Audit 409520

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: 2025-5 MATERIAL WEAKNESS 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 40 instances of case records not containing the proper verifications or proper computations as required by policy. The files for five claims did not contain appropriate verification of real property ownership with the Register of Deeds Office and the Tax Office. Files for 2 claims did not properly verify or document vehicles per policy. Vehicles were not rebutted per policy or not keyed into evidence at all. Four of the claims had files that did not properly verify or document bank accounts and life insurance policies, correctly document ownership of liquid resources, and enter information in to evidence correctly or timely for liquid resources. There was 1 case where disability information was not properly entered into evidence. 1 claim did not properly verify and document the household members of the applicant. There 12 claims where the corresponding files show that policy was not followed and verified correctly including exparte reviews not being completed timely, social security number enumeration, citizenship, evidence was deleted instead of end dated, online data hits run for all household members, and reserves reduction being applied appropriately. There were files related to 15 claims that income was not counted correctly or not updated in evidence involving earned, unearned and self-employed income. Questioned Costs: There were 5 claims paid for a recipient that was not eligible or eligibility had not been determined for the specific date of service. Those known costs totaled $2,122. Context: Out of $57,669,982 during the year on 162,742 Medicaid claims, 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 that totaled $50,128. The conditions noted above were noted in 35 of the 101 claims tested. Effect: Case files not containing all required documentation result in a risk that the County could provide services to individuals not eligible to receive such services or that such individuals could be denied access to eligible benefits. 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 most cases. Identification of a repeat finding: This is a repeat finding from previous audits, 2024-3, 2023-3, 2022-4, 2021-5, 2020-1, 2019-1, 2017-1, 2017-2, 2016-1, 2016-2, 2016-3, 2016-4, 2016-5, and 2016- 6. Cause: The County did not obtain or retain required documentation in case files at the time that eligibility was determined. The review performed by the caseworker was ineffective in determining that all required items were retained, that all calculations were accurate, and that all necessary information was entered into NCFast. Recommendation: 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. Work aids for areas such as resources may be helpful for Caseworkers as they document the eligibility process. NCFast 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. Views of responsible officials and planned corrective actions: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations.