Audit 337085

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-002 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: There were 5 errors discovered during our procedures that inaccurate information was entered when determining eligibility. Section III. Federal Award Findings and Questioned Costs Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. This is a repeat finding from the immediate previous audit, 2023-001. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County agrees with the finding. See Corrective Action Plan in the following section. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. This is a repeat finding from the immediate previous audit, 2023-002. There were 2 errors discovered during our procedures where resources were incorrectly calculated or were not properly documented in the case file. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. Section III. Federal Award Findings and Questioned Costs (continued) For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-004 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. The County agrees with the finding. See Corrective Action Plan in the following section. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2023-003. Section III. Federal Award Findings and Questioned Costs (continued) As a result of the lack of a proper eligibility determination, federal funds were distributed to ineligible recipients. Due to the nature of these types of eligibility determinations and the lack of a proper review by the department, the auditor is unable to determine the known or likely questioned costs. There were 2 applicants/beneficiaries not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. Of these 2 errors, one was determined to be an eligibility error with potential questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit.

Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-005 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and redeterminations. There were 2 errors discovered during our procedures where required information needed for eligibility determinations were not requested or not requested timely at applications or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County agrees with the finding. See Corrective Action Plan in the following section. Section III. Federal Award Findings and Questioned Costs (continued) This is a repeat finding from the immediate previous audit, 2023-004. Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received.

Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-006 Untimely IV-D referrals SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Recommendation: Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determining eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. There was 1 error discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. The County agrees with the finding. See Corrective Action Plan in the following section. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-002 Inaccurate Information Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: There were 5 errors discovered during our procedures that inaccurate information was entered when determining eligibility. Section III. Federal Award Findings and Questioned Costs Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. There was no known affect to eligibility and there were no known questioned costs. In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. In accordance with 2 CFR 200, management should have an adequate system of internal controls procedures in place to ensure an applicant is properly determined or redetermined for benefits. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. This is a repeat finding from the immediate previous audit, 2023-001. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-003 Inaccurate Resources Entry SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: Recommendation: Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County agrees with the finding. See Corrective Action Plan in the following section. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources of income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. This is a repeat finding from the immediate previous audit, 2023-002. There were 2 errors discovered during our procedures where resources were incorrectly calculated or were not properly documented in the case file. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. In accordance with Medicaid Manual MA-2230, Medicaid for Aged, Blind and Disabled case records should contain documentation that verifications were done in preparation of the application and these items will agree to reports in the NC FAST system. In this process, the countable resources should be calculated correctly and agree back to the amounts in the NC FAST system. Any items discovered in the verification process should be considered countable or noncountable resources and explained within the documentation. Section III. Federal Award Findings and Questioned Costs (continued) For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and a participant could have been approved for benefits for which they were not eligible.

US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-004 Untimely Review of SSI Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. The County agrees with the finding. See Corrective Action Plan in the following section. Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible. This is a repeat finding from the immediate previous audit, 2023-003. Section III. Federal Award Findings and Questioned Costs (continued) As a result of the lack of a proper eligibility determination, federal funds were distributed to ineligible recipients. Due to the nature of these types of eligibility determinations and the lack of a proper review by the department, the auditor is unable to determine the known or likely questioned costs. There were 2 applicants/beneficiaries not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. Of these 2 errors, one was determined to be an eligibility error with potential questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit.

Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-005 Inadequate Request for Information SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: In accordance with 42 CFR 435, documentation must be obtained as needed to determine if a recipient meets specific standards, and documentation must be maintained to support eligibility determinations. Electronic matches are required at applications and redeterminations. There were 2 errors discovered during our procedures where required information needed for eligibility determinations were not requested or not requested timely at applications or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. The County agrees with the finding. See Corrective Action Plan in the following section. Section III. Federal Award Findings and Questioned Costs (continued) This is a repeat finding from the immediate previous audit, 2023-004. Any State communications related to applicants’ benefits received by any DSS department should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received.

Recommendation: Views of responsible officials and planned corrective actions: US Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-006 Untimely IV-D referrals SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Cause: Recommendation: Files should be reviewed internally to ensure proper information is in place and necessary procedures are taken when determining eligibility. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. In accordance with the Medicaid Manual MA-3365, all Medicaid cases should be evaluated and referred to the Child Support Enforcement Agency (IV-D). The Child Support Enforcement Agency (IV-D) can assist the family in obtaining financial and/or medical support or medical support payments from the child’s non-custodial parent. Cooperation requirement with Social Services and Child Support Agencies must be met or good cause for not cooperating must be established when determining Medicaid eligibility. There was 1 error discovered during our procedures that inadequate information was requested at applications and/or redeterminations. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit. For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to NC FAST and applicants could have been approved for benefits for which they were not eligible. The County agrees with the finding. See Corrective Action Plan in the following section. Files should be reviewed internally to ensure proper documentation is in place for eligibility. Workers should be retrained on what files should contain and the importance of complete and accurate record keeping. We recommend that all files include online verifications, documented resources and income and those amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly indicate what actions were performed and the results of those actions. Human error in reading the Automated Collection and Tracking System (ACTS) report and/or ineffective case review process.