Pandemic Electronic Benefit Transfer Food Benefits 10.542 COVID-19 - Pandemic Electronic Benefit Transfer Food Benefits (P-EBT) See Schedule of Findings and Questioned Costs for chart/table within the text DSS controls over the P-EBT program were insufficient to prevent improper benefit issuances on behalf of school children. Our audit sample of payments for 60 school children noted the DSS issued benefits on behalf of one ineligible child and made overpayments on behalf of another child. During the year ended June 30, 2022, the DSS issued P-EBT program benefits totaling approximately $75 million on behalf of approximately 78,000 school children and approximately $144 million on behalf of approximately 163,000 children in child care. The objective of the P-EBT program is to provide nutrition assistance on EBT cards for school children who would have received free or reduced price school meals under the National School Lunch Program and School Breakfast Program had their schools not been closed or operating with reduced hours due to the COVID-19 public health emergency. The P-EBT program similarly provides benefits for Supplemental Nutrition Assistance Program-enrolled children in child care. The Families First Coronavirus Response Act, Pub. L. 116-127, Section 1101, requires P-EBT program benefits be issued in accordance with the state's approved plan. For benefits for school children, the DSS and the Department of Elementary and Secondary Education jointly developed a plan for the administration of the P-EBT program for the 2020-2021 school year and a plan amendment for the summer 2021 period. The plan and 2 plan amendments were approved by the USDA in June 2021, August 2021, and September 2021, respectively; and the DSS began issuing P-EBT program benefits in July 2021. Under the state's plan, the DSS would receive from all school districts in the state (1) surveys indicating the extent of school closures in the district due to COVID-19 for each month during the school year, and (2) listings of students eligible for free or reduced price meals during the school year. Pursuant to the plan, the DSS required parents to submit applications for benefits, and established procedures to verify the applications to the listings obtained from the school districts, determine benefit amounts for each eligible child, and issue P-EBT program benefits to households with eligible children. Eligible participants were entitled to receive $129.58 per month of virtual learning and/or $77.75 per month of hybrid (mixed) learning. For the summer period, each eligible child was entitled to the standard summer benefit of $375 despite the school's operating status during the school year. To test compliance with the plan's provisions for school children, we reviewed a randomly-selected sample of P-EBT program payments for 60 school children, totaling $31,009. The DSS made improper payments for 2 of 60 participants reviewed (3 percent). The DSS issued benefits totaling $596 for one ineligible child who was not included in the listing of children eligible for free or reduced priced meals, and issued benefits for another child totaling $414 in excess of amounts the child was entitled to receive. DSS officials indicated processing errors were made without detection for both children. We question the unallowable benefits totaling $1,010 (100 percent federal share) issued on behalf of these children. Without adequate internal controls, the DSS cannot ensure that P-EBT program benefits are issued in accordance with the approved state plan. Rule 2 CFR Section 200.303(a) requires the nonfederal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the FSD strengthen internal controls to ensure P-EBT program benefit issuances are in accordance with the state plan, and review and correct the overpayments for the children identified in this finding. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
DESE FFATA Reporting 84.425C COVID-19 - Governor's Emergency Education Relief (GEER) Fund 84.425R COVID-19 - Emergency Assistance for Non-Public Schools (EANS) See Schedule of Findings and Questioned Costs for chart/table within the text The DESE needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting for the Education Stabilization Fund. As similarly noted in our previous audit, during state fiscal year 2022, the DESE did not comply with FFATA reporting requirements for any of the subawards reviewed for the GEER Fund or the EANS program. In addition, the DESE has not made corrections and resubmitted state fiscal year 2021 FFATA reports for the GEER Fund grants. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DESE to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov. The GEER Fund grants were initially awarded to the Governor's office. The Office of Administration (OA), on behalf of the Governor's office, entered into an interagency agreement with the DESE and the Department of Higher Education and Workforce Development (DHEWD), designating the DESE as the fiscal agent for the GEER Fund for the State of Missouri. The DESE draws down and disburses the funds to the DESE subrecipients (Local Education Agencies [LEAs]) and to the DHEWD. The DHEWD disburses funds to the DHEWD subrecipients (Institutions of Higher Education [IHEs]). The GEER interagency agreement states the DESE shall manage all reporting requirements by collecting information and data including data from the DHEWD and the OA. For the EANS program, the DESE received the grant on behalf of the Governor's office, was designated the fiscal agent, and disbursed funds to the LEAs. During state fiscal year 2022, the DESE and the DHEWD disbursed approximately $21.6 million of first-tier subawards to 348 subrecipients of the GEER Fund and the DESE disbursed approximately $3.3 million in first-tier subawards to 82 subrecipients of the EANS program. First-tier subaward payments accounted for approximately 99 percent of the GEER Fund expenditures and 7 percent of the EANS program expenditures. Internal controls: DESE policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DESE personnel prepare an excel spreadsheet of the awards allocated to subrecipients, transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DESE personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during state fiscal year 2023. Without documented supervisory review over FFATA reporting, the DESE cannot demonstrate adherence to the established policies and procedures, and has less assurance the information included in the FFATA reporting for the Education Stabilization Fund is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DESE did not comply with FFATA reporting requirements for the GEER Fund and the EANS program. To test compliance with FFATA reporting requirements for the GEER Fund and the EANS program, we reviewed the FSRS reports submitted by DESE personnel during state fiscal year 2022. For the GEER Fund, the DESE did not report any of the 81 LEA subawards requiring FFATA reporting, totaling approximately $9.7 million, or the 22 IHE subawards, totaling approximately $12 million, in the FSRS. Instead, the DESE incorrectly reported as subawards, the allocations by the Governor's office to the DESE and the DHEWD. For the EANS program, the DESE did not report any of the 9 subawards requiring FFATA reporting, totaling approximately $3.7 million, in the FSRS. Instead, the DESE incorrectly reported as a subaward, the grant award received by the DESE on behalf of the Governor's office. All of these errors occurred prior to auditors identifying and communicating similar errors during the state fiscal year 2021 audit. Additionally, the DESE made some corrections to FFATA reports; however, as of April 2023, the DESE had not resubmitted fully corrected state fiscal year 2021 FFATA reports for the GEER Fund grants. DESE personnel indicated the FFATA reporting errors occurred due to a misunderstanding of FFATA reporting requirements as well as the unusual nature of the GEER Fund and EANS program allocations. DESE personnel also indicated they have been working with the ED since April 2022 in an effort to correct the erroneous FFATA reports; however, due to technical difficulties with the FSRS, they have been unable to timely and fully correct the reports. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS accurately and timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DESE strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported in the FSRS for the Education Stabilization Fund. In addition, the DESE should complete FFATA reporting for the Education Stabilization Fund programs in accordance with the applicable requirements and continue to work toward resubmitting corrected reports for state fiscal years 2021 and 2022. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
