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1homas . ulnapoll
ulvlslon of SLaLe CovernmenL AccounLablllLy
8eporL 2012-S-162 March 2014
,5"'6780* &/ 9&.+47:"6; <=&'*6 *&
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<N".K:5" )K22+'M
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1o deLermlne wheLher Lhe ueparLmenL of PealLh eecuvely oversaw locallues' eorLs Lo
coordlnaLe veLerans' healLh care beneLs provlded Lhrough Medlcald and Lhe u.S. ueparLmenL of
veLerans Aalrs (vA). 1he audlL covers Lhe perlod Aprll 1, 2008 Lhrough CcLober 31, 2013.
B+.(8'&K?>
Many of new ?ork's Medlcald reclplenLs are veLerans. uurlng Lhe ve-year perlod endlng March
31, 2013, new ?ork's Medlcald program relmbursed healLh care provlders $3.47 bllllon for medlcal
servlces provlded Lo more Lhan 70,000 veLerans. Many veLerans enrolled ln Medlcald are also
enuLled Lo healLh care beneLs Lhrough Lhe vA. Whlle lL ls a veLeran's cholce Lo use a vA healLh
care beneL or a Medlcald beneL, Lhe ueparLmenL of PealLh (ueparLmenL) has acknowledged
LhaL slgnlcanL cosL savlngs could be reallzed by asslsung veLerans and coordlnaung Lhelr healLh
care beneLs Lhrough Lhe vA. As parL of Lhe SLaLe's Medlcald ellglblllLy process, veLerans musL
be ldenued and referred Lo Lhe SLaLe ulvlslon of veLerans' Aalrs (SLaLe uvA) or local veLerans'
servlce agencles (local vSA) so Lhey can le for federal beneLs. Such referrals are crlucal for
enhanclng Lhe coordlnauon of veLerans' Medlcald and vA beneLs, as well as for helplng ensure
veLerans access all federal beneLs Lhey are enuLled Lo.
O"M P7?>7?86
- 1he ueparLmenL dld noL eecuvely oversee locallues' eorLs Lo coordlnaLe veLerans' Medlcald
and vA healLh beneLs. A revlew of case records aL counues wlLh hlgh Medlcald expenses for
veLerans showed LhaL referrals Lo Lhe SLaLe uvA/local vSA were noL made ln 81 of 91 (or 89
percenL) of Lhe cases LesLed. lurLher, local deparLmenLs of soclal servlces dld noL use avallable
resources Lo ldenufy veLerans and coordlnaLe Lhelr healLh care beneLs beLween Medlcald and
Lhe vA.
- 1he Medlcald savlngs Lo SLaLe and local Laxpayers could be several mllllons of dollars annually,
lf Lhe locallues dld a beuer [ob coordlnaung veLerans' Medlcald and vA healLh beneLs.
- 1he ueparLmenL has noL used Lhe federal ubllc AsslsLance 8eporung lnformauon SysLem
(A8lS) Lo ldenufy veLerans' spouses and dependenLs ellglble for vA healLh care beneLs.
- ln accordance wlLh Lhe Aordable Care AcL, Lhe ueparLmenL lmplemenLed Lhe new ?ork PealLh
8eneL Lxchange. Powever, Lhe ueparLmenL has noL developed a meLhod Lo lnform veLerans
applylng for Medlcald Lhrough Lhe new Lxchange of Lhelr vA beneLs.
O"M Q".&22"?>+:&?6
- Lnforce Medlcald pollcles regardlng Lhe coordlnauon of veLerans' healLh care beneLs beLween
Medlcald and Lhe vA, ensure all referrals are made ln order Lo maxlmlze veLerans' healLh care
beneLs.
- lmprove Lhe uullLy of perunenL Lools and resources Lo ldenufy veLerans and veLerans' spouses
and dependenLs who may be ellglble for vA healLh care beneLs.
,*0"' Q"4+*"> HK>7*RQ"3&'* &/ S?*"'"6*
ueparLmenL of PealLh: lnapproprlaLe aymenLs for Medlcald 8eclplenLs 8esldlng and Lnrolled ln
CLher SLaLes (8eporL 2008-S-4)
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March 19, 2014
nlrav 8. Shah, M.u., M..P.
Commlssloner
ueparLmenL of PealLh
Cornlng 1ower
Lmplre SLaLe laza
Albany, n? 12237
uear ur. Shah:
1he Cmce of Lhe SLaLe CompLroller ls commlued Lo helplng SLaLe agencles, publlc auLhorlues
and local governmenL agencles manage governmenL resources emclenLly and eecuvely and, by
so dolng, provldlng accounLablllLy for Lax dollars spenL Lo supporL governmenL operauons. 1he
CompLroller oversees Lhe scal aalrs of SLaLe agencles, publlc auLhorlues and local governmenL
agencles, as well as Lhelr compllance wlLh relevanL sLaLuLes and Lhelr observance of good
buslness pracuces. 1hls scal overslghL ls accompllshed, ln parL, Lhrough our audlLs, whlch ldenufy
opporLunlues for lmprovlng operauons. AudlLs can also ldenufy sLraLegles for reduclng cosLs and
sLrengLhenlng conLrols LhaL are lnLended Lo safeguard asseLs.
lollowlng ls a reporL of our audlL of Lhe Medlcald program enuLled !"#$%&'() +, -+./0&1#%2 34+$)%
)+ 5++$6&7/)# 8#)#$/7%2 9#/0)( 5/$# :#7#;)% <76#$ =#6&./&6 /76 )(# <>?> @#A/$)B#7) +, 8#)#$/7%
C4/&$%> 1hls audlL was performed pursuanL Lo Lhe SLaLe CompLroller's auLhorlLy under Arucle v,
Secuon 1 of Lhe SLaLe ConsuLuuon and Arucle ll, Secuon 8 of Lhe SLaLe llnance Law.
