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EOHHS is in agreement with these findings. EOHHS has successfully addressed the deficiencies noted in these findings with updated requirements for this provider type. Community Health Workers have been elevated to high-risk status by Medicaid under “Medicaid Payments and Providers” 210-RICR-20-00-1,...
EOHHS is in agreement with these findings. EOHHS has successfully addressed the deficiencies noted in these findings with updated requirements for this provider type. Community Health Workers have been elevated to high-risk status by Medicaid under “Medicaid Payments and Providers” 210-RICR-20-00-1, which necessitates a National Criminal Background Check through fingerprinting. All enrolled community health worker providers were disenrolled effective December 1, 2025, and required to apply for enrollment under the new, enhanced requirements in the latest Community Health Worker Provider Manual, including the background check and requirement to enroll as a group with a National Provider Identifier (NPI), and as individual rendering providers with an NPI. All current CHW providers are now enrolled with the enhanced screening requirements. Limitations on reimbursement for services have also been successfully implemented, with system edits in place to deny claims billed in noncompliance with the new requirements outlined in the provider manual. Additionally, EOHHS Office of Program Integrity has audited outlier providers (in terms of utilization metrics), identifying overpayments and also collaborating with the MFCU for law enforcement intervention. EOHHS considers finding 2025-070a to be completed based on previous activities. For finding, 2025-070b, EOHHS is finalizing its last CHW audits while the MFCU completes its investigations based on Program Integrity’s referrals. Anticipated Completion Dates: 2025-070a: Complete 2025-070b: Estimate is August 2026 Contact Person: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov
EOHHS will establish an audit cycle to this service that will ensure the billing requirements for all bundled services are clear and that it is also clear that the unbundling of the rates is not allowed and may cause recoups for the services billed. Based on the results of the audit, systemic billin...
EOHHS will establish an audit cycle to this service that will ensure the billing requirements for all bundled services are clear and that it is also clear that the unbundling of the rates is not allowed and may cause recoups for the services billed. Based on the results of the audit, systemic billing error issues will be reviewed with Gainwell and evaluated for edits to correct the issues. EOHHS will also engage with Gainwell and BHDDH to implement enhanced technical assistance to ensure compliance. Anticipated Completion Date: December 31, 2026 Contact Persons: David McMahon, Assistant Director of Financial Contracts, Executive Office of Health and Human Services david.g.mcmahon@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov
2025-068a: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. 2025-068b: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell Technologies, a dedicated project is un...
2025-068a: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. 2025-068b: EOHHS is actively reassessing the current MMIS system configuration and operational processes. In collaboration with Gainwell Technologies, a dedicated project is underway to strengthen controls and implement guardrails designed to prevent this from occurring in the future. Several potential solutions are currently being evaluated and developed, with the goal of enhancing the system, oversight, and compliance. 2025-068c: EOHHS is actively reassessing the current provider Billing Manual to ensure the billing requirements for all bundled services is clear and that it is also clear that the unbundling of the rates is not allowed and may cause recoups for the services billed. 2025-068d: EOHHS will establish a systemwide audit cycle of this service to ensure the providers are appropriately billing. Anticipated Completion Date: November 30, 2026 Contact Persons: David McMahon, Assistant Director of Financial Contracts, Executive Office of Health and Human Services david.g.mcmahon@ohhs.ri.gov Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov
To satisfy this audit finding, EOHHS requested a systems solution to process Eleanor Slater Hospital (ESH) claims which would automate a recipient’s TPL, Medicare, and MCO financial obligations before Medicaid is billed. EOHHS, BHDDH, and Gainwell Technologies have been working on said system modifi...
To satisfy this audit finding, EOHHS requested a systems solution to process Eleanor Slater Hospital (ESH) claims which would automate a recipient’s TPL, Medicare, and MCO financial obligations before Medicaid is billed. EOHHS, BHDDH, and Gainwell Technologies have been working on said system modification project (PJ0630 – Other Insurance Edits for Eleanor Slater Hospital Claims) and the Business Design Document was reviewed with all parties on 6/22/2026. Anticipated Completion Date: SFY 2027 Q1 Contact Person: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov
2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned in...
2025-066a: In order to address repeat income deficiencies from SWICA, Medicaid added The Work Number (TWN) as a new data source in August 2025. Since then, RI Bridges has been modified to first verify earned income against TWN. With this enhancement, Medicaid has seen an improvement in how earned income is verified during the post-eligibility verification (PEV) and annual renewal processes. Medicaid has determined the individuals flagged as being enrolled under the expansion pathway beyond their 65th birthday are the result of exceptions to the mass update eligibility process. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate expansion eligibility for those turning 65 years old. RI Bridges appropriately identified the individual in question as requiring verification of citizenship status. However, as noted in the expansion age-out response, the mass update eligibility process exceptioned out, leaving the verification as unresolved and requiring manual review. Medicaid is working with our system vendor to develop a solution that will bypass this exception and terminate eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. In July 2024, federal partners operating the PARIS interstate match informed the State of a hold on PARIS interstate matching files. PARIS lifted the hold in October 2024. In November 2024, the State identified several defects in the PARIS results and suppressed requests for verification. A temporary system enhancement was logged to address the deficiencies and ensure the process was only requesting residency verification from individuals believed to be receiving Medicaid in another State. Long-term enhancements to the PARIS interstate match process are scheduled for late 2027. 2025-066b: Medicaid will continue to work with the Department of Human Services and HealthSource RI to improve reconciliation and quality assurance monitoring of eligibility and operational processes. Including, but not limited to automated quality control checks on batch processes, manual eligibility reviews of quarterly/annual activities, creating specialized reports, improving task logic, and identifying areas of repeat non-compliance to ensure appropriate controls are in place. 2025-066c: Upon notification from the systems team, Medicaid Finance will return any identified ineligible costs to the federal grantor. Anticipated Completion Dates: 2025-066a: Q4 2026 (exception scenarios) and Q4 2027 (PARIS) 2025-066b: Q4 2026 2025-066c: Ongoing Contact Persons: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov
Consistent with RIGL 40-8-13.4, the Rhode Island Medicaid State Plan includes the following: Annual review. EOHHS will review the DRG payment method at least annually, making updates as appropriate through the rule-making process. The scope of the annual review will include at least the DRG algorith...
Consistent with RIGL 40-8-13.4, the Rhode Island Medicaid State Plan includes the following: Annual review. EOHHS will review the DRG payment method at least annually, making updates as appropriate through the rule-making process. The scope of the annual review will include at least the DRG algorithm version, the DRG Relative Weights, the DRG Base Price(s), the outlier thresholds, outlier payment parameters, policy adjustors and the age adjustors. With respect to the DRG Base Price, EOHHS will take into consideration at least the following factors in deciding what change, if any, to implement: changes or levels of beneficiary access to quality care; the Center for Medicare and Medicaid Services (CMS) Inpatient Hospital Prospective Payment System Market Basket Update without productivity adjustment for the current federal fiscal year; technical corrections to offset changes in DRG Relative Weights or policy adjustors; changes in how hospitals provide diagnosis and procedure codes on claims; and budget allocations.” EOHHS annually reviews the inpatient hospital rate components in conjunction with annual market basket adjustments for the upcoming fiscal year. For example, this review for SFY 2027 occurred on June 18, 2026. However, in response to this finding, EOHHS will request amendment to the Rhode Island General Laws through the FY 2028 budget process. Then, upon enactment, it will then pursue a state plan amendment (SPA) to more specifically align with current practices. If CMS opposes the amendment, then EOHHS could pursue an update to the DRG model. Doing so would first require procurement of actuarial services to analyze six months of inpatient claims in order to determine new rates. Following the analysis, significant work in the MMIS would be needed to implement the rate and update the DRG grouper. MMIS work is estimated to require about 1,000 project hours. Additionally state funding would be needed to implement this change; as EOHHS does not currently have funding to accommodate this work, it would seek budget authority before moving forward. Anticipated Completion Date: FY 2028 Contact Person:Patricia Arruda, Interdepartmental Project Manager, Executive Office of Health and Human Services patricia.arruda@ohhs.ri.gov
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s T...