DESE FFATA Reporting 84.425C COVID-19 - Governor's Emergency Education Relief (GEER) Fund 84.425R COVID-19 - Emergency Assistance for Non-Public Schools (EANS) See Schedule of Findings and Questioned Costs for chart/table within the text The DESE needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting for the Education Stabilization Fund. As similarly noted in our previous audit, during state fiscal year 2022, the DESE did not comply with FFATA reporting requirements for any of the subawards reviewed for the GEER Fund or the EANS program. In addition, the DESE has not made corrections and resubmitted state fiscal year 2021 FFATA reports for the GEER Fund grants. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DESE to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov. The GEER Fund grants were initially awarded to the Governor's office. The Office of Administration (OA), on behalf of the Governor's office, entered into an interagency agreement with the DESE and the Department of Higher Education and Workforce Development (DHEWD), designating the DESE as the fiscal agent for the GEER Fund for the State of Missouri. The DESE draws down and disburses the funds to the DESE subrecipients (Local Education Agencies [LEAs]) and to the DHEWD. The DHEWD disburses funds to the DHEWD subrecipients (Institutions of Higher Education [IHEs]). The GEER interagency agreement states the DESE shall manage all reporting requirements by collecting information and data including data from the DHEWD and the OA. For the EANS program, the DESE received the grant on behalf of the Governor's office, was designated the fiscal agent, and disbursed funds to the LEAs. During state fiscal year 2022, the DESE and the DHEWD disbursed approximately $21.6 million of first-tier subawards to 348 subrecipients of the GEER Fund and the DESE disbursed approximately $3.3 million in first-tier subawards to 82 subrecipients of the EANS program. First-tier subaward payments accounted for approximately 99 percent of the GEER Fund expenditures and 7 percent of the EANS program expenditures. Internal controls: DESE policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DESE personnel prepare an excel spreadsheet of the awards allocated to subrecipients, transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DESE personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during state fiscal year 2023. Without documented supervisory review over FFATA reporting, the DESE cannot demonstrate adherence to the established policies and procedures, and has less assurance the information included in the FFATA reporting for the Education Stabilization Fund is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DESE did not comply with FFATA reporting requirements for the GEER Fund and the EANS program. To test compliance with FFATA reporting requirements for the GEER Fund and the EANS program, we reviewed the FSRS reports submitted by DESE personnel during state fiscal year 2022. For the GEER Fund, the DESE did not report any of the 81 LEA subawards requiring FFATA reporting, totaling approximately $9.7 million, or the 22 IHE subawards, totaling approximately $12 million, in the FSRS. Instead, the DESE incorrectly reported as subawards, the allocations by the Governor's office to the DESE and the DHEWD. For the EANS program, the DESE did not report any of the 9 subawards requiring FFATA reporting, totaling approximately $3.7 million, in the FSRS. Instead, the DESE incorrectly reported as a subaward, the grant award received by the DESE on behalf of the Governor's office. All of these errors occurred prior to auditors identifying and communicating similar errors during the state fiscal year 2021 audit. Additionally, the DESE made some corrections to FFATA reports; however, as of April 2023, the DESE had not resubmitted fully corrected state fiscal year 2021 FFATA reports for the GEER Fund grants. DESE personnel indicated the FFATA reporting errors occurred due to a misunderstanding of FFATA reporting requirements as well as the unusual nature of the GEER Fund and EANS program allocations. DESE personnel also indicated they have been working with the ED since April 2022 in an effort to correct the erroneous FFATA reports; however, due to technical difficulties with the FSRS, they have been unable to timely and fully correct the reports. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS accurately and timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DESE strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported in the FSRS for the Education Stabilization Fund. In addition, the DESE should complete FFATA reporting for the Education Stabilization Fund programs in accordance with the applicable requirements and continue to work toward resubmitting corrected reports for state fiscal years 2021 and 2022. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
ELC Program Subrecipient Monitoring 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the DCPH did not adequately monitor ELC program subrecipient contracts during the year ended June 30, 2022. In our review of a sample of 21 contracts requiring financial monitoring reviews, we noted 7 had not been completed as of June 30, 2022. Rule 2 CFR Section 200.332(d) requires pass-through entities to monitor the activities of subrecipients as necessary to ensure the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Pass-through entities are required to follow up and ensure the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and other means. The DHSS, as a pass-through entity, disbursed approximately $61.7 million among 219 ELC program subrecipient contracts during the year ended June 30, 2022. In response to the prior finding, the DCPH developed a monitoring plan for ELC program subrecipients, hired additional staff, and began performing monitoring reviews during the year ended June 30, 2022. The monitoring plan requires annual risk assessments, quarterly progress reviews, and completion of a financial monitoring review once during the contract period. If deficiencies are found during the monitoring review, the monitoring plan requires the subrecipient to submit a written corrective action plan to the DCPH, and the DCPH to follow up on the corrective action plan. Due to the delayed implementation of the monitoring plan, the DCPH did not perform all required financial monitoring reviews of ELC program subrecipients during state fiscal year 2022. Our review of a randomly-selected sample of contracts for 21 of the 219 ELC program subrecipient contracts requiring financial monitoring reviews noted risk assessments had been performed for all contracts; however, financial monitoring reviews had not been completed as of June 30, 2022, for 7 contracts (33 percent). We noted financial monitoring reviews were subsequently performed in state fiscal year 2023 for all 7 contracts included in the sample. DCPH officials indicated the delayed implementation of subrecipient monitoring procedures was due to the rapid distribution of COVID-19 funding to subrecipients and insufficient staffing, but they intend to have all reviews completed by March 2024. When subrecipient monitoring procedures are not performed timely and in accordance with monitoring plan requirements, there is increased risk that noncompliance with program requirements will go undetected. Recommendation: The DHSS through the DCPH continue to implement and perform financial monitoring reviews in accordance with the ELC program monitoring plan. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
ELC Program Subrecipient Monitoring 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the DCPH did not adequately monitor ELC program subrecipient contracts during the year ended June 30, 2022. In our review of a sample of 21 contracts requiring financial monitoring reviews, we noted 7 had not been completed as of June 30, 2022. Rule 2 CFR Section 200.332(d) requires pass-through entities to monitor the activities of subrecipients as necessary to ensure the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Pass-through entities are required to follow up and ensure the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and other means. The DHSS, as a pass-through entity, disbursed approximately $61.7 million among 219 ELC program subrecipient contracts during the year ended June 30, 2022. In response to the prior finding, the DCPH developed a monitoring plan for ELC program subrecipients, hired additional staff, and began performing monitoring reviews during the year ended June 30, 2022. The monitoring plan requires annual risk assessments, quarterly progress reviews, and completion of a financial monitoring review once during the contract period. If deficiencies are found during the monitoring review, the monitoring plan requires the subrecipient to submit a written corrective action plan to the DCPH, and the DCPH to follow up on the corrective action plan. Due to the delayed implementation of the monitoring plan, the DCPH did not perform all required financial monitoring reviews of ELC program subrecipients during state fiscal year 2022. Our review of a randomly-selected sample of contracts for 21 of the 219 ELC program subrecipient contracts requiring financial monitoring reviews noted risk assessments had been performed for all contracts; however, financial monitoring reviews had not been completed as of June 30, 2022, for 7 contracts (33 percent). We noted financial monitoring reviews were subsequently performed in state fiscal year 2023 for all 7 contracts included in the sample. DCPH officials indicated the delayed implementation of subrecipient monitoring procedures was due to the rapid distribution of COVID-19 funding to subrecipients and insufficient staffing, but they intend to have all reviews completed by March 2024. When subrecipient monitoring procedures are not performed timely and in accordance with monitoring plan requirements, there is increased risk that noncompliance with program requirements will go undetected. Recommendation: The DHSS through the DCPH continue to implement and perform financial monitoring reviews in accordance with the ELC program monitoring plan. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