1hls audlL's resulLs and recommendauons are resources for you Lo use ln eecuvely managlng
your operauons and ln meeung Lhe expecLauons of Laxpayers. lf you have any quesuons abouL
Lhls reporL, please feel free Lo conLacL us.
8especuully submlued,
!D.# +, )(# ?)/)# 5+BA)$+00#$
@&"&%&+7 +, ?)/)# E+"#$7B#7) C..+F7)/G&0&)H
!"#!$%$#&!
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)*+*" J&5"'?2"?* H..&K?*+L747*M 1&?*+.* S?/&'2+:&?T
HK>7* E+?+8"'T Andrea lnman
I0&?"T (318) 474-3271
<2+74T SLaLeCovernmenLAccounLablllLy[osc.sLaLe.ny.us
H>>'"66T
Cmce of Lhe SLaLe CompLroller
ulvlslon of SLaLe CovernmenL AccounLablllLy
110 SLaLe SLreeL, 11Lh lloor
Albany, n? 12236
1hls reporL ls also avallable on our webslLe aL: www.osc.sLaLe.ny.us
U+L4" &/ 1&?*"?*6
8ackground 4
AudlL llndlngs and 8ecommendauons 6
Local ulsLrlcL veLeran 8eferrals 6
8ecommendauons 8
Cognos 8eporLs 9
8ecommendauons 9
veLerans' uependenLs' LllglblllLy 9
8ecommendauons 10
new ?ork PealLh 8eneL Lxchange 10
8ecommendauon 11
AudlL Scope and MeLhodology 11
AuLhorlLy 12
8eporung 8equlremenLs 12
ConLrlbuLors Lo 1hls 8eporL 13
Agency CommenLs 14
SLaLe CompLroller's CommenLs 18
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Medlcald ls a federal, SLaLe and local governmenL program LhaL provldes a wlde range of medlcal
servlces Lo Lhose who are economlcally dlsadvanLaged and/or have speclal healLh care needs.
1he federal governmenL funds abouL 48.3 percenL of new ?ork's Medlcald clalm cosLs, Lhe SLaLe
funds abouL 34 percenL, and Lhe locallues (Lhe ClLy of new ?ork and counues) fund Lhe remalnlng
17.3 percenL. lor Lhe scal year ended March 31, 2013, new ?ork's Medlcald program had
approxlmaLely 6 mllllon enrollees and Medlcald clalm cosLs LoLaled approxlmaLely $31 bllllon.
Accordlng Lo Lhe u.S. ueparLmenL of veLerans Aalrs (vA), over 913,000 veLerans llve ln new ?ork.
1he new ?ork SLaLe Medlcald program provldes healLh care servlces Lo many veLerans. uurlng Lhe
ve-year perlod endlng March 31, 2013, new ?ork's Medlcald program relmbursed healLh care
provlders $3.47 bllllon for medlcal servlces provlded Lo more Lhan 70,000 veLerans. 1hls lncluded
$2.16 bllllon Lo nurslng homes carlng for 20,269 veLerans, abouL $310 mllllon pald Lo managed
care organlzauons, $410 mllllon for home healLh servlces, and Lhe remalnder (approxlmaLely
$390 mllllon) pald for varlous hosplLal, ouLpauenL, pharmacy and oLher medlcal servlces.
veLerans also recelve healLh care beneLs Lhrough Lhe vA. 1he vA provldes healLh care aL llule or
no charge Lo veLerans. Medlcal servlces are provlded by lnpauenL and ouLpauenL faclllues run by
Lhe vA's veLerans PealLh AdmlnlsLrauon. Servlces lnclude, buL are noL llmlLed Lo, prlmary care,
counsellng, physlcal Lherapy, home healLh care, hosplLallzauon, surgery, rehablllLauon and nurslng
home care. uurlng 2012, abouL 231,000 veLerans recelved medlcal care cosung approxlmaLely
$2.3 bllllon Lhrough Lhe vA ln new ?ork.
ln mosL cases, vA beneLs are noL auLomauc, and veLerans musL apply for Lhem. Accordlng Lo
Lhe vA, ln 2010, approxlmaLely 14 mllllon veLerans (of abouL 22 mllllon veLerans nauonwlde who
qualled for veLerans' beneLs) dld noL recelve care from vA faclllues - many because Lhey dld noL
know Lhey could. Several sLaLes have sLarLed helplng veLerans (and veLerans' spouses and chlldren)
obLaln healLh care beneLs Lhrough Lhe vA. lurLher, sLaLes such as Callfornla, ConnecucuL, kansas,
MonLana, 1exas and WashlngLon have ldenued Lhe poLenual for slgnlcanL Medlcald savlngs by
lmplemenung programs LhaL help coordlnaLe veLerans' vA beneLs. lor example, WashlngLon
reporLed savlng more Lhan $30 mllllon ln long-Lerm care and oLher Medlcald expendlLures durlng
Lhe slx-year perlod endlng March 2013 by coordlnaung veLerans' beneLs. Also, a reporL by Lhe
Callfornla Leglslauve AnalysL's Cmce esumaLed Lhe poLenual for $230 mllllon ln Medlcald savlngs.