A file exchange process has been implemented where Gainwell pulls a monthly TPL report for each MCO which is shared with EOHHS to share with the MCO’s. EOHHS is unable to force the MCO’s to use the shared TPL data, we can only suggest they use it. At this point in time, the accuracy of the State’s TPL data is not good enough to reject encounter claims from the MCO’s. EOHHS continues to work on improving the TPL process specifically cleaning up the TPL data in the MMIS and eligibility system today. Future system enhancements include a direct TPL vendor and new TPL module which should improve TPL accuracy. Anticipated Completion Date: July 31, 2028 Contact Person: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov
2025-063a: On 5/14/2026 an IES system enhancement was deployed targeting the CHIP population. The change implemented allows the system to expedite automatic eligibility determinations on CHIP/MAGI cases when TPL is entered into the eligibility system. This will ensure that when TPL is added for a CH...
2025-063a: On 5/14/2026 an IES system enhancement was deployed targeting the CHIP population. The change implemented allows the system to expedite automatic eligibility determinations on CHIP/MAGI cases when TPL is entered into the eligibility system. This will ensure that when TPL is added for a CHIP member, the eligibility system will redetermine that eligibility automatically saving months of the member being in the incorrect category. EOHHS will work with Deloitte to continue to monitor the impacts of this change. OAG also noted there are cases where “eligibility terminated within RIBridges not populated within the MMIS”. As of today, there are only 62 cases for ALL of Medicaid categories where eligibility is closed in RIBridges and open in the MMIS. This count is very low when compared to each year since Bridges go-live in 2016. 2025-063b: EOHHS acknowledges that staff turnover and a lack of sufficient staff on the financial reporting team contributed to SFY 2025 reporting variances. Medicaid finance will continue to implement necessary changes to ensure accurate reporting. Changes implemented during SFY 2026 to reduce variances and assist with reconciliation work include: • Additional staffing o In process of hiring 3.0 additional FTEs directly to this team, increasing staff from 3.0 FTEs to 6.0 FTEs. o Temporarily transferred 2.0 FTEs from sister agencies to the Medicaid program to assist in federal reconciliations for SFY 2025 expenditures. o Temporary staff support has allowed existing staff to cross train team members on core functions to allow supervisors to focus on quarterly reporting challenges and improvements. • Contract support and review o Contracted with vendor that supported other Medicaid programs to review EOHHS’ CMS-64 quarterly reporting process and internal files to identify efficiencies and areas to automate to reduce the likelihood of human error. The vendor is also assisting with SFY 2025 reconciliation work. • Additional supervisory review and cross training o Prior to the start of each CMS-64, the team supervisor creates a work schedule with double-checks built into the processes which require numerous manual adjustments. The work is documented and reviewed to ensure timely submission of an accurate CMS-64. Three additional team members have also been trained in reconciling non-provider cycle expenditures each quarter. • Coordination of Medicaid Administrative Claiming draw downs and reporting o Beginning in SFY 2026, Q3, the Medicaid finance team now coordinates all administration claiming drawdowns to eliminate variances between drawn downs and reported expenditures. The coordination entails:  Switching the administrative draw down from bi-weekly to once a quarter.  Sending the proposed drawdowns to administrative claiming agencies.  Drawing down only what agencies verified should be drawn.  Sharing with sister agencies all draw down backup and final amounts.  Holding office hours each quarter before each draw down and federal reporting submission to address questions and concerns.  Reviewing and checking that each submitted administrative claiming quarterly report ties to the amount draw in that quarter. If there are variances, Medicaid finance works with the sister agencies to identify and correct the variance. 2025-063c: During SFY 2026 Medicaid Finance implemented changes to the administrative claiming and reporting process to help reconcile expenditures prior to the submission of the CMS-64 quarterly report. • Medicaid finance held training on February 4th detailing the historical draw down and reconciliation process and why it has not been effective. The training detailed possible changes to solicit agency input. • Beginning in SFY 2026, Q3, the Medicaid finance team now coordinates all administration claiming drawdowns to eliminate variances between drawn downs and reported expenditures. The coordination entails: o Switching the administrative draw down from bi-weekly to once a quarter. o Sending the proposed drawdowns to administrative claiming agencies. o Drawing down only what agencies verified should be drawn. o Sharing with sister agencies all draw down backup and final amounts. o Holding office hours each quarter before each draw down and federal reporting submission to address questions and concerns. o Reviewing and checking that each submitted administrative claiming quarterly report ties to the amount draw in that quarter. If there are variances, Medicaid finance works with the sister agencies to identify and correct the variance. • Contracted with vendor that supported other Medicaid programs to review EOHHS’ CMS-64 quarterly reporting process and internal files to identify efficiencies and areas to automate to reduce the likelihood of human error. Anticipated Completion Dates: 2025-063a: May 14, 2026 2025-063b / 2025-063c: Ongoing Contact Persons: Jeffrey Schmeltz, Chief, Family Health Systems, Executive Office of Health and Human Services jeffrey.schmeltz@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov
2025-062a: EOHHS recently determined that the MCOs were unknowingly assigning the incorrect Organization Type Code to multiple provider types since EOHHS adopted the 837 standard in SFY 2014. This created unacceptably high encounter denial rates that led EOHHS to relax certain edits in the years tha...