DSS FFATA Reporting 93.667 Social Services Block Grant (SSBG) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our previous audit, the DFAS needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting. During state fiscal year 2022, the DFAS did not comply with FFATA reporting requirements for any of the subawards reviewed for the SSBG program. During state fiscal year 2022, the DSS disbursed approximately $7 million in first-tier subawards to 20 subrecipients of the SSBG program. First-tier subaward payments accounted for approximately 14 percent of the program's expenditures. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DFAS to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov Internal controls: DFAS policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DFAS personnel prepare a monthly Excel spreadsheet of data from various sources including contracts and federal funding disclosure information sheets. DFAS personnel transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DFAS personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during the state fiscal year 2023. Without documented supervisory reviews over FFATA reporting, the DFAS cannot demonstrate adherence to the established policies and procedures, and there is less assurance the information included in the FFATA reporting is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DFAS did not comply with FFATA reporting requirements for the SSBG program. To test compliance with FFATA reporting requirements, we reviewed a sample of subawards for 2 of the 20 SSBG subrecipients, totaling $1,952,465, awarded in state fiscal year 2022. Neither of the subawards were uploaded to the FSRS timely. The DSS entered into grant agreements with the subrecipients during July 2020 for the 2-year period of July 1, 2020, through June 30, 2022. DFAS personnel indicated they were required to report these subawards no earlier than November 2020 and November 2021, when they received the corresponding grants. However, DFAS personnel did not upload the subawards to the FSRS until August 2021 and February 2022, 9 months and 3 months later, respectively. DFAS personnel indicated the FFATA reporting delays occurred because of staff turnover, federal government delays in uploading grant information into the FSRS, and FSRS limitations associated with changes in personnel who have system access. They indicated the DSS cannot prepare FFATA reports until the federal awarding agency first enters the federal award information into the FSRS; and since the DSS does not receive notification of this event, the DSS must continually check the system for updates. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DSS through the DFAS strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported to the FSRS. In addition, the DFAS should timely complete FFATA reporting in accordance with the applicable requirements. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS does not agree that documentation of supervisory reviews directly correlates to strong internal controls. The CAP further states the DSS adheres to formalized procedures for FFATA reporting, which includes managerial oversight and contends documented reviews may be preferred but are not required by regulation. However, without requiring documentation of supervisory reviews performed, the DSS cannot demonstrate adherence to the established policies and procedures. Additionally, the noncompliance identified in this audit and the previous audit is an indicator that DSS internal controls may not be operating as intended. Because effective internal controls include documentation demonstrating the controls are operating in accordance with the established internal control system, this finding is valid.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid Facility Survey Timeliness 93.777 COVID-19 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.777 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the SLCR did not perform facility survey procedures within required timeframes. In our test of compliance with facility survey requirements for the year ended June 30, 2022, we noted some Statement of Deficiencies and Plan of Corrections were sent 11 to 26 days after survey exit instead of within 10 days, and some facility revisits were completed between 61 and 82 days instead of within 60 days of the initial survey date. The DHSS is the state survey agency charged with inspecting providers of the Medical Assistance Program (Medicaid), including hospitals, nursing facilities, and other long-term care facilities. Under 42 CFR Section 431.108, as a basis for participation in Medicaid, providers are subject to survey and certification by the DHHS - Centers for Medicare and Medicaid Services (DHHS-CMS) or the DHSS to ensure providers and suppliers are in compliance with regulatory health and safety standards and conditions of participation. During the year ended June 30, 2022, the DHSS through the SLCR surveyed 527 providers, including 514 long-term care nursing facilities and 13 intermediate care facilities for individuals with intellectual disabilities. The DHHS-CMS provides the State Operations Manual (SOM) to state agencies as guidelines for the survey and certification of providers. SOM Chapter 2, Section 2728, requires the state agency to mail the provider a copy of Form CMS-2567 (Statement of Deficiencies and Plan of Correction) within 10 working days after the survey exit. In addition, SOM Chapter 7, Section 7317.2, requires onsite revisits for long-term care nursing facilities to occur any time between the last correction date on the plan of correction and the 60th day from the survey date to confirm the facility is in substantial compliance, and in certain cases, has the ability to remain in substantial compliance. To test compliance with survey and certification requirements, we randomly selected 35 long-term care nursing facilities surveys, and 5 intermediate care facilities for individuals with intellectual disabilities surveys, performed between July 1, 2021, and June 30, 2022. Of 22 surveys that required a Statement of Deficiencies and Plan of Correction, 8 statements (36 percent) were sent to facilities between 11 and 26 working days after the survey exit instead of within 10 working days as required. In addition, of the 19 long-term care nursing facilities that required a revisit, the revisits to 4 facilities (21 percent) were completed between 61 and 82 days after the initial survey date instead of within 60 days as required. DHSS officials indicated there were multiple contributing factors for these delays including DHSS staffing shortages, industry labor shortages, insufficient federal funding, and increased workloads due to increased volume and complexity of complaints received and the backlog of surveys due. DHSS officials further stated they are working to request additional staff and increased salaries, and to contract with outside survey companies to help with the increased workload and backlog. Conducting survey procedures within required timeframes helps to ensure providers are timely notified of deficiencies requiring correction so that timely follow up on those deficiencies can occur to provide assurance facilities are providing services to their clients that are in compliance with health and safety standards and conditions of participation. Recommendation: The DHSS through the SLCR ensure survey procedures are conducted within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid Facility Survey Timeliness 93.777 COVID-19 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.777 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the SLCR did not perform facility survey procedures within required timeframes. In our test of compliance with facility survey requirements for the year ended June 30, 2022, we noted some Statement of Deficiencies and Plan of Corrections were sent 11 to 26 days after survey exit instead of within 10 days, and some facility revisits were completed between 61 and 82 days instead of within 60 days of the initial survey date. The DHSS is the state survey agency charged with inspecting providers of the Medical Assistance Program (Medicaid), including hospitals, nursing facilities, and other long-term care facilities. Under 42 CFR Section 431.108, as a basis for participation in Medicaid, providers are subject to survey and certification by the DHHS - Centers for Medicare and Medicaid Services (DHHS-CMS) or the DHSS to ensure providers and suppliers are in compliance with regulatory health and safety standards and conditions of participation. During the year ended June 30, 2022, the DHSS through the SLCR surveyed 527 providers, including 514 long-term care nursing facilities and 13 intermediate care facilities for individuals with intellectual disabilities. The DHHS-CMS provides the State Operations Manual (SOM) to state agencies as guidelines for the survey and certification of providers. SOM Chapter 2, Section 2728, requires the state agency to mail the provider a copy of Form CMS-2567 (Statement of Deficiencies and Plan of Correction) within 10 working days after the survey exit. In addition, SOM Chapter 7, Section 7317.2, requires onsite revisits for long-term care nursing facilities to occur any time between the last correction date on the plan of correction and the 60th day from the survey date to confirm the facility is in substantial compliance, and in certain cases, has the ability to remain in substantial compliance. To test compliance with survey and certification requirements, we randomly selected 35 long-term care nursing facilities surveys, and 5 intermediate care facilities for individuals with intellectual disabilities surveys, performed between July 1, 2021, and June 30, 2022. Of 22 surveys that required a Statement of Deficiencies and Plan of Correction, 8 statements (36 percent) were sent to facilities between 11 and 26 working days after the survey exit instead of within 10 working days as required. In addition, of the 19 long-term care nursing facilities that required a revisit, the revisits to 4 facilities (21 percent) were completed between 61 and 82 days after the initial survey date instead of within 60 days as required. DHSS officials indicated there were multiple contributing factors for these delays including DHSS staffing shortages, industry labor shortages, insufficient federal funding, and increased workloads due to increased volume and complexity of complaints received and the backlog of surveys due. DHSS officials further stated they are working to request additional staff and increased salaries, and to contract with outside survey companies