Medicaid Program – Improper Payments of Medicare Buy-In Premiums for Ineligible Recipients

Issued Date
November 29, 2021
Agency/Authority
Health, Department of (Medicaid Program)

Objective

To determine if Medicaid made improper Medicare premium payments on behalf of recipients enrolled in the Medicare buy-in program. The audit covered Medicaid payments for individuals enrolled in the Medicare buy-in program for the period from January 1, 2015 through December 31, 2019 and associated Medicare buy-in program credits from January 1, 2015 to November 30, 2020.

About the Program

The Department of Health (Department) administers New York’s Medicaid program. Many Medicaid recipients are also enrolled in Medicare. Under the Medicare buy-in program (Buy-in Program), administered by the Centers for Medicare & Medicaid Services (CMS), Medicaid pays Medicare premiums for individuals who meet Buy-in Program eligibility requirements. The State’s Local Departments of Social Services (Local Districts) determine eligibility and authorize and process enrollment in the Buy-in Program. In addition, CMS automatically enrolls certain individuals. Medicaid should not pay premiums for Buy-in Program coverage on behalf of individuals who do not have a benefit eligibility period established in the Department’s Medicaid claims processing system. For the period January 1, 2015 through December 31, 2019, New York’s Medicaid program paid $8 billion in Buy-in Program premiums for 1,025,008 individuals.

Key Findings

We found that the Department needs additional controls to ensure timely Buy-in Program eligibility determinations and to prevent improper premium payments. During our audit scope:

  • Medicaid made $31.7 million in improper Medicare premium payments on behalf of 42,586 individuals who did not have a benefit eligibility period established in the Department’s Medicaid claims processing system. Medicaid also paid $372,716 in Medicare premiums for 282 individuals identified as deceased. According to CMS, improper premium payments beyond two months for reasons other than death are not recoverable.
  • Medicaid paid $23.6 million in premiums for 3,439 individuals who were automatically added to the Buy-in Program by CMS with coverage beginning more than two years retroactively, despite limitations on premium liability beyond two years. The State may be eligible for equitable relief from CMS for its share of $13 million in premiums paid beyond the two years.

Key Recommendations

  • Increase oversight of Local Districts to ensure accurate eligibility determinations and timely closure of Buy-in Program cases for ineligible individuals.
  • Review the active cases of Buy-in Program coverage for individuals without a benefit eligibility period in eMedNY and remove them from the Buy-in Program, as warranted.
  • Follow up with CMS to request payment relief on the 3,439 cases where recipients were added to the Buy-in Program retroactively beyond the two-year limit.
  • Review and recover the premiums paid for deceased individuals, as warranted.

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