Review of State Children's Health Insurance Program Eligibility in New York State

EXECUTIVE SUMMARY:

The New York State Department of Health (the State agency) (1) made some State Children's Health Insurance Program (SCHIP) payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements and (2) did not always adequately document eligibility determinations.  As a result, for the 6-month audit period, we estimated that the State agency made SCHIP payments totaling between $17,682,343 and $32,892,050 (Federal share) on behalf of ineligible beneficiaries.  In addition, we estimated that case file documentation did not adequately support eligibility determinations for SCHIP payments totaling between $9,529,453 and $20,176,073 (Federal share). 

We recommended that the State agency use the results of this review to help ensure compliance with Federal and State eligibility requirements by (1) reemphasizing to beneficiaries the need to provide accurate and timely information and (2) requiring employees of managed care organizations to verify eligibility information and maintain appropriate documentation in all case files.  We also recommended that the State agency work with the Centers for Medicare & Medicaid Services to resolve the estimated improper SCHIP payments of at least $17,682,343 identified in the review. The State agency's comments did not directly address the recommendations.