Finding: 2024-067 - Sixty Medicaid and 60 CHIP recipients were randomly selected for eligibility testing. Testing revealed the following errors:
Medicaid - 22 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies):
• One of 60 files was approved by the federa...
Finding: 2024-067 - Sixty Medicaid and 60 CHIP recipients were randomly selected for eligibility testing. Testing revealed the following errors:
Medicaid - 22 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies):
• One of 60 files was approved by the federally facilitated marketplace in 2015 and has been rolling forward ever since with no review and no documentation to support the case as an ongoing Medicaid eligible case. Electronic review did not have enough information so roll forward was cancelled as of June 30, 2024.
In addition:
• Ten of 60 cases, one of which was a behavioral health case, lacked documentation to indicate the participant submitted a signed Medicaid application.
• Ten of 60 files, one of which was behavioral health, lacked documentation of facts supporting the eligibility determination.
• Two of 60 cases were determined to not be part of one of the non-Modified Adjusted Gross Income (MAGI) covered groups and did not fit into one of the MAGI-exempted categories.
• One of 60 participants did not meet income eligibility requirements.
• Fifteen of 60 cases, five of which are behavioral health, lacked documentation to verify that IEVS was used to verify income eligibility.
• Two of 60 cases lacked review by the appropriate staff/supervisor for manual overrides.
CHIP - 23 of 60 cases lacked eligibility determination issues (note, some case had multiple deficiencies):
• Three of 60 cases lacked adequate support to eligibility determinations redeterminations, one ofwhich was a behavioral health case.
• Two of 60 cases were not covered groups, one of which was a behavioral health case.
• One of 60 participant files did not contain a social security number. During testing it was noted that the application was denied once reviewed, but it was initially allowed through the federally facilitated marketplace.
• Three of 60 participants received benefits after aging out of the program (age 19). One of these was a behavioral health case.
• One of sixty behavioral health case files was missing a CHIP-specific application and support for determination.
• Eighteen of 60 case files, four of which were behavioral health cases, lacked sufficient documentation to indicate that IEVS participation was verified.
Questioned Costs: AL 93.778: $ 5,691 (known questioned costs); $762,897,131 (likely questioned costs); AL 93.767: $ 5,019 (known questioned costs); $ 2,537,251 (likely questioned costs)
Assistance Listing Number: 93.767; 93.775, 93.777, 93.778
Assistance Listing Title: CHIP; Medicaid Cluster
Views of Responsible Officials (state whether your agency agrees or disagrees with the finding; if you disagree, briefly explain why): The department agrees with the finding but does not concur with the questioned costs. CMS has notified the state that financial recoveries based on eligibility errors can only be pursued when identified by programs operating under CMS’ Payment Error Rate Measurement (PERM) program, under section 1903(u) of the Social Security Act and regulations at 42 CFR Part 431, Subpart Q
Corrective Action (corrective action planned): Division of Public Assistance continues to leverage automated renewals for Medicaid and expects processing timeliness to continue improving. Staff will be coached on proper case documentation standards and procedures such as including appropriate information in case notes and uploading documentation in ILINX to support eligibility determinations. The Division intends to implement quality control and training efforts using the newly formed Staff Learning & Development team.
Completion Date (list anticipated completion date): The department anticipates the finding will be resolved in FY2026.
Agency Contact (name of person responsible for corrective action): Pam Halloran, Assistant Commissioner