2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Current...
2025-034 Medicaid Cluster 93.775, 93.777, 93.778 Recommendation: The Department should enhance its procedures and internal controls to ensure it maintains documentation of participant eligibility and that this documentation is readily available for audit. Action taken in response to finding: Currently, when a document is received at a MassHealth Enrollment Center, it is the worker’s responsibility to collect the documentation and send it to the Electronic Document Management Center (EDMC) in New Bedford. Once the document is received it is prepped, scanned, and indexed to enable a worker to process the documentation within our eligibility system. We are proposing a short-term and long-term solution to address the audit finding. Short term solution: This approach involves minimal modifications to the current operational process and can be quickly put into practice across all locations. All staff at the MassHealth document received at a MEC that was submitted by applicants or members. Subsequently, the document must be mailed to EDMC for further processing. Long term solution: Implementing this solution will involve modifications to the current operational processes and workflows within MassHealth Eligibility Operations and the system. To facilitate this, we plan to initiate a comprehensive internal discussion involving different teams to gather insights, understand existing procedures, and identify areas where changes are needed to support the new solution. Once these preliminary discussions are completed, we will work with the relevant stakeholders to begin the development of the specific requirements that the new process will entail. Name(s) of the contact person(s) responsible for corrective action: Tosin Adebiyi, Director of Special Eligibility Programs and Audits, Marco Gonzales, Eligibility Quality Assurance Team Leader, April Aguiar, Director of EDMC, Rosana Senise, Director of MassHealth Eligibility Planned completion date for corrective action plan: Short Term solution: April 1, 2026, Long Term solution: December 2027