A New York state audit found over $700 million in overpayments for ineligible members of Medicaid Managed Long-Term Care and $2.8 billion in payments for inadequate care.

In his audit, Thomas DiNapoli, New York state comptroller, discovered hundreds of millions of dollars were spent on MLTC costs for state residents no longer qualified for the program.

The audit states that inadequate oversight for more than six years by the state Department of Health led to over $700 million in overpayments for ineligible members and $2.8 billion for minimal services for eligible members.

“My latest Medicaid audit found more examples of how oversight weaknesses impose unnecessary costs on taxpayers.” DiNapoli said. “This time, failure to effectively monitor money allowed $701 million worth of improper spending, and may have also led to unsatisfactory long-term care for eligible patients in need.”

DiNapoli has asked the Department of Health to act upon the results of the audit and take steps to ensure proper oversight of MLTC.

Medicaid’s MLTC program offers long-term care services, such as home health care and nursing home care, to chronically ill or disabled patients. Eligible patients are required to meet certain criteria, such as needing community-based long-term care services longer than 120 days.

While some people are automatically enrolled in MLTC based on their condition, other people can choose to enroll. However, DOH contracts with Maximus Health Services Inc. to determine whether individuals meet the MLTC criteria.

The audit, which examined the period from January 2015 to March 2021, highlighted issues with how MLTC plans reviewed a person’s eligibility and removed ineligible members from the program.

One example cited by the audit found that Medicaid made 48 monthly premium payments to an MLTC plan from 2016 to 2021, totaling $151,490, for a patient that should not have qualified for MLTC.

DiNapoli suggested that ineligible individuals should be moved to a less costly Medicaid coverage plan.

Another problem DiNapoli found was that eligible members did not always receive the level of care and services they paid for. Auditors found 626,435 payments, totaling $2.8 billion, that were made on behalf of 51,947 members who did not receive adequate services.

DiNapoli suggested that ineligible individuals should be moved to a less costly Medicaid coverage plan.

Despite the program’s purpose to aid disabled and chronically ill individuals who wish to remain home and in their communities, the audit found 42% of these members only received between 1 to 30 days of services during their 6-month assessment periods.

The audit showed multiple cases of patients significantly overpaying for the services they were offered. DiNapoli cited one instance where the state paid for $268,724 over three years for a MLTC plan, however, the patient only received $13,907 in care services.

The DOH and MLTC plan officials said the COVID-19 pandemic, inability to contact ineligible members, and DOH’s difficulty in identifying those not receiving adequate services were some of the reasons for the audit’s findings.

DiNapoli stressed the importance of the MLTC program in order to guarantee people the treatment and services they require, while managing costs.