2025-062a: EOHHS recently determined that the MCOs were unknowingly assigning the incorrect Organization Type Code to multiple provider types since EOHHS adopted the 837 standard in SFY 2014. This created unacceptably high encounter denial rates that led EOHHS to relax certain edits in the years that followed. An MMIS project is currently underway that will help ensure the plans are assigning the correct codes to their providers. Once the MCO's are submitting the correct codes, EOHHS will be able to begin the process of re-enabling the edits in the 2nd half of SFY 2027, which will improve controls over encounter claims data submissions. 2025-062b: Medicaid has deployed several control measures to improve the identification and processing of individuals determined to be deceased and living out State. In January 2026, the State operationalized a new interface with the National Change of Address (NCOA) database. The RI Bridges system verifies addresses of Medicaid recipients on a weekly (those with returned mail) and monthly (entire Medicaid population) basis. Automated rules ensure individuals with an out of State address received from NCOA are provided an opportunity to verify their residency. Failure to respond to the verification results in termination of eligibility. Effective December 2025, the RI Bridges system receives quarterly matches from the SSA Death Master File (DMF). The DMF is automatically sent to the State as part of the quarterly PARIS data matching process. The State has deployed temporary system measures to process the file and automatically terminate Medicaid eligibility for individuals flagged as deceased on the DMF. As per section 71104 of the Working Families Tax Cut (WFTC) legislation, signed by the President on 7/4/25, the State will be deploying a long-term system enhancement to, “at least a quarterly basis, check the DMF to identify if enrolled individuals are deceased. If an individual is identified as deceased on the DMF, then the state must treat this information as factual, disenroll the individual, and discontinue any payments for items or services furnished after the death of the individual.” This enhancement is scheduled for the March 2027 release. Anticipated Completion Dates: 2025-062a: Q4 SFY 2027 2025-062b: March 2027 Contact Persons: Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services anthony.salvo@ohhs.ri.gov
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ na...
EOHHS is in agreement with these findings and is in the process of working with Gainwell and its managed care partners to address these discrepancies. The providers that were not properly subjected to EOHHS’s enrollment processes were out of network providers within one of the managed care plans’ national network provider management system. These providers have been incorrectly included in provider network data as this managed care plan is in the process of end-dating these providers, which will resolve this discrepancy. EOHHS has reorganized Provider Enrollment oversight functions under the Office of Program Integrity (OPI) in alignment with federal standards, and as such will continue to audit and monitor enrollment files to ensure compliance with state and federal requirements. OPI is formalizing a process to swiftly terminate providers who have lost their licensure, as well as randomly auditing enrollment files to ensure proper licensure. Additionally, EOHHS will begin collecting DCYF licensure data as required. Anticipated Completion Date: December 31, 2026 Contact Persons: Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services nicholas.james@ohhs.ri.gov Rob Tingle, Chief of Program Analytics, Executive Office of Health and Human Services robert.tingle@ohhs.ri.gov
EOHHS acknowledges the federal reporting requirement specific to the State’s non-emergency medical transportation (NEMT) vendor. The State’s contract with the vendor, more specifically Article I Section 18.13.6, does require the financial reporting necessary to comply with this federal requirement. ...
EOHHS acknowledges the federal reporting requirement specific to the State’s non-emergency medical transportation (NEMT) vendor. The State’s contract with the vendor, more specifically Article I Section 18.13.6, does require the financial reporting necessary to comply with this federal requirement. EOHHS is currently working with vendor and their independent auditor to isolate the necessary financial claims to resolve this deficiency finding for reporting/calendar year 2025. Anticipated Completion Date: EOHHS estimates that the 2025 report will be brought into compliance no later than December 1, 2026. Contact Persons: Storm Lawrence, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health and Human Services storm.lawrence@ohhs.ri.gov Melanie Oxley, Administrator of Medical Services, Division of Healthcare Delivery Contracting, Executive Office of Health and Human Services melanie.j.oxley@ohhs.ri.gov
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicai...