1he federal governmenL provldes sLaLes wlLh lnformauon LhaL ldenues publlc asslsLance
reclplenLs who are also veLerans. 1he u.S. ueparLmenL of PealLh and Puman Servlces admlnlsLers
Lhe ubllc AsslsLance 8eporung lnformauon SysLem (A8lS). A8lS ls a compuLer daLa maLchlng
and lnformauon exchange sysLem used by sLaLes Lo lmprove Lhe admlnlsLrauon of publlc and
medlcal asslsLance programs.
A8lS conLalns lnformauon on veLerans who recelve or have recelved dlsablllLy compensauon
or a penslon Lhough Lhe vA. SLaLes use Lhe A8lS veLerans Aalrs MaLch Lo ldenufy Medlcald
reclplenLs who are also veLerans who may quallfy for vA healLh care beneLs. 1he A8lS veLerans
!"#!$%$#&!
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maLch also provldes lnformauon regardlng veLerans' dependenLs. under cerLaln condluons,
spouses and chlldren of veLerans may be ellglble for medlcal beneLs under a vA program known
as Lhe Clvlllan PealLh and Medlcal rogram, or CPAMvA.
Cn a quarLerly basls, Lhe new ?ork SLaLe Cmce of 1emporary and ulsablllLy AsslsLance (C1uA)
recelves A8lS veLerans maLch les and updaLes Lhe SLaLe's Welfare ManagemenL SysLem (WMS)
wlLh veLerans' lnformauon. As a resulL, Medlcald reclplenL ellglblllLy les are updaLed wlLh veLeran
ldenucauon lnformauon. C1uA also developed reporLs conLalnlng perunenL veLeran lnformauon
Lo ald ln Lhe admlnlsLrauon of Lhe SLaLe's varlous publlc asslsLance programs. 1he SLaLe's 38 local
deparLmenLs of soclal servlces (37 counues and new ?ork ClLy) access Lhese reporLs Lhrough Lhe
Cognos" sysLem. Cognos, an l8M soware producL, enables users Lo exLracL daLa, analyze lL and
creaLe reporLs. C1uA has creaLed several pre-dened reporLs avallable Lhrough Cognos Lo enable
users wlLhouL Lechnlcal knowledge Lo access and analyze publlc asslsLance lnformauon easlly,
lncludlng veLerans' lnformauon.
!"#!$%$#&!
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HK>7* P7?>7?86 +?> Q".&22"?>+:&?6
1he ueparLmenL has noL adequaLely overseen locallues' eorLs Lo ensure LhaL veLerans' Medlcald
and vA healLh care beneLs are coordlnaLed eecuvely. ConsequenLly, Lhere ls conslderable rlsk
LhaL SLaLe and local Laxpayers have pald slgnlcanLly more for veLerans' Medlcald servlces Lhan
was necessary. Speclcally, Lhe ueparLmenL has noL enforced SLaLe laws or Medlcald pollcles LhaL
requlre local deparLmenLs of soclal servlces (local dlsLrlcLs) Lo ldenufy and refer veLerans applylng
for Medlcald Lo Lhe SLaLe ulvlslon of veLerans' Aalrs and local veLerans' servlce agencles Lo
obLaln asslsLance regardlng Lhelr federal beneLs. 8eferrals were noL made ln 89 percenL of Lhe
cases we LesLed aL Lhe local dlsLrlcLs.
We also deLermlned LhaL local dlsLrlcLs can use cerLaln reporLs Lo ldenufy veLerans and coordlnaLe
Lhelr healLh care beneLs beLween Medlcald and Lhe vA. Powever, Lhe ueparLmenL has falled
Lo make Lhese reporLs compleLe and lnsLrucL local dlsLrlcLs on Lhelr proper use. We furLher
deLermlned Lhe ueparLmenL has noL developed a meLhod Lo lnform veLerans applylng for
Medlcald Lhrough Lhe new ?ork PealLh 8eneL Lxchange of Lhelr vA beneLs. Also, under cerLaln
clrcumsLances, veLerans' spouses and dependenLs may be ellglble for vA healLh care beneLs.
Powever, Lhe ueparLmenL has falled Lo make use of federal lnformauon LhaL ldenues spouses
and dependenLs.
9&.+4 G76*'7.* @"*"'+? Q"/"''+46
Lecuve !une 16, 1992, Lhe new ?ork SLaLe Lxecuuve Law (Law) requlres local deparLmenLs of
soclal servlces (commonly referred Lo as local dlsLrlcLs) Lo deLermlne lf lndlvlduals applylng for
publlc beneLs are veLerans or have served ln Lhe mlllLary. 1he Law furLher requlres local dlsLrlcLs
Lo advlse veLerans LhaL Lhe SLaLe ulvlslon of veLerans' Aalrs (SLaLe uvA) and local veLerans'
servlce agencles (local vSA) provlde asslsLance Lo veLerans regardlng beneLs under federal and
SLaLe law.
Cn AugusL 18, 1993, an admlnlsLrauve dlrecuve was lssued Lo all local dlsLrlcLs clarlfylng Lhe Law's
requlremenLs, Lhe relaLed Medlcald pollcles, and Lhe duues of local dlsLrlcLs. Accordlng Lo Lhe
dlrecuve:
- Medlcald ellglblllLy workers musL advlse veLerans of poLenual federal healLh care beneLs
avallable Lhrough Lhe vA,
- as a condluon of Medlcald ellglblllLy, local dlsLrlcLs musL requlre lndlvlduals who lndlcaLe
Lhey served ln Lhe mlllLary Lo le for beneLs aL Lhe approprlaLe SLaLe uvA or local vSA,
and
- local dlsLrlcLs' case records musL lndlcaLe LhaL Lhe proper referrals were made and such
referrals musL be kepL on le as parL of Lhe Medlcald reclplenL's case record.
