U.S. Department of Health and Human Services
Pass-through Entity: North Carolina Department of Health and Human Services
Program Name: Medical Assistance
Federal Assistance Listing Number: 93.778
Material Weakness and Non-Material Non-Compliance – Eligibility
Finding 2023-002
Criteria or specific re...
U.S. Department of Health and Human Services
Pass-through Entity: North Carolina Department of Health and Human Services
Program Name: Medical Assistance
Federal Assistance Listing Number: 93.778
Material Weakness and Non-Material Non-Compliance – Eligibility
Finding 2023-002
Criteria or specific requirement: Per Section 200.303 of the Uniform Grant Guidance, a non-federal entity must establish 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. The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria:
a) The caseworker should prepare and submit a DMA-5097 form in the case of noncooperation as described in the Eligibility Review Document.
b) When the Social Security Administration (SSA) terminates social security income (SSI) eligibility, the county is required to make an ex-parte determination for eligibility. This determination is required to be made within 120 days after the termination of the SSI payment.
c) An OVS inquiry must be completed and agreed to information reported in NC FAST.
d) An AVS inquiry must be completed and agreed to information reported in NC FAST.
e) When forcing eligibility, documentation explaining the reasoning for the forced eligibility is required to be maintained on file.
Condition: The following are the results of non-material non-compliance noted for each criteria listed above out of the 122 program participants selected for testing:
a) There were two instances where the non-cooperation with IV-D was identified but no DMA-5097 was sent. (93 and 105)
b) There were two instances where the County did not complete the ex-parte review for a participant whose SSI benefits were terminated during the year. The County should have forced eligibility, due to the COVID-19 exemption, but did not force eligibility for these instances. (63 and 121) There was one other instance where the County did force eligibility, but they forced it to the wrong program. (47)
c) There was one instance where the resources found through the register of deeds did not agree to the resources in NC FAST which affected the countable resource calculation. (68)
d) There were two instances where the OVS query was not ran at the time of the determination. (92 and 93)
e) There were two instances where eligibility was forced but no documentation explaining the reasoning for was documented at the time of the determination. (114 and 122)
Lastly, there were 31 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely.
Context: There were 9 out of 122 unique participants tested with the errors noted above, in which one was determined to have been improperly determined eligible.
Questioned Costs: We noted a total of $59,534 in benefit payment claims paid by the State of North Carolina based on an improper eligibility determination made by the County for which the State relied on; see item “c” above. As the County did not make the payment directly, it is not considered questioned cost for the County under Uniform Grant Guidance §200.516(a)(3); however, in accordance with NC general statutes §108A-25.1A, the County is financially responsible for the $59,534 of erroneous issuance of Medicaid benefits for an ineligible individual.
Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk that the County could provide funding to individuals who are not eligible.
Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis.
Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified.
Views of responsible officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the corrective action plan.
Corrective Action Plan:
The County will take a multi-faceted approach to mitigating such errors in the future.
Training:
The Quality and Training unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified including completing ex-parte determinations for eligibility when SSA terminates SSI eligibility, properly documenting and reacting to IV-D non-cooperation, correct and appropriate usage of forced eligibility, and performing the required electronic verifications to complete an application or review. This training will be delivered by the end of the third quarter of fiscal year 2024.
Responsible Individual(s): Ellese Massey, ESD Quality & Training Manager
Anticipated Completion Date: March 31, 2024
Process Improvement:
The Economic Services Division (ESD) has begun training new hires in one function of the Medicaid program, for
example, processing applications or recertifications/changes. This is to build a stronger foundation before they learn
the second function of their assigned program. Our Quality and Training Team is adding additional time for training,
as needed, to ensure our trainees receive the support they need while learning a new program.
ESD has specific protocol for managing the recertification process for SSI terminations and will ensure this policy is
followed moving forward.
Responsible Individual(s): Kim Konior, Medicaid Program Manager and Ellese Massey, ESD Quality & Training
Manager
Anticipated Completion Date: March 31, 2024
Quality Sampling and Accountability:
The Quality and Training Unit will complete monthly quality sampling for Medicaid. Error trends will be shared with
the managers and their supervisors, who will work collaboratively with Quality and Training staff to coordinate
appropriate strategies to train and coach staff to mitigate errors moving forward.
Supervisors will review specific quality sampling results with their staff. The supervisor will, when necessary and
appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher
training, additional second party review and/or initiating the formal documentation process.
Managers will review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings
completed and progress with individual Corrective Action Plans.
The Quality Assurance team in OSI/CFAS will conduct an independent evaluation and review the second party
review process at the divisional level to ensure review was accurate and errors were corrected timely. This team will
report out to ESD Leadership quarterly on findings.
Responsible Individual(s): Kim Konior, Medicaid Program Manager & Sonya English, Quality Assurance Supervisor
Anticipated Completion Date: Currently Ongoing