to help with the increased workload and backlog. Conducting survey procedures within required timeframes helps to ensure providers are timely notified of deficiencies requiring correction so that timely follow up on those deficiencies can occur to provide assurance facilities are providing services to their clients that are in compliance with health and safety standards and conditions of participation. Recommendation: The DHSS through the SLCR ensure survey procedures are conducted within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Pandemic Electronic Benefit Transfer Food Benefits 10.542 COVID-19 - Pandemic Electronic Benefit Transfer Food Benefits (P-EBT) See Schedule of Findings and Questioned Costs for chart/table within the text DSS controls over the P-EBT program were insufficient to prevent improper benefit issuances on behalf of school children. Our audit sample of payments for 60 school children noted the DSS issued benefits on behalf of one ineligible child and made overpayments on behalf of another child. During the year ended June 30, 2022, the DSS issued P-EBT program benefits totaling approximately $75 million on behalf of approximately 78,000 school children and approximately $144 million on behalf of approximately 163,000 children in child care. The objective of the P-EBT program is to provide nutrition assistance on EBT cards for school children who would have received free or reduced price school meals under the National School Lunch Program and School Breakfast Program had their schools not been closed or operating with reduced hours due to the COVID-19 public health emergency. The P-EBT program similarly provides benefits for Supplemental Nutrition Assistance Program-enrolled children in child care. The Families First Coronavirus Response Act, Pub. L. 116-127, Section 1101, requires P-EBT program benefits be issued in accordance with the state's approved plan. For benefits for school children, the DSS and the Department of Elementary and Secondary Education jointly developed a plan for the administration of the P-EBT program for the 2020-2021 school year and a plan amendment for the summer 2021 period. The plan and 2 plan amendments were approved by the USDA in June 2021, August 2021, and September 2021, respectively; and the DSS began issuing P-EBT program benefits in July 2021. Under the state's plan, the DSS would receive from all school districts in the state (1) surveys indicating the extent of school closures in the district due to COVID-19 for each month during the school year, and (2) listings of students eligible for free or reduced price meals during the school year. Pursuant to the plan, the DSS required parents to submit applications for benefits, and established procedures to verify the applications to the listings obtained from the school districts, determine benefit amounts for each eligible child, and issue P-EBT program benefits to households with eligible children. Eligible participants were entitled to receive $129.58 per month of virtual learning and/or $77.75 per month of hybrid (mixed) learning. For the summer period, each eligible child was entitled to the standard summer benefit of $375 despite the school's operating status during the school year. To test compliance with the plan's provisions for school children, we reviewed a randomly-selected sample of P-EBT program payments for 60 school children, totaling $31,009. The DSS made improper payments for 2 of 60 participants reviewed (3 percent). The DSS issued benefits totaling $596 for one ineligible child who was not included in the listing of children eligible for free or reduced priced meals, and issued benefits for another child totaling $414 in excess of amounts the child was entitled to receive. DSS officials indicated processing errors were made without detection for both children. We question the unallowable benefits totaling $1,010 (100 percent federal share) issued on behalf of these children. Without adequate internal controls, the DSS cannot ensure that P-EBT program benefits are issued in accordance with the approved state plan. Rule 2 CFR Section 200.303(a) requires the nonfederal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the FSD strengthen internal controls to ensure P-EBT program benefit issuances are in accordance with the state plan, and review and correct the overpayments for the children identified in this finding. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
DESE FFATA Reporting 84.425C COVID-19 - Governor's Emergency Education Relief (GEER) Fund 84.425R COVID-19 - Emergency Assistance for Non-Public Schools (EANS) See Schedule of Findings and Questioned Costs for chart/table within the text The DESE needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting for the Education Stabilization Fund. As similarly noted in our previous audit, during state fiscal year 2022, the DESE did not comply with FFATA reporting requirements for any of the subawards reviewed for the GEER Fund or the EANS program. In addition, the DESE has not made corrections and resubmitted state fiscal year 2021 FFATA reports for the GEER Fund grants. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DESE to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov. The GEER Fund grants were initially awarded to the Governor's office. The Office of Administration (OA), on behalf of the Governor's office, entered into an interagency agreement with the DESE and the Department of Higher Education and Workforce Development (DHEWD), designating the DESE as the fiscal agent for the GEER Fund for the State of Missouri. The DESE draws down and disburses the funds to the DESE subrecipients (Local Education Agencies [LEAs]) and to the DHEWD. The DHEWD disburses funds to the DHEWD subrecipients (Institutions of Higher Education [IHEs]). The GEER interagency agreement states the DESE shall manage all reporting requirements by collecting information and data including data from the DHEWD and the OA. For the EANS program, the DESE received the grant on behalf of the Governor's office, was designated the fiscal agent, and disbursed funds to the LEAs. During state fiscal year 2022, the DESE and the DHEWD disbursed approximately $21.6 million of first-tier subawards to 348 subrecipients of the GEER Fund and the DESE disbursed approximately $3.3 million in first-tier subawards to 82 subrecipients of the EANS program. First-tier subaward payments accounted for approximately 99 percent of the GEER Fund expenditures and 7 percent of the EANS program expenditures. Internal controls: DESE policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DESE personnel prepare an excel spreadsheet of the awards allocated to subrecipients, transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DESE personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during state fiscal year 2023. Without documented supervisory review over FFATA reporting, the DESE cannot demonstrate adherence to the established policies and procedures, and has less assurance the information included in the FFATA reporting for the Education Stabilization Fund is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DESE did not comply with FFATA reporting requirements for the GEER Fund and the EANS program. To test compliance with FFATA reporting requirements for the GEER Fund and the EANS program, we reviewed the FSRS reports submitted by DESE personnel during state fiscal year 2022. For the GEER Fund, the DESE did not report any of the 81 LEA subawards requiring FFATA reporting, totaling approximately $9.7 million, or the 22 IHE subawards, totaling approximately $12 million, in the FSRS. Instead, the DESE incorrectly reported as subawards, the allocations by the Governor's office to the DESE and the DHEWD. For the EANS program, the DESE did not report any of the 9 subawards requiring FFATA reporting, totaling approximately $3.7 million, in the FSRS. Instead, the DESE incorrectly reported as a subaward, the grant award received by the DESE on behalf of the Governor's office. All of these errors occurred prior to auditors identifying and communicating similar errors during the state fiscal year 2021 audit. Additionally, the DESE made some corrections to FFATA reports; however, as of April 2023, the DESE had not resubmitted fully corrected state fiscal year 2021 FFATA reports for the GEER Fund grants. DESE personnel indicated the FFATA reporting errors occurred due to a misunderstanding of FFATA reporting requirements as well as the unusual nature of the GEER Fund and EANS program allocations. DESE personnel also indicated they have been working with the ED since April 2022 in an effort to correct the erroneous FFATA reports; however, due to technical difficulties with the FSRS, they have been unable to timely and fully correct the reports. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS accurately and timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DESE strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported in the FSRS for the Education Stabilization Fund. In addition, the DESE should complete FFATA reporting for the Education Stabilization Fund programs in accordance with the applicable requirements and continue to work toward resubmitting corrected reports for state fiscal years 2021 and 2022. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