When Medlcald appllcanLs Lell local dlsLrlcLs Lhey are veLerans or lndlcaLe on Lhelr appllcauon for
Medlcald Lhey are veLerans, Lhe local dlsLrlcLs are requlred Lo advlse Lhem of Lhe poLenual for vA
beneLs and refer Lhem Lo Lhe SLaLe uvA/local vSA. lL ls crlucal for local dlsLrlcLs Lo make such
referrals slnce many veLerans may noL be aware of Lhe beneLs avallable Lo Lhem Lhrough Lhe
!"#!$%$#&!
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vA. ln 2010, Lhe vA conducLed a nauonal survey and esumaLed LhaL approxlmaLely 42 percenL of
veLerans are unaware of Lhe healLh care beneLs Lhey are enuLled Lo. lurLhermore, ueparLmenL
and C1uA lnformauon lndlcaLes LhaL veLerans oen do noL recelve all of Lhe federal vA beneLs
Lhey are enuLled Lo for a number of reasons - lncludlng lack of awareness, undersLandlng and
access Lo help.
ln accordance wlLh Lhe freedom of cholce" provlslon ln secuon 360-6.3 of Lhe ueparLmenL's
regulauons, veLerans ellglble for Medlcald cannoL be requlred Lo use Lhelr vA healLh care beneLs
over Medlcald. 1herefore, lL ls Lhe veLerans' cholce Lo use Lhelr vA healLh care beneLs, Medlcald
beneLs, or boLh. Powever, Lhe ueparLmenL has acknowledged LhaL slgnlcanL cosL savlngs could
be reallzed by asslsung veLerans and coordlnaung Lhelr healLh care beneLs Lhrough Lhe vA.
ln 2002, wlLh C1uA's asslsLance, Lhe ueparLmenL deLermlned LhaL 13,390 veLerans recelved
Medlcald servlces LoLallng over $191 mllllon ln 2001. AL LhaL ume Lhe ueparLmenL senL a leuer Lo
all local dlsLrlcL commlssloners Lo lnform Lhem LhaL much of Lhese expendlLures could have been
avolded lf veLerans accessed care Lhrough Lhe vA. 1he leuer Lold local dlsLrlcL commlssloners
Lhey should conslder esLabllshlng local procedures for educaung veLerans abouL Lhelr ellglblllLy
for healLh care beneLs Lhrough Lhe vA. 1he leuer also lnsLrucLed commlssloners Lo develop
proLocols for asslsung veLerans ln obLalnlng servlces Lhrough Lhe vA. Slnce Lhen, Lhe ueparLmenL
has done llule Lo ensure local dlsLrlcLs comply wlLh SLaLe laws and Lhe ueparLmenL's Medlcald
pollcles regardlng Lhe coordlnauon of veLerans' healLh care beneLs.
lor Lhe perlod !anuary 2013 Lhrough CcLober 2013, Medlcald pald more Lhan $103 mllllon for
servlces provlded Lo veLerans.
1
A revlew of Lhose expendlLures showed mosL of Lhe servlces are
also covered by Lhe vA. lor example, Medlcald pald $19,862 for lnpauenL servlces provlded Lo
a veLeran Lo LreaL hearL fallure. ln anoLher case, Medlcald pald $10,123 for an appendecLomy.
AnoLher veLeran recelved $1,618 ln counsellng servlces from !anuary Lhrough CcLober 2013
for chemlcal dependency. lurLhermore, for one veLeran enrolled ln a Medlcald managed care
plan, Medlcald pald $21,696 for lnpauenL psychlaLrlc servlces, whlch are carved ouL of Medlcald
managed care beneL packages and, Lherefore, were noL pald by Lhe managed care plan. Pad
Lhese varlous servlces been provlded by Lhe vA, Medlcald would have pald noLhlng for Lhem. lL
ls dlmculL Lo accuraLely esumaLe Lhe amounL Lhe SLaLe's Medlcald program could save lf veLerans
obLalned healLh care Lhrough Lhe vA. Powever, based on Lhe resulLs of our audlL, Lhe savlngs Lo
SLaLe and local Laxpayers could be slgnlcanL - llkely several mllllons of dollars annually sLaLewlde.
We LesLed Lhe coordlnauon of veLerans' healLh care beneLs aL slx local dlsLrlcLs. We selecLed 91
Medlcald reclplenLs who recelved a slgnlcanL amounL of Medlcald servlces durlng our ve-year
audlL perlod - abouL $12.1 mllllon. AL Lhe local dlsLrlcLs, we examlned Medlcald appllcauons and
oLher documenLs malnLalned ln Lhe veLerans' case records. Cur LesLs showed LhaL Lhe proper
referrals Lo Lhe SLaLe uvA/local vSA were made for only 10 of Lhe 91 lndlvlduals examlned. ln
oLher words, ln 81 of 91 (or 89 percenL) of Lhe cases we examlned, local dlsLrlcLs dld noL follow Lhe
ueparLmenL's requlremenLs for coordlnaung veLerans' beneLs beLween Lhe vA and Medlcald.
1able 1 summarlzes Lhe resulLs of our LesLs by counLy soclal servlces dlsLrlcL.
1
neL of nurslng home cosLs and paymenLs Lo managed care plans
!"#!$%$#&!
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Moreover, ln 64 cases, Lhe appllcanLs elLher Lold Lhe local dlsLrlcL worker or recorded on Lhelr
Medlcald appllcauons LhaL Lhey were ln facL veLerans. Powever, we found no noLauons ln Lhe
case record lndlcaung LhaL a referral was made on Lhelr behalf Lo Lhe SLaLe uvA/local vSA or LhaL
Lhe appllcanL led for healLh care beneLs aL Lhe approprlaLe SLaLe/local vA omce.
1he locallues oen dld noL make Lhe requlred referrals, alLhough Lhey had cerLaln procedures ln
place for asslsung veLerans. lor example, ChauLauqua and Cnondaga omclals sLaLed Lhey work
wlLh Lhe local vSA Lo asslsL veLerans ln obLalnlng beneLs. Cnondaga has a daLabase LhaL Lracks
veLerans' progress ln obLalnlng vA beneLs, however, we found slx of Lhe 11 lndlvlduals we LesLed
were noL on Lhe daLabase. Also, whlle ChauLauqua, Cnondaga and Cnelda use a referral form Lo
communlcaLe wlLh Lhe local vSA, our LesLs found Lhe forms were noL always used and referrals
were noL always made.
As a resulL of Lhe audlL, local dlsLrlcL omclals sLaLed Lhey would relnforce Lhelr pollcles and ensure
all case workers are aware of Lhe varlous procedures Lo coordlnaLe veLerans' healLh care beneLs.
Also, durlng Lhe audlL, some of Lhe local dlsLrlcLs we vlslLed sLarLed maklng lmprovemenLs Lo
Lhelr referral process and began Laklng sLeps Lo lmplemenL Lhe ueparLmenL's requlremenLs. lor
example, Albany local dlsLrlcL omclals now paruclpaLe ln a veLerans' consoruum LhaL meeLs Lo
dlscuss besL pracuces, such as ways Lo dlscover a veLeran's sLaLus durlng Lhe appllcauon process.
1hey also plan Lo creaLe a new posluon and ll lL wlLh a veLeran Lo work wlLh oLher veLerans
seeklng beneLs. Lrle local dlsLrlcL omclals updaLed Lhelr procedures for referrlng veLerans Lo
Lhe vSA. Slmllarly, Monroe local dlsLrlcL omclals updaLed Lhelr procedures for referrlng veLerans
Lo Lhe local vSA. And, ln con[uncuon wlLh Lhe vSA, Lhey now hold group lnformauonal sesslons
wlLh veLerans applylng for Medlcald. 1hese sesslons educaLe veLerans on avallable vA healLh care
beneLs.
Q".&22"?>+:&?6
1. 8elnforce pollcles and procedures regardlng local dlsLrlcLs' responslblllues, lncludlng ldenufylng
veLerans, advlslng veLerans of federal healLh care beneLs, referrlng veLerans and keeplng
records of referrals Lo Lhe SLaLe uvA/local vSA, and ensurlng veLerans le for federal beneLs.
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2. ldenufy local dlsLrlcL besL pracuces and share among all counues.
3. Acuvely monlLor Lhe performance of local dlsLrlcLs Lo ensure Lhey comply wlLh Lhe Law and
Lhe ueparLmenL's pollcles and procedures regardlng Lhe coordlnauon of veLerans' healLh care
beneLs.
1&8?&6 Q"3&'*6
ln accordance wlLh Lhe Law, local dlsLrlcLs are requlred Lo deLermlne lf lndlvlduals applylng for
beneLs served ln Lhe mlllLary. veLeran sLaLus lnformauon on WMS comes from Lwo sources: (1)
Medlcald appllcauons of persons who ldenued Lhemselves as veLerans, and (2) quarLerly A8lS
veLeran maLches. 1he lnformauon ls made avallable Lo local dlsLrlcLs Lhrough Cognos" reporLs
LhaL ldenufy Medlcald reclplenLs who are poLenually ellglble for federal healLh care beneLs
Lhrough Lhe vA because of Lhelr veLeran sLaLus. uslng lnformauon avallable Lhrough Lhe Cognos
reporLs, we ldenued 49,963 veLerans who recelved approxlmaLely $1.3 bllllon ln non-nurslng
home Medlcald servlces for Lhe ve-year perlod endlng March 31, 2013.
ln addluon Lo Lhe slx local dlsLrlcLs we vlslLed, we also revlewed Lhe coordlnauon of veLerans'
beneLs aL four addluonal local dlsLrlcLs. We deLermlned none of Lhe 10 local dlsLrlcLs use Cognos
Lo ldenufy veLerans Lo help coordlnaLe veLerans' beneLs beLween Medlcald and Lhe vA. 1he 10
local dlsLrlcLs represenLed approxlmaLely $946 mllllon of Lhe $1.3 bllllon ln Medlcald paymenLs.
Monroe local dlsLrlcL omclals lnformed us Lhey have noL used Cognos veLerans reporLs slnce
AugusL 2012 because of sysLem changes LhaL no longer allowed local dlsLrlcLs Lo deLermlne whlch
veLerans llsLed on Lhe reporLs were new Medlcald reclplenLs. CLher local dlsLrlcL personnel Lold
us Lhey were unfamlllar wlLh Cognos veLerans reporLs or dld noL undersLand Lhe reporLs and LhaL
lnsLrucuons from Lhe ueparLmenL on Lhe proper use of Cognos would help.
