93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2022-025 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response:...
93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) Eligibility 2022-025 Strengthen Controls to Ensure Compliance with Eligibility Requirements of the Children's Health Insurance Program (CHIP) and the Medical Assistance Program DOM Response: DOM acknowledges OSA's concern regarding the initial review of case files and the prompt action to select and provide a new sample of cases. Historically, DOM has provided a hardcopy of the actual beneficiary case files to OSA. Since those cases were active, an inventory control process, which included a notation in the electronic beneficiary file of the request to send the physical folder to the central office, was implemented. Likewise, upon arrival in the central office, notation of receipt of the files are added to the system prior to providing said files to the auditor. Occasionally, there are multiple files depending on the office with whom a beneficiary communicates, and multiple individual files associated with a family case. Additionally, cases in the sample may also be undergoing redetermination. To ensure that OSA has all the documentation needed for their case review, DOM staff reviews the files prior to sending them to central office. If an adverse eligibility determination is discovered, DOM has an obligation to correct at the time of discovery. As such, changes to the files are noted in the case history, which is available to the auditors. DOM will be transitioning to a paperless environment, which should alleviate any concerns during future audits. Use of Tax Return Resources DOM Does Not Concur. OSA compared eligibility data to state income tax returns. DOM is prohibited from accessing state income tax records per Mississippi Code Annotated ?27-3-73 and currently, does not have access to federal income tax records. DOM maintains that for determining eligibility, it has complied with the CMS-approved state plan. Using the approved CMS MAGI Based Verification plan in effect during the audit time period, the state sought to verify the reported income to the standard of reasonable compatibility, as defined by CMS, through all available electronic data sources. Further, DOM is required to accept the information provided by the applicant and utilize the available verification methods as detailed in the CMS-approved state plan to evaluate the accuracy of the information provided. If an applicant does not report self-employment income, and the tools available to DOM do not reveal such, DOM has performed its due diligence in the eligibility process and complied with the requirements of CMS, DOM's federal regulatory and oversight agency. OSA questioning DOM's determinations based on information that DOM was not provided nor have access to is shortsighted and does not align with the federal regulations that are imposed on this agency. While DOM is only required to use tax return information in certain circumstances, the agency continues to pursue the authority to review state and/or federal tax return information. To date, DOM has not been provided statutory authority to access Mississippi Department of Revenue tax information and is still awaiting IRS approval of the Safeguard Security Risks document. DOM plans to continue to follow the approved federal/state plan for eligibility determinations and will utilize additional resources as they become available. One MAGI beneficiary - DOM did not use taxable unearned income reported on tax return DOM Concurs. The application on file states neither parent has earned income. Although, the unearned income was not included in the initial calculation, adding it did not result in the beneficiary being ineligible. One MAGI beneficiary - self-employment income was reported to MDOM, but MDOM did not request a tax return from the beneficiary. DOM Concurs. The tax return was not requested for this particular beneficiary. This was an oversight, and the issue has been corrected. Two of the 180 MAGI beneficiaries - income was not verified through Mississippi Department of Employment Security DOM Concurs. There were multiple transactions associated with each of the beneficiaries identified. As a result, DOM's eligibility vendor is investigating to determine the reason the MDES search was not performed. One of the 180 MAGI beneficiaries - the beneficiary's case file did not contain an application or verification of income. DOM Concurs. This file could not be located. One of the 300 beneficiaries - auditors were unable to verify that any eligibility redeterminations have been performed since 2018. DOM Does not Concurs. A redetermination was not completed prior to the PHE. During the PHE, DOM was not allowed to performed redeterminations, which would have allowed DOM to update this file. Nine instances - resources were not verified through AVS at the time of redetermination. DOM Does not Concur. This is a prior finding from OSA 2021-041. Please note that all redeterminations in question occurred prior to the OSA audit period (FY22) and were suspended due to the public health emergency from March 2020 to June 2023. The eligibility system was updated in June 2022, after finding 2021-041, to include automatic asset checks within the system processing workflow to eliminate the manual request process and facilitate asset verification through AVS. Again, each instance identified above occurred prior to this implementation. In addition, AVS was checked on the 9 instances OSA sited, which resulted in no change in the eligibility determination. One instance - the beneficiary's case file did not contain a current level of care decision. DOM Does not Concur. DOM disagrees with this finding as redeterminations for the category of eligibility in question were suspended due to the public health emergency from March 2020 to June 2023. The date in question is from July 2021, which falls within this timeframe, and the child would have been eligible regardless. Seventy-three beneficiaries were not included on all of the required quarterly Public Assistance Reporting Information System (PARIS) file transmissions for fiscal year 2022. Of the 73 beneficiaries, six beneficiaries were not included on any quarterly PARIS file transmissions during fiscal year 2022. DOM Does not Concur. Per an amendment to DOM's CMS-approved State Plan, DOM is only required to verify Title XIX applicants and individuals eligible for covered Title XIX services. The above members were covered in Family Planning, which is not considered Title XIX, and did not receive Title XIX services. Therefore, these members should not have been included on any of the PARIS file transmissions. DOM Corrective Action Plan: a. All issues identified will be reviewed with regional office staff. Further, examples of these issues will be included in annual training sessions performed by Eligibility. DOM will continue to work with the vendor to ensure that income is verified through MOES, as applicable, and to implement controls that will limit this issue in the future. Further, DOM is implementing an electronic storage system to house all documents associated with applicants/beneficiary files. b. Cindy Bradshaw c. December 31, 2024