DESE FFATA Reporting 84.425C COVID-19 - Governor's Emergency Education Relief (GEER) Fund 84.425R COVID-19 - Emergency Assistance for Non-Public Schools (EANS) See Schedule of Findings and Questioned Costs for chart/table within the text The DESE needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting for the Education Stabilization Fund. As similarly noted in our previous audit, during state fiscal year 2022, the DESE did not comply with FFATA reporting requirements for any of the subawards reviewed for the GEER Fund or the EANS program. In addition, the DESE has not made corrections and resubmitted state fiscal year 2021 FFATA reports for the GEER Fund grants. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DESE to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov. The GEER Fund grants were initially awarded to the Governor's office. The Office of Administration (OA), on behalf of the Governor's office, entered into an interagency agreement with the DESE and the Department of Higher Education and Workforce Development (DHEWD), designating the DESE as the fiscal agent for the GEER Fund for the State of Missouri. The DESE draws down and disburses the funds to the DESE subrecipients (Local Education Agencies [LEAs]) and to the DHEWD. The DHEWD disburses funds to the DHEWD subrecipients (Institutions of Higher Education [IHEs]). The GEER interagency agreement states the DESE shall manage all reporting requirements by collecting information and data including data from the DHEWD and the OA. For the EANS program, the DESE received the grant on behalf of the Governor's office, was designated the fiscal agent, and disbursed funds to the LEAs. During state fiscal year 2022, the DESE and the DHEWD disbursed approximately $21.6 million of first-tier subawards to 348 subrecipients of the GEER Fund and the DESE disbursed approximately $3.3 million in first-tier subawards to 82 subrecipients of the EANS program. First-tier subaward payments accounted for approximately 99 percent of the GEER Fund expenditures and 7 percent of the EANS program expenditures. Internal controls: DESE policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DESE personnel prepare an excel spreadsheet of the awards allocated to subrecipients, transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DESE personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during state fiscal year 2023. Without documented supervisory review over FFATA reporting, the DESE cannot demonstrate adherence to the established policies and procedures, and has less assurance the information included in the FFATA reporting for the Education Stabilization Fund is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DESE did not comply with FFATA reporting requirements for the GEER Fund and the EANS program. To test compliance with FFATA reporting requirements for the GEER Fund and the EANS program, we reviewed the FSRS reports submitted by DESE personnel during state fiscal year 2022. For the GEER Fund, the DESE did not report any of the 81 LEA subawards requiring FFATA reporting, totaling approximately $9.7 million, or the 22 IHE subawards, totaling approximately $12 million, in the FSRS. Instead, the DESE incorrectly reported as subawards, the allocations by the Governor's office to the DESE and the DHEWD. For the EANS program, the DESE did not report any of the 9 subawards requiring FFATA reporting, totaling approximately $3.7 million, in the FSRS. Instead, the DESE incorrectly reported as a subaward, the grant award received by the DESE on behalf of the Governor's office. All of these errors occurred prior to auditors identifying and communicating similar errors during the state fiscal year 2021 audit. Additionally, the DESE made some corrections to FFATA reports; however, as of April 2023, the DESE had not resubmitted fully corrected state fiscal year 2021 FFATA reports for the GEER Fund grants. DESE personnel indicated the FFATA reporting errors occurred due to a misunderstanding of FFATA reporting requirements as well as the unusual nature of the GEER Fund and EANS program allocations. DESE personnel also indicated they have been working with the ED since April 2022 in an effort to correct the erroneous FFATA reports; however, due to technical difficulties with the FSRS, they have been unable to timely and fully correct the reports. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS accurately and timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DESE strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported in the FSRS for the Education Stabilization Fund. In addition, the DESE should complete FFATA reporting for the Education Stabilization Fund programs in accordance with the applicable requirements and continue to work toward resubmitting corrected reports for state fiscal years 2021 and 2022. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
ELC Program Subrecipient Monitoring 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the DCPH did not adequately monitor ELC program subrecipient contracts during the year ended June 30, 2022. In our review of a sample of 21 contracts requiring financial monitoring reviews, we noted 7 had not been completed as of June 30, 2022. Rule 2 CFR Section 200.332(d) requires pass-through entities to monitor the activities of subrecipients as necessary to ensure the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Pass-through entities are required to follow up and ensure the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and other means. The DHSS, as a pass-through entity, disbursed approximately $61.7 million among 219 ELC program subrecipient contracts during the year ended June 30, 2022. In response to the prior finding, the DCPH developed a monitoring plan for ELC program subrecipients, hired additional staff, and began performing monitoring reviews during the year ended June 30, 2022. The monitoring plan requires annual risk assessments, quarterly progress reviews, and completion of a financial monitoring review once during the contract period. If deficiencies are found during the monitoring review, the monitoring plan requires the subrecipient to submit a written corrective action plan to the DCPH, and the DCPH to follow up on the corrective action plan. Due to the delayed implementation of the monitoring plan, the DCPH did not perform all required financial monitoring reviews of ELC program subrecipients during state fiscal year 2022. Our review of a randomly-selected sample of contracts for 21 of the 219 ELC program subrecipient contracts requiring financial monitoring reviews noted risk assessments had been performed for all contracts; however, financial monitoring reviews had not been completed as of June 30, 2022, for 7 contracts (33 percent). We noted financial monitoring reviews were subsequently performed in state fiscal year 2023 for all 7 contracts included in the sample. DCPH officials indicated the delayed implementation of subrecipient monitoring procedures was due to the rapid distribution of COVID-19 funding to subrecipients and insufficient staffing, but they intend to have all reviews completed by March 2024. When subrecipient monitoring procedures are not performed timely and in accordance with monitoring plan requirements, there is increased risk that noncompliance with program requirements will go undetected. Recommendation: The DHSS through the DCPH continue to implement and perform financial monitoring reviews in accordance with the ELC program monitoring plan. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
ELC Program Subrecipient Monitoring 93.323 COVID-19 - Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) 93.323 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the DCPH did not adequately monitor ELC program subrecipient contracts during the year ended June 30, 2022. In our review of a sample of 21 contracts requiring financial monitoring reviews, we noted 7 had not been completed as of June 30, 2022. Rule 2 CFR Section 200.332(d) requires pass-through entities to monitor the activities of subrecipients as necessary to ensure the subaward is used for authorized purposes, complies with the terms and conditions of the subaward, and achieves performance goals. Pass-through entities are required to follow up and ensure the subrecipient takes timely and appropriate action on all deficiencies detected through audits, on-site reviews, and other means. The DHSS, as a pass-through entity, disbursed approximately $61.7 million among 219 ELC program subrecipient contracts during the year ended June 30, 2022. In response to the prior finding, the DCPH developed a monitoring plan for ELC program subrecipients, hired additional staff, and began performing monitoring reviews during the year ended June 30, 2022. The monitoring plan requires annual risk assessments, quarterly progress reviews, and completion of a financial monitoring review once during the contract period. If deficiencies are found during the monitoring review, the monitoring plan requires the subrecipient to submit a written corrective action plan to the DCPH, and the DCPH to follow up on the corrective action plan. Due to the delayed implementation of the monitoring plan, the DCPH did not perform all required financial monitoring reviews of ELC program subrecipients during state fiscal year 2022. Our review of a randomly-selected sample of contracts for 21 of the 219 ELC program subrecipient contracts requiring financial monitoring reviews noted risk assessments had been performed for all contracts; however, financial monitoring reviews had not been completed as of June 30, 2022, for 7 contracts (33 percent). We noted financial monitoring reviews were subsequently performed in state fiscal year 2023 for all 7 contracts included in the sample. DCPH officials indicated the delayed implementation of subrecipient monitoring procedures was due to the rapid distribution of COVID-19 funding to subrecipients and insufficient staffing, but they intend to have all reviews completed by March 2024. When subrecipient monitoring procedures are not performed timely and in accordance with monitoring plan requirements, there is increased risk that noncompliance with program requirements will go undetected. Recommendation: The DHSS through the DCPH continue to implement and perform financial monitoring reviews in accordance with the ELC program monitoring plan. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.
