An audit by New York State Comptroller Thomas P. DiNapoli has identified significant shortcomings in the state’s process for confirming Medicaid recipients’ residency, raising concerns about nearly $1.2 billion in managed care premiums paid for individuals who may not live in New York.
The review found that the state Department of Health (DOH) did not adequately verify whether Medicaid members were residents of New York and was slow to recover payments made on behalf of those potentially living elsewhere. The audit covered activity from July 2017 through October 2024.
“Medicaid is a vital program and the single biggest expense in the state budget. We cannot afford any wasteful spending,” DiNapoli said. “If a person is enrolled in more than one state at the same time, both states may end up paying premiums to his or her managed care plans. Responsibility for preventing enrollment in more than one state lies at both the federal and state levels, and stronger coordination is needed to reduce improper payments, protect the program’s integrity, and ensure New York is only paying Medicaid costs for its residents.”
Enrollment into Medicaid can occur either through the New York State of Health (NYSOH) exchange or local social service departments. Most enrollees are placed into managed care plans that receive monthly premium payments from DOH to cover health services.
According to auditors, if a member moves out of New York but remains enrolled, their plan should disenroll them and return any premiums paid during their absence from the state.
The audit found that DOH delayed submitting NYSOH member data to the federal Public Assistance Reporting Information System (PARIS), which helps identify individuals enrolled in public assistance programs across multiple states. This data sharing did not begin until May 2017—almost three years after NYSOH launched—and reviews of match results started two years later, in October 2019. As a result, $1.5 billion in premium payments were made between 2017 and 2019 for unreviewed NYSOH members.
Further examination revealed another $1.2 billion was spent on managed care premiums for people who might have lived outside New York during this period.
Even when eligibility was closed based on PARIS matches indicating out-of-state residency, DOH and the Office of the Medicaid Inspector General (OMIG) often failed to fully pursue recovery of premium payments made while these individuals were no longer residents. OMIG officials noted they could have lost up to $11.4 million due to limitations imposed by regulatory look-back rules.
DiNapoli urged OMIG to move quickly on reviewing audit findings so that improper payments can be recovered where possible.
All U.S. states as well as Washington D.C., and Puerto Rico participate in PARIS matching; however, participation varies each quarter, which can limit its effectiveness for identifying non-resident enrollees.
In response to recommendations from DiNapoli’s office, DOH officials generally agreed with suggested changes and stated they are already taking steps toward improvement. The department said it would consider using additional data sources such as NCOA records and work with federal agencies to enhance residency verification within PARIS matching procedures.