EOHHS understands that the audit findings primarily resulted from three items: 1. Lack of management oversight of the AlloCAP system’s functionality and its effect on financial reporting. 2. The use of incorrect FMAPs on sister agencies’ quarterly administrative claiming reports submitted to Medicaid Finance, and Medicaid’s subsequent lack of review of these reports. 3. No segregation of duties in the Assistant Director Financial and Contract Management position within the EOHHS Central Management finance team. Several actions have been taken to enhance oversight of the AlloCAP system functionality and improve the overall cost allocation process, including hiring an Administrator, Financial Management position. This position has been cross trained and is completing the quarterly AlloCAP activities with review completed by the Assistant Director Financial and Contract Management position. Management’s additional correction action plans for each of these are below. 1. Finance will request a SOC I Type II report from its AlloCAP vendor. The report(s) will be shared with CFOs at all agencies using the AlloCAP system for Medicaid allocations for their review. 2. Finance has already implemented controls to rectify this finding. The items below were implemented during SFY 2026. a. Additional training for sister agencies on the administrative claiming reporting process. Trainings were held on February 4th and April 15th, 2026, and included the importance of the correct FMAP and a list of FMAPs by CMS-64 line item. b. Office hours with Medicaid administrative claiming agencies prior to the submission of quarterly expenditure reports. This allows agencies to ask questions and troubleshoot possible issues prior to report submission. c. Medicaid Finance review of all agency-submitted quarterly expenditure reports. This includes checking that: i. the reported federal amounts tie to the quarterly draw down amount. If there is a variance, the variance must be explained and documented for future reconciliation; ii. FMAPs are used and align with CMS-64 line item FMAPs; iii. The reported federal amounts do not exceed CMS-64 line item budgets (when applicable). d. Training additional Medicaid Finance staff on the review of agency submitted reports and data entry to separate staff duties and allow for double-checking of staff work. Finance will continue to refine improvements and implement processes to ensure reporting accuracy, including drafting relevant SOPs. Additionally, Medicaid Finance retained a contractor that has worked with other states to review the CMS-64 claiming process to suggest further areas of improvement and automation. 3. EOHHS will continue to explore options for improving controls over AlloCAP system functionality and cost allocation work. 4. Finance staff across EOHHS and Medicaid teams will detail additional controls and recommendations for implementation. Anticipated Completion Date: September 1, 2026 Contact Persons: Dezeree Hodish, Associate Director, Financial Management, Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov Victoria Pavao, Assistant Director, Financial and Contract Management, Executive Office of Health and Human Services victoria.pavao@ohhs.ri.gov
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying acces...
2025-032a: MMIS system access is controlled via an electronic system called GainwellNow. An MMIS access request form must be completed by the requestor, signed by that individual and their supervisor, and then sent to the Systems Group staff members who are responsible for approving or denying access requests. The Systems Group will sign the request form and approve the request within GainwellNow and the requestor will be granted access. The GainwellNow system also generates and sends email notifications to the Systems Group Administrators notifying them of a pending access request if the requestor enters it into GainwellNow directly. From there, the same approval/denial process occurs. If an individual has not logged into MMIS for 30 days, then they require a password reset in order to regain access. Those password reset requests create system generated emails that are sent to the Systems Group Admins for approval or denial. After 60 days of inactivity, the individual is locked out and cannot access the MMIS without requesting and obtaining approval of the password reset. If someone leaves state employment, then the Systems Group Admins submit an access deletion request into GainwellNow, deleting the account completely. Gainwell Technologies also sends monthly access reports to the Systems Group for review and confirmation that account deletion requests were completed as submitted. Additionally, Gainwell sends monthly “New or Deleted Users” reports to the Systems group for review. For IT security, the Systems Group receives and reviews the following reports: · RI-CDM-ASQC-Security-Report · RI-CSHARP-ASQC-Security-Report · RI-Java-ASQC-Security Report · RI-XIX-DR Exercise Scope · RI-XIX-DR Executive Summary Report 2025-032b: The Arc-Ampe (formerly called MARS-E) third party