DSS FFATA Reporting 93.667 Social Services Block Grant (SSBG) See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our previous audit, the DFAS needs to strengthen internal controls related to Federal Funding Accountability and Transparency Act (FFATA) reporting. During state fiscal year 2022, the DFAS did not comply with FFATA reporting requirements for any of the subawards reviewed for the SSBG program. During state fiscal year 2022, the DSS disbursed approximately $7 million in first-tier subawards to 20 subrecipients of the SSBG program. First-tier subaward payments accounted for approximately 14 percent of the program's expenditures. The FFATA requires comprehensive reporting for certain federal awards to promote transparency and accountability over the use of the federal funds. Rule 2 CFR Part 170, Appendix A, requires the DFAS to report first-tier subawards of $30,000 or more to the FFATA Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was made. Information entered into the FSRS is publicly available at USASpending.gov Internal controls: DFAS policies and procedures over the FFATA reporting process require supervisory review of the information uploaded to the FSRS, but do not require the supervisors maintain documentation of reviews performed. DFAS personnel prepare a monthly Excel spreadsheet of data from various sources including contracts and federal funding disclosure information sheets. DFAS personnel transfer the spreadsheet data to the federal FSRS template, and upload the data to the FSRS. Various subaward data is uploaded, including the entity name, award amount, and the date issued. DFAS personnel could not provide documentation supporting the supervisory reviews performed, but indicated they intend to implement documented reviews during the state fiscal year 2023. Without documented supervisory reviews over FFATA reporting, the DFAS cannot demonstrate adherence to the established policies and procedures, and there is less assurance the information included in the FFATA reporting is complete and accurate. Rule 2 CFR Section 200.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." FFATA reporting: The DFAS did not comply with FFATA reporting requirements for the SSBG program. To test compliance with FFATA reporting requirements, we reviewed a sample of subawards for 2 of the 20 SSBG subrecipients, totaling $1,952,465, awarded in state fiscal year 2022. Neither of the subawards were uploaded to the FSRS timely. The DSS entered into grant agreements with the subrecipients during July 2020 for the 2-year period of July 1, 2020, through June 30, 2022. DFAS personnel indicated they were required to report these subawards no earlier than November 2020 and November 2021, when they received the corresponding grants. However, DFAS personnel did not upload the subawards to the FSRS until August 2021 and February 2022, 9 months and 3 months later, respectively. DFAS personnel indicated the FFATA reporting delays occurred because of staff turnover, federal government delays in uploading grant information into the FSRS, and FSRS limitations associated with changes in personnel who have system access. They indicated the DSS cannot prepare FFATA reports until the federal awarding agency first enters the federal award information into the FSRS; and since the DSS does not receive notification of this event, the DSS must continually check the system for updates. In addition to noncompliance with federal requirements, not reporting subawards to the FSRS timely increases the risk that those using the reports could rely on inaccurate information. Recommendation: The DSS through the DFAS strengthen internal controls related to FFATA reporting by having supervisors maintain documentation of reviews performed of the information reported to the FSRS. In addition, the DFAS should timely complete FFATA reporting in accordance with the applicable requirements. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS does not agree that documentation of supervisory reviews directly correlates to strong internal controls. The CAP further states the DSS adheres to formalized procedures for FFATA reporting, which includes managerial oversight and contends documented reviews may be preferred but are not required by regulation. However, without requiring documentation of supervisory reviews performed, the DSS cannot demonstrate adherence to the established policies and procedures. Additionally, the noncompliance identified in this audit and the previous audit is an indicator that DSS internal controls may not be operating as intended. Because effective internal controls include documentation demonstrating the controls are operating in accordance with the established internal control system, this finding is valid.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid Facility Survey Timeliness 93.777 COVID-19 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.777 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the SLCR did not perform facility survey procedures within required timeframes. In our test of compliance with facility survey requirements for the year ended June 30, 2022, we noted some Statement of Deficiencies and Plan of Corrections were sent 11 to 26 days after survey exit instead of within 10 days, and some facility revisits were completed between 61 and 82 days instead of within 60 days of the initial survey date. The DHSS is the state survey agency charged with inspecting providers of the Medical Assistance Program (Medicaid), including hospitals, nursing facilities, and other long-term care facilities. Under 42 CFR Section 431.108, as a basis for participation in Medicaid, providers are subject to survey and certification by the DHHS - Centers for Medicare and Medicaid Services (DHHS-CMS) or the DHSS to ensure providers and suppliers are in compliance with regulatory health and safety standards and conditions of participation. During the year ended June 30, 2022, the DHSS through the SLCR surveyed 527 providers, including 514 long-term care nursing facilities and 13 intermediate care facilities for individuals with intellectual disabilities. The DHHS-CMS provides the State Operations Manual (SOM) to state agencies as guidelines for the survey and certification of providers. SOM Chapter 2, Section 2728, requires the state agency to mail the provider a copy of Form CMS-2567 (Statement of Deficiencies and Plan of Correction) within 10 working days after the survey exit. In addition, SOM Chapter 7, Section 7317.2, requires onsite revisits for long-term care nursing facilities to occur any time between the last correction date on the plan of correction and the 60th day from the survey date to confirm the facility is in substantial compliance, and in certain cases, has the ability to remain in substantial compliance. To test compliance with survey and certification requirements, we randomly selected 35 long-term care nursing facilities surveys, and 5 intermediate care facilities for individuals with intellectual disabilities surveys, performed between July 1, 2021, and June 30, 2022. Of 22 surveys that required a Statement of Deficiencies and Plan of Correction, 8 statements (36 percent) were sent to facilities between 11 and 26 working days after the survey exit instead of within 10 working days as required. In addition, of the 19 long-term care nursing facilities that required a revisit, the revisits to 4 facilities (21 percent) were completed between 61 and 82 days after the initial survey date instead of within 60 days as required. DHSS officials indicated there were multiple contributing factors for these delays including DHSS staffing shortages, industry labor shortages, insufficient federal funding, and increased workloads due to increased volume and complexity of complaints received and the backlog of surveys due. DHSS officials further stated they are working to request additional staff and increased salaries, and to contract with outside survey companies to help with the increased workload and backlog. Conducting survey procedures within required timeframes helps to ensure providers are timely notified of deficiencies requiring correction so that timely follow up on those deficiencies can occur to provide assurance facilities are providing services to their clients that are in compliance with health and safety standards and conditions of participation. Recommendation: The DHSS through the SLCR ensure survey procedures are conducted within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid Facility Survey Timeliness 93.777 COVID-19 - State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare 93.777 State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our prior audit report, the SLCR did not perform facility survey procedures within required timeframes. In our test of compliance with facility survey requirements for the year ended June 30, 2022, we noted some Statement of Deficiencies and Plan of Corrections were sent 11 to 26 days after survey exit instead of within 10 days, and some facility revisits were completed between 61 and 82 days instead of within 60 days of the initial survey date. The DHSS is the state survey agency charged with inspecting providers of the Medical Assistance Program (Medicaid), including hospitals, nursing facilities, and other long-term care facilities. Under 42 CFR Section 431.108, as a basis for participation in Medicaid, providers are subject to survey and certification by the DHHS - Centers for Medicare and Medicaid Services (DHHS-CMS) or the DHSS to ensure providers and suppliers are in compliance with regulatory health and safety standards and conditions of participation. During the year ended June 30, 2022, the DHSS through the SLCR surveyed 527 providers, including 514 long-term care nursing facilities and 13 intermediate care facilities for individuals with intellectual disabilities. The DHHS-CMS provides the State Operations Manual (SOM) to state agencies as guidelines for the survey and certification of providers. SOM Chapter 2, Section 2728, requires the state agency to mail the provider a copy of Form CMS-2567 (Statement of Deficiencies and Plan of Correction) within 10 working days after the survey exit. In addition, SOM Chapter 7, Section 7317.2, requires onsite revisits for long-term care nursing facilities to occur any time between the last correction date on the plan of correction and the 60th day from the survey date to confirm the facility is in substantial compliance, and in certain cases, has the ability to remain in substantial compliance. To test compliance with survey and certification requirements, we randomly selected 35 long-term care nursing facilities surveys, and 5 intermediate care facilities for individuals with intellectual disabilities surveys, performed between July 1, 2021, and June 30, 2022. Of 22 surveys that required a Statement of Deficiencies and Plan of Correction, 8 statements (36 percent) were sent to facilities between 11 and 26 working days after the survey exit instead of within 10 working days as required. In addition, of the 19 long-term care nursing facilities that required a revisit, the revisits to 4 facilities (21 percent) were completed between 61 and 82 days after the initial survey date instead of within 60 days as