Q".&22"?>+:&?6
4. rovlde lnsLrucuons Lo local dlsLrlcLs on how Lo eecuvely use Cognos reporLs Lo ldenufy
veLerans.
3. ulrecL local dlsLrlcL omclals Lo use Lhe Cognos reporLs Lo ldenufy all veLerans ln Lhelr dlsLrlcLs
who are enrolled ln Medlcald, buL have noL yeL been referred Lo Lhe SLaLe uvA/local vSA.
Lnsure Lhose SLaLe uvA/local vSA referrals are made and LhaL veLerans le for vA healLh care
beneLs.
@"*"'+?6; G"3"?>"?*6; <4787L747*M
1he A8lS veLerans Aalrs MaLch le allows Lhe ueparLmenL and local dlsLrlcLs Lo perform a
number of acuvlues LhaL have Lhe poLenual Lo enhance veLerans' federal healLh care beneLs
whlle reduclng Medlcald cosLs. Powever, noL all lnformauon reLurned by Lhe A8lS veLerans maLch
le ls made avallable Lo Lhe local dlsLrlcLs. Speclcally, lnformauon on Lhe ellglblllLy of veLerans'
!"#!$%$#&!
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M #"
dependenLs for vA beneLs ls noL updaLed Lo WMS, or Cognos. ConsequenLly, Lhe ueparLmenL
and local dlsLrlcLs are noL uslng A8lS veLerans maLch daLa Lo lLs fullesL poLenual.
CPAMvA, Lhe Clvlllan PealLh and Medlcal rogram of Lhe vA, provldes relmbursemenL for mosL
medlcal expenses lncurred by Lhe spouse or wldow(er) and chlldren of veLerans who meeL cerLaln
requlremenLs. under CPAMvA, Lhe vA shares Lhe cosL of covered healLh care servlces wlLh
ellglble beneclarles. 8y law, CPAMvA ls always a secondary payer Lo oLher lnsurers, excepL Lo
Medlcald. As such, Medlcald remalns as Lhe payer of lasL resorL and, Lherefore, all eorLs should
be made Lo enroll ellglble Medlcald reclplenLs ln CPAMvA. Powever, under Lhe ueparLmenL's
pollcles, Lhls lnformauon ls noL capLured (updaLed Lo WMS) and provlded Lo local dlsLrlcLs.
Accordlng Lo A8lS veLerans maLch daLa we obLalned, 679 Medlcald reclplenLs appeared Lo be
veLerans' dependenLs and, Lherefore, poLenually ellglble for CPAMvA durlng Lhe ve-year
perlod Aprll 1, 2008 Lhrough March 31, 2013. We deLermlned Medlcald relmbursed healLh care
provlders nearly $30 mllllon for Lhese reclplenLs. 1he servlces lncluded home healLh care, lnpauenL,
pharmacy, cllnlc and physlclan servlces. Slnce CPAMvA covers Lhese servlces, Lhe poLenual for
Medlcald cosL savlngs ls slgnlcanL. 1he ueparLmenL should use Lhe A8lS veLerans maLch daLa Lo
lLs fullesL poLenual Lo maxlmlze veLerans' and Lhelr dependenLs' healLh care beneLs.
Q".&22"?>+:&?6
6. updaLe WMS wlLh A8lS veLerans maLch daLa on spouses and dependenLs of veLerans who
may be ellglble for CPAMvA.
7. lnclude veLerans' spouse and dependenL lnformauon on Cognos reporLs.
!"# %&'( A"+4*0 B"?"C* <N.0+?8"
ln accordance wlLh Lhe Aordable Care AcL, on CcLober 1, 2013, Lhe ueparLmenL lmplemenLed
Lhe new ?ork PealLh 8eneL Lxchange (Lxchange). 1he Lxchange ls an organlzed markeLplace
deslgned Lo help lndlvlduals shop for and obLaln healLh lnsurance coverage. 1he Lxchange also
allows people Lo check Lhelr ellglblllLy for, and enroll ln, Medlcald.
WlLh Lhe lmplemenLauon of Lhe Lxchange, Lhere wlll be a decrease ln Medlcald enrollmenLs
Lhrough Lhe local dlsLrlcLs. As a resulL, veLerans applylng for Medlcald Lhrough Lhe Lxchange wlll
noL have Lhe opporLunlLy Lo be referred Lo Lhelr SLaLe uvA/local vSA Lo be advlsed of Lhelr vA
beneLs. ln order Lo comply wlLh Lhe Law, Lhe ueparLmenL needs Lo develop a meLhod Lo lnform
veLerans applylng for Medlcald Lhrough Lhe Lxchange of Lhelr vA beneLs.
ln Lhe ueparLmenL's response Lo Lhe audlL, omclals sLaLed Lhe ueparLmenL wlll lmplemenL a
noucauon process on Lhe Lxchange Lo lnform veLerans of Lhelr poLenual ellglblllLy for vA beneLs.
Cmclals sLaLe Lhls process wlll begln aer A8lS daLa ls made avallable, ln 2013, Lhrough a federal
daLa hub for Lhe Lxchange. Powever, we deLermlned noL all veLerans are ldenued on Lhe A8lS
sysLem. A8lS conLalns lnformauon on veLerans who recelve or have recelved compensauon or
!"#!$%$#&!
