Audit 397021

US Department of Health and Human Services Passed-through the NC Dept. of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) CFDA #: 93.778 Finding: 2025-2 MATERIAL WEAKNESS / NON-MATERIAL NONCOMPLIANCE Required verifications and documentation for Eligibility Criteria: Per the North Carolina Medicaid Assistance Program Compliance Supplement, the DSS manuals (Aged, Blind and Disabled manual and the Family and Children Medicaid manual), and Administrative Letters from the Division of Health Benefits case files for individuals or families receiving assistance are required to retain documentation to evidence appropriate eligibility determination, including verifications of and support for:  Age  Citizenship/Identity  State residency  Household composition and relationship  Living arrangement  Social Security Number  Pregnancy (if applicable)  Disability, Blindness (if applicable)  Medicare  Cooperation with Child Support  Liquid Assets  Vehicles and Other Personal Property  Real Property  Deductibles  Income (Self-employment, Other earned income, Unearned income)  Accurate computation of countable income and resources.  Reviews/Applications must be completed timely. The DSS manuals and Administrative letters also provide income maintenance amounts and resource limits for the respective Medicaid program and budget unit size. The computed countable income and resources must be under these limits for the person / family to be eligible for the Medicaid program. Condition: We noted 26 instances of case records not containing the proper verifications, documentation or computations as required by policy for the claim that we tested. Three cases were not properly documented in evidence for liquid assets based on the verifications received. Three claims did not have proper verification and documentation for real property. Seven cases had a review that was not completed timely. Six cases did not have proper verification and / or documentation of income. Three cases did not properly document household composition, relationships, and tax filing status. Two cases did not properly document residency for type of verification used. Two cases did not properly record liquid assets based on the verifications received. One case did not properly document receipt of Medicare. Two cases did not properly record cases on the Covid Batch Report. Questioned Costs: There were five known errors in our testing for claims being paid on an ineligible recipient. Those five claims totaled $1,548. Context: Out of 492,890 Medicaid claims paid during the year, we tested the Medicaid certification of eligibility (initial application or recertification of eligibility) that related to the period that included the date of service for the claim being tested for 101 claims. The conditions noted above were noted in 24 of the 101 claims tested. Effect: Case files not containing all required documentation results in a risk that services could be provided to individuals not eligible and that individuals could be denied benefits for which they are eligible. Upon notification of the missing documentation or the errors in calculations in the case files, the County was able to obtain documentation and provide corrected calculations to substantiate that the recipients tested were eligible to receive benefits in all but 5 cases. Identification of a repeat finding: Missing documentation/information has been a finding in previous audits, 2024-2, 2023-2, 2022-2, 2021-1, 2020-2, 2019-1, 2017-1, 2017-2, 2016-2, and 2016-3. Cause: Missing information could result in improper determination of eligibility. The eligibility determined by the caseworker in twenty of the claims failed to ensure that all required items were retained, that all calculations were accurate, and that all necessary information was entered into NC FAST. In six claims, the review process was not completed in a timely manner. Recommendations: We recommend that the County train and monitor employees on the eligibility determination process, specifically those areas noted to have errors above. Files should be reviewed internally to ensure proper documentation is in place for eligibility. NC FAST should be reviewed to determine that information gathered during the review is properly input into the system and that system driven calculations are utilizing the available information. We also recommend that the County review and amend current policies and procedures in place to ensure that all eligibility determination documentation is completed and retained by the County. Views of responsible officials and planned corrective actions: The county acknowledges the technical and internal control errors noted and has ongoing measures in place to ensure that both initial determination and ongoing redetermination in timeliness and accuracy of eligibility determination is in the Medicaid program. The agency has measures in place with the Quality Assurance unit, who is solely dedicated to second party reviews to identify any errors and determine needed training and/or supervision for staff. The agency recognizes the critical importance of ensuring accuracy and timeliness in the Medicaid program and strives to make efforts to ensure that all measures are in place for training, second party reviews, and quality control to include Quality Assurance team, Medicaid Supervisors, and Medicaid Lead Workers.