required. DHSS officials indicated there were multiple contributing factors for these delays including DHSS staffing shortages, industry labor shortages, insufficient federal funding, and increased workloads due to increased volume and complexity of complaints received and the backlog of surveys due. DHSS officials further stated they are working to request additional staff and increased salaries, and to contract with outside survey companies to help with the increased workload and backlog. Conducting survey procedures within required timeframes helps to ensure providers are timely notified of deficiencies requiring correction so that timely follow up on those deficiencies can occur to provide assurance facilities are providing services to their clients that are in compliance with health and safety standards and conditions of participation. Recommendation: The DHSS through the SLCR ensure survey procedures are conducted within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid National Correct Coding Initiative 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As noted in our 2 previous audits, the MHD did not fully implement the Medicaid National Correct Coding Initiative (NCCI) edits in the Medicaid Management Information System (MMIS) as required. During the year ended June 30, 2022, the MHD made Medical Assistance Program (Medicaid) and Children's Health Insurance Program (CHIP) payments, subject to NCCI edits, totaling approximately $8.9 billion. The DSS contracts for the operation and maintenance of the MMIS. Medical providers submit fee-for-service claims for services provided to Medicaid and CHIP participants in the MMIS, and payments are made through the MMIS. To help ensure only allowable claims are paid, system edit checks flag and/or deny payment on suspicious or unusual claims. Section 6507 of the Affordable Care Act (Section 1903(r) of the Social Security Act ) requires the MHD to completely and correctly implement specific NCCI methodologies and edits into the MMIS. The purpose of the NCCI is to promote correct coding, prevent coding errors, prevent coding manipulation, and reduce improper payments. The DHHS - Centers for Medicare and Medicaid Services (CMS) published the Medicaid NCCI Policy Manual and the Medicaid NCCI Technical Guidance Manual to provide specific requirements and assist state Medicaid agencies to implement the NCCI methodologies. The two NCCI edit categories are Procedure-to-Procedure (PTP) edits that are designed to identify pairs of procedure codes that should not be reported together; and Medically Unlikely Edits (MUE) that limit the number of units of service allowed for certain services and items. The DHHS-CMS provides PTP and MUE edit files to the MHD quarterly. Each quarterly edit file contains all current edits and replaces the previously provided edit file. Section 7 of the Medicaid NCCI Technical Guidance Manual requires the MHD to implement the edit files into the MMIS on the first day of each quarter. If the applicable edit files are not implemented by the first day of the second month of the quarter, the MHD is required to reprocess any claims processed with outdated edits once the updates are implemented. During the year ended June 30, 2022, rather than quarterly implementation, the MHD through the MMIS contractor implemented the PTP edit files annually; and the MHD did not reprocess claims upon implementation of the edits. For example, the MMIS contractor implemented the PTP edit file for the quarter ended March 31, 2022, in January 2022; and the MHD did not implement the prior quarters' edit files or reprocess claims paid for the quarters ended June 30, 2021, September 30, 2021, and December 31, 2021, with the updated edits. In addition, the MHD had not implemented any of the MUE edit files received. MHD officials indicated they worked with the MMIS contractor to fully implement both the PTP and MUE edits effective July 1, 2022, for claims processed in the quarter ended September 30, 2022. However, these changes were effective after the period covered by the audit. In addition to noncompliance with Section 6507 of the Affordable Care Act, the failure to fully implement the NCCI edits and reprocess claims paid with incorrect edits increases the risk that coding errors or irregularities will go undetected, and improper payments will be made. To ensure compliance with the NCCI requirements, the MHD should establish internal controls over NCCI edits. Rule 45 CFR Section 75.303(a) requires the non-Federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD continue to strengthen controls over the NCCI requirements to ensure NCCI edits are fully implemented and reprocess claims paid when edits are not implemented timely, as required. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Medicaid and CHIP MAGI-Based Participant Eligibility 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text As similarly noted in our 3 previous audits, the DSS does not have sufficient controls to ensure compliance with the eligibility requirements of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP) for certain participants whose eligibility is based on their Modified Adjusted Gross Income (MAGI). The DSS did not correct manual system overrides for some MAGI-based participants, preventing their cases from being closed when necessary. Of the approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022, approximately 942,000 were MAGI-based participants. To ensure MAGI-based participants continue to be eligible for benefits, 42 CFR Section 435.916 requires a redetermination of eligibility once every 12 months, or when circumstances affecting a participant's eligibility change. The regulation requires termination of benefits when a participant no longer meets eligibility requirements. On March 19, 2020, the eligibility redetermination and most termination requirements were temporarily suspended in response to the COVID-19 Public Health Emergency (PHE). All validly enrolled participants on March 19, 2020, were to remain continuously enrolled except for participants who requested removal, moved out of state, or died. Subsequent to the audit period, the PHE and related requirement suspensions were lifted. Effective April 1, 2023, the DSS is required to initiate redeterminations within 12 months, and complete redeterminations within 14 months for all participants. The Medicaid Eligibility Determination and Enrollment System (MEDES), implemented in January 2014, tracks eligibility information for MAGI-based participants, including redetermination due dates; and in some cases, performs redeterminations. Non-automatic redeterminations for MAGI-based participants are performed manually by FSD eligibility specialists. Eligibility information is transferred from the MEDES into the Medicaid Management System (MMIS), the Medicaid claims payment system, nightly. To ensure continuous enrollment during the PHE, the DSS programmed the MEDES to continue coverage effective March 18, 2020, except in the case of a participant's death, an out-of-state move, or voluntary closure. For some exceptions, the MEDES automatically closes the case. For other exceptions, an FSD eligibility specialist manually records the reason for closure and initiates closure of the participant's case in the MEDES. MEDES operations have been problematic since implementation and manual overrides to individual cases to compensate for previous system errors and limitations were not corrected. DSS officials explained there was a period of time when the MEDES was incorrectly closing some eligible cases before a redetermination could be performed. To prevent affected cases from being closed, DSS personnel manually overrode system controls. However, once these system limitations were corrected in June 2017, the DSS did not remove the previously-established manual overrides, which prevented the system from taking automatic actions such as identifying cases needing redetermination and closing cases. In response to prior audit recommendations, DSS officials indicated they developed a report to identify MEDES participants with overdue redeterminations due to these system problems. However, the DSS did not review all of these participants to ensure they remained eligible and did not meet one of the exceptions requiring termination during the PHE. As a result, cases for participants with manual overrides that did not meet eligibility requirements prior to and/or during the PHE, may not have been closed. Our random sample of 60 MAGI-based participants that were continuously enrolled during the year ended June 30, 2022, did not identify any participants with previously-established overrides. The DSS Corrective Action Plan (CAP) and Summary Schedule of Prior Audit Findings for finding number 2021-005 state the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, these processes have not been applied to all participant cases with manual system overrides needing closure. Missouri's system testing plan relating to the PHE unwinding processes, submitted to the DHHS - Centers for Medicare and Medicaid Services (CMS), states after the PHE is lifted, on April 1, 2023, the DSS plans to begin removing the manual overrides and performing redeterminations for these participants. The failure to implement adequate internal controls to ensure ineligible participant cases are closed can result in Medicaid and CHIP payments being made on behalf of ineligible individuals, which would be unallowable costs of the federal programs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal controls over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the MHD and the FSD review and correct cases for participants with manual overrides in the MEDES, ensure redeterminations are completed for these participants as required, and close the cases of any ineligible participants. In addition, the DSS should ensure system controls are functioning as designed for these participants. Auditee's Response: We disagree with the auditor's finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS disagrees there is a significant deficiency in internal controls because no participants with manual overrides were identified in the audit sample. However, the State Auditor's Office feels it is important to note the internal control weaknesses associated with these participants, which have existed for many years, remain regardless of whether any of these participants are selected in the audit sample of 60 of the approximately 942,000 participants. The CAP states the DSS has processes in place to terminate eligibility for individuals who are deceased, voluntarily request closure, or report they have moved out of state. However, as noted in the finding, these processes have not been applied to all participant cases with manual system overrides, and instead of proactively reviewing cases as recommended, the DSS is merely reacting when information is provided to them. Although recommended in the prior 3 audits, the DSS has not performed a review for all of these cases. Until the manual overrides are corrected and/or applicable participants reviewed, there will be continued circumvention of established internal controls and risk of improper payments on these cases. Therefore, this finding is valid.