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M ##
a penslon Lhough Lhe vA. ?eL Lhere are veLerans ln new ?ork who are noL enuLled Lo a moneLary
beneL, and Lherefore noL on A8lS, buL who are enuLled Lo healLh care beneLs Lhrough Lhe vA.
1he ueparLmenL needs Lo develop a mechanlsm Lo lnform Lhese veLerans of Lhelr vA beneLs.
lurLhermore, Lhe ueparLmenL should noL walL unul 2013.
Q".&22"?>+:&?
8. rompLly develop and lmplemenL a meLhod Lo lnform all veLerans, who apply for Medlcald
Lhrough Lhe Lxchange, of Lhe healLh care beneLs avallable Lhrough Lhe vA. lurLher, advlse
veLerans of Lhe SLaLe uvAs/local vSAs LhaL provlde asslsLance Lo veLerans regardlng healLh care
beneLs.
HK>7* ).&3" +?> E"*0&>&4&8M
1he ob[ecuve of our audlL was Lo deLermlne wheLher Lhe ueparLmenL of PealLh eecuvely
oversaw locallues' eorLs Lo coordlnaLe veLerans' healLh care beneLs provlded Lhrough Medlcald
and Lhe u.S. ueparLmenL of veLerans Aalrs. Cur audlL covered Lhe perlod Aprll 1, 2008 Lhrough
CcLober 31, 2013.
1o accompllsh our ob[ecuves, we lnLervlewed ueparLmenL omclals, revlewed appllcable secuons
of federal and SLaLe laws and regulauons, and examlned Lhe ueparLmenL's relevanL Medlcald
pollcles and procedures. We used Lhe A8lS veLerans maLch le from March 2013 Lo ldenufy
lndlvlduals poLenually ellglble for federal healLh care beneLs Lhrough Lhe vA. We analyzed
Medlcald clalms for lndlvlduals ldenued by Lhe vA (from A8lS les) as veLerans and Lhelr
dependenLs. We excluded Medlcald clalms for nurslng home care.
We lnLervlewed local dlsLrlcL personnel from 10 local dlsLrlcLs wlLh Lhe hlghesL Medlcald
expendlLures for veLerans and Lhelr dependenLs (Albany, ChauLauqua, Lrle, Monroe, nassau,
Cnelda, Cnondaga, Suolk, WesLchesLer and n?C-P8A). We vlslLed slx of Lhese local dlsLrlcLs
(Albany, ChauLauqua, Lrle, Monroe, Cnelda and Cnondaga) and examlned Medlcald ellglblllLy and
enrollmenL records and oLher documenLs malnLalned ln case les for 91 reclplenLs [udgmenLally
selecLed for Lhelr uullzauon of Medlcald servlces.
We conducLed our performance audlL ln accordance wlLh generally accepLed governmenL audlung
sLandards. 1hose sLandards requlre LhaL we plan and perform Lhe audlL Lo obLaln sumclenL,
approprlaLe evldence Lo provlde a reasonable basls for our ndlngs and concluslons based on our
audlL ob[ecuves. We belleve Lhe evldence obLalned provldes a reasonable basls for our ndlngs
and concluslons based on our audlL ob[ecuves.
ln addluon Lo belng Lhe SLaLe AudlLor, Lhe CompLroller performs cerLaln oLher consuLuuonally and
sLaLuLorlly mandaLed duues as Lhe chlef scal omcer of new ?ork SLaLe. 1hese lnclude operaung
Lhe SLaLe's accounung sysLem, preparlng Lhe SLaLe's nanclal sLaLemenLs, and approvlng SLaLe
conLracLs, refunds and oLher paymenLs. ln addluon, Lhe CompLroller appolnLs members (some
of whom have mlnorlLy voung rlghLs) Lo cerLaln boards, commlsslons and publlc auLhorlues.
!"#!$%$#&!
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M #!
1hese duues may be consldered managemenL funcuons for purposes of evaluaung organlzauonal
lndependence under generally accepLed governmenL audlung sLandards. ln our oplnlon, Lhese
funcuons do noL aecL our ablllLy Lo conducL lndependenL audlLs of program performance.
HK*0&'7*M
1he audlL was performed pursuanL Lo Lhe SLaLe CompLroller's auLhorlLy as seL forLh ln Arucle v,
Secuon 1 of Lhe SLaLe ConsuLuuon and Arucle ll, Secuon 8 of Lhe SLaLe llnance Law.
Q"3&':?8 Q"VK7'"2"?*6
We provlded a dra copy of Lhls reporL Lo ueparLmenL omclals for Lhelr revlew and formal
commenL. We consldered Lhe ueparLmenL's commenLs ln preparlng Lhls reporL and have lncluded
Lhem ln Lhelr enureLy aL Lhe end of lL. ln Lhelr response, ueparLmenL omclals concurred wlLh
several of our recommendauons and lndlcaLed LhaL cerLaln acuons wlll be Laken Lo address Lhem.
Cmclals also lndlcaLed, however, LhaL Lhey would noL lmplemenL several oLher recommendauons.
Cur re[olnders Lo cerLaln ueparLmenL commenLs are lncluded ln Lhe reporL's SLaLe CompLroller's
CommenLs.
WlLhln 90 days of Lhe nal release of Lhls reporL, as requlred by Secuon 170 of Lhe Lxecuuve
Law, Lhe Commlssloner of PealLh shall reporL Lo Lhe Covernor, Lhe SLaLe CompLroller, and Lhe
leaders of Lhe LeglslaLure and scal commluees, advlslng whaL sLeps were Laken Lo lmplemenL
Lhe recommendauons conLalned hereln, and where recommendauons were noL lmplemenLed,
Lhe reasons why.
!"#!$%$#&!
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M #'
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M
Andrew A. Sanllllppo, Lxecuuve uepuLy CompLroller
318-474-4393, asanllppo[osc.sLaLe.ny.us
1lna klm, uepuLy CompLroller
318-473-3396, Lklm[osc.sLaLe.ny.us
8rlan Mason, AsslsLanL CompLroller
318-473-0334, bmason[osc.sLaLe.ny.us
@767&?
A Leam of accounLablllLy experLs respecLed for provldlng lnformauon LhaL declslon makers value.
E7667&?
1o lmprove governmenL operauons by conducung lndependenL audlLs, revlews and evaluauons
of new ?ork SLaLe and new ?ork ClLy Laxpayer nanced programs.
1&?*'7LK*&'6 *& U076 Q"3&'*
H?>'"+ S?2+?, AudlL Manager
W+''"? P7*X8"'+4>, AudlL Supervlsor
H2+?>+ )*'+7*, Lxamlner-ln-Charge
<274M I'&K4N, SLa Lxamlner
Q"L"..+ UK.XM?6(7, SLa Lxamlner
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H8"?.M 1&22"?*6
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* See SLaLe CompLroller's CommenLs on page 18.
*
CommenL
1
*
CommenL
2
*
CommenL
3
!"#!$%$#&!
G75767&? &/ )*+*" J&5"'?2"?* H..&K?*+L747*M #&
!"#!$%$#&!
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*
CommenL
4
*
CommenL
3
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)*+*" 1&23*'&44"';6 1&22"?*6
1. As noLed ln our reporL, Medlcald spenL abouL $1 bllllon on varlous home healLh,
hosplLal, ouLpauenL, pharmacy and oLher medlcal servlces for veLerans durlng our audlL
perlod. 1hese paymenLs were made under fee-for-servlce arrangemenLs. Moreover, we
acknowledge LhaL Medlcald ls Lransluonlng reclplenLs Lo managed care. neverLheless, from
!anuary 2013 Lhrough CcLober 2013, abouL 17,800 veLerans recelved Medlcald servlces
LoLallng more Lhan $103 mllllon on a fee-for-servlce basls. lf even a small percenLage of
Lhe servlces ln quesuon were rendered Lhrough Lhe u.S. ueparLmenL of veLerans Aalrs
(vA), Lhe savlngs Lo Medlcald could have been maLerlal.
2. 1he ueparLmenL's commenL ls mlsleadlng. When veLerans enrolled ln Medlcald managed
care plans recelve covered servlces Lhough Lhe vA, Lhe managed care plans lncur no
expense. As a resulL, Medlcald managed care organlzauons have less [usucauon Lo
lncrease Lhe premlums of such reclplenLs, and Lhe SLaLe may be beuer posluoned Lo
negouaLe favorable raLes wlLh Lhose organlzauons, Lhereby conLalnlng Medlcald cosLs. ln
addluon, cerLaln medlcal servlces are noL covered by managed care plans, and Lherefore,
Medlcald musL pay for Lhese carve-ouL" servlces on a fee-for-servlce basls. lf a veLeran
recelves a carved-ouL servlce from Lhe vA (as opposed Lo Medlcald), Medlcald saves cosLs.
lurLher, 1 Lo 2 percenL of annual Medlcald spendlng amounLs Lo abouL $300 mllllon Lo $1
bllllon.
3. We are pleased LhaL Lhe ueparLmenL concurs LhaL all avenues Lo save Medlcald dollars
should be pursued." ConsequenLly, Lo help conLaln Medlcald cosLs, we encourage Lhe
ueparLmenL Lo lmplemenL each of our reporL recommendauons.
4. As noLed ln our reporL, uslng Cognos reporLs, we ldenued 49,963 veLerans who recelved
abouL $1.3 bllllon ln non-nurslng home Medlcald beneLs durlng our audlL perlod. ln
addluon, based on A8lS daLa, we deLermlned LhaL veLerans' dependenLs recelved abouL
$30 mllllon ln Medlcald beneLs LhaL mlghL have been covered by CPAMvA. Clven Lhe
magnlLude of Lhe Medlcald paymenLs ln quesuon, we malnLaln LhaL Lhe ueparLmenL
should Lake Lhe sLeps Lo ensure Lhe opumal use of Cognos and A8lS daLa Lo help mlnlmlze
Medlcald cosLs.
3. 1he facL remalns LhaL Lhe SLaLe requlres locallues Lo advlse veLerans LhaL Lhe SLaLe ulvlslon
of veLerans' Aalrs and local veLerans' servlce agencles provlde asslsLance regardlng healLh
care and oLher beneLs under federal and SLaLe law. lurLhermore, glven Lhe mandaLes of
Lhe Aordable Care AcL, lL ls reasonable Lo expecL many veLerans Lo seek healLh care
coverage Lhrough Lhe Lxchange (as opposed Lo Lhe locallues, whlch oen dld noL comply
wlLh SLaLe requlremenLs Lo advlse veLerans of Lhe avallable servlce resources anyhow).
ConsequenLly, we malnLaln LhaL Lhe ueparLmenL should develop a mechanlsm Lo lnform
veLerans, who seek healLh care coverage Lhrough Lhe Lxchange, of perunenL resources
(lncludlng Lhe SLaLe ulvlslon of veLerans' Aalrs) for asslsLance.