum eligible threshold level, which is 138 percent of the federal poverty level. For example, one beneficiary was verified as having an annual income of $35,000 with a household size of one, even through the allowed maximum income threshold level is $16,105 for a household size of one. In addition, the state agency incorrectly determined that 20 beneficiaries were determined as newly eligible even though their household income amount was below the allowed minimum threshold level, which is 100 percent of the federal poverty level.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

As a reminder, we have all of our Federal Funding Training Forums scheduled for 2018. Please let me know if you have questions or can make any of these. We hope to see you there!

  • Wednesday Feb 7 – Friday Feb 9 in PHOENIX

  • Wednesday May 1 – Friday May 4 in ST LOUIS

  • Wednesday July 25 – Friday July 27 in MINNEAPOLIS

  • Wednesday October 17 – Friday October 19 in ATLANTA


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