Medicaid and CHIP Eligibility Determination Timeliness 93.767 Children's Health Insurance Program 93.778 COVID-19 - Medical Assistance Program 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text The DSS did not perform eligibility determinations within required timeframes for participants of the Medical Assistance Program (Medicaid) and the Children's Health Insurance Program (CHIP). There were approximately 1.3 million Medicaid and CHIP participants as of June 30, 2022. The FSD is responsible for determining the eligibility of Medicaid and CHIP participants. FSD eligibility specialists perform the majority of eligibility determinations using participants' Modified Adjusted Gross Income (MAGI). For the remaining non-MAGI participants, including participants in the MO HealthNet Aged, Blind, and Disabled programs, eligibility is not based on their MAGI. As of June 30, 2022, there were approximately 942,000 MAGI-based participants and approximately 369,000 non-MAGI-based participants. To ensure applicants are able to receive necessary medical care timely, 42 CFR Section 435.912(c)(3) requires new Medicaid eligibility determinations be made within 45 days of application and within 90 days of application for applicants who apply for benefits on the basis of disability. Rule 42 CFR Section 435.912(e) allows exceptions to these timeframes in certain unusual circumstances, such as a doctor's delay. Rule 42 CFR Section 457.340(d) requires the same timeliness standards for CHIP participants. To test compliance with eligibility requirements, we reviewed randomly-selected samples of 60 MAGI-based participants, of which 55 were new enrollments, and 60 non-MAGI-based participants, all of which were new enrollments, subject to the timeliness requirements. The DSS did not meet timeliness requirements for 30 of the 55 MAGI-based eligibility determinations (55 percent) and 10 of the 60 non-MAGI-based determinations (17 percent). The 40 late determinations were made 2 to 144 days after the required 45 or 90-day requirement, and averaged 68 days late. DSS officials indicated increased workloads hindered the department's ability to process applications within required timeframes during the year ended June 30, 2022. They also indicated a backlog of eligibility determinations for the Medicaid Adult Expansion Group, a new population that became eligible with the Medicaid expansion effective as of July 1, 2021, occurred due to the volume of new applications and litigation that prevented processing of the applications until October 2021. DSS officials stated there were also increased workloads associated with annual open enrollment applications from the federal Health Insurance Marketplace. In addition to noncompliance with federal requirements, the failure to ensure determinations are performed timely can result in potentially eligible participants not receiving necessary medical care. Recommendation: The DSS through the MHD and the FSD ensure participant eligibility is determined within required timeframes. Auditee's Response: We agree with the auditor's finding. Our Corrective Action Plan includes our planned actions to address the finding.
Department of Social Services Cost Allocation 93.090 Guardianship Assistance 93.558 Temporary Assistance for Needy Families 93.658 Foster Care Title IV-E 93.659 Adoption Assistance 93.667 Social Services Block Grant 93.778 Medical Assistance Program See Schedule of Findings and Questioned Costs for chart/table within the text DFAS controls and procedures to allocate some administrative costs to federal programs were not sufficient to prevent and/or detect errors. Our testing of AlloCAP system allocations identified an error in 1 cost allocation methodology. For the year ended June 30, 2022, costs totaling approximately $38.5 million were incorrectly allocated to 6 programs. As a result, approximately $10.2 million (federal share) was allocated to state funding, that could have been allocated to federal funding for 4 programs. The DFAS uses the AlloCAP system to identify, measure, and allocate costs to state and federal programs in accordance with its Public Assistance Cost Allocation Plan (PACAP). Each quarter, DFAS personnel import expenditure data from the state's accounting system into the AlloCAP system, which allocates costs to programs through allocation methodologies outlined in the department's PACAP. The DSS uses the random moment time studies (RMTS) allocation method (as outlined in the PACAP) to allocate various administrative costs including salaries, benefits, and other operational costs. As part of this process, randomly-selected Children's Division staff are contacted by email at random moments and asked to record what program/activity they are engaged in at that moment. These surveyed time results are used to approximate the proportion of the administrative costs that apply to the various programs. In addition, the DSS uses quarterly penetration rates to further allocate the costs to the programs. The penetration rate for a given program reflects the percentage of federally-eligible children served by the state, compared to the total number of children served by the state. During the year ended June 30, 2022, administrative costs totaling approximately $127.8 million were allocated through the RMTS allocation method to 6 programs through the AlloCAP system: Social Services Block Grant (SSBG), Temporary Assistance for Needy Families (TANF), Guardianship Assistance, Foster Care, Adoption Assistance, and the Medical Assistance Program. Our testing noted the RMTS cost allocation methodology, and use of quarterly penetration rates, were not configured in the AlloCAP system correctly. This resulted in over-allocation of costs to the SSBG program and under-allocation of costs to the other programs during the year ended June 30, 2022, as shown in the following table. See Schedule of Findings and Questioned Costs for chart/table within the text DFAS officials indicated when developing the AlloCAP system, they intended the RMTS cost allocation methodology to mirror the previous manual allocation process; however, a configuration error was made and not detected by the DFAS. After we notified the DFAS of the errors, the DFAS updated the RMTS cost allocation methodology, and use of quarterly penetration rates. The DFAS then used the updated methodology to revise previous quarters' AlloCAP results, including administrative allocations. Finally, the DFAS resolved the 4 programs with under-allocations (federal share) by requesting increasing adjustments totaling $21.6 million, in each program's September 30, 2022, and December 31, 2022, quarterly expenditure reports. These adjustments included the approximately $10.2 million for the year ended June 30, 2022, plus another approximately $11.4 million for the year ended June 30, 2021. DSS personnel indicated it was unnecessary to revise the federal reports for the SSBG and TANF programs because allocations for those grants were already fully expended. Because significant portions of those programs are state-funded, the allocation errors could be applied to state funding portions. We do not question any federal costs associated with the errors identified in this finding because the resulting over-allocations were not attributable to federal funding. Without adequate internal controls and procedures over the allocation of administrative costs, there is increased risk that DFAS staff will not properly allocate an appropriate share of costs to federal programs, and that errors will not be detected timely. In addition, cost allocation methodology errors could result in over-allocation of costs and potentially unallowable costs. Rule 45 CFR Section 75.303(a) requires the non-federal entity to "[e]stablish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." Recommendation: The DSS through the DFAS continue to strengthen internal controls and procedures over the PACAP and the AlloCAP system to ensure costs are properly allocated to federal programs. Auditee's Response: We partially agree with the auditor?s finding. Our Corrective Action Plan includes an explanation and specific reasons for our disagreement and any planned actions to address the finding. Auditor's Comment: The DSS Corrective Action Plan (CAP) states the DSS partially agrees with the finding because the calculation error was the result of an isolated error that occurred during design and development of the new cost allocation system, effective October 2017. The CAP further states this error is not indicative of the strength of current internal controls. While the error noted was isolated to the costs allocated through the RMTS allocation method, those costs are significant, totaling over $127 million and allocated to 6 different programs during the year ended June 30, 2022, alone. Furthermore, the fact that neither the DSS's original development effort in 2017, nor ongoing internal controls and procedures (from October 2017 through June 2022) detected this error, indicates there were internal control weaknesses associated with the design and testing of the system as well as reviews of system calculations. The DSS is responsible for ensuring adequate controls are in place to detect errors and ensure costs are properly allocated to federal programs. Therefore, this finding is valid. If this cost allocation issue had not been identified during the audit, approximately $10 million could have continued to be spent each year from state taxpayer funds instead of claimed to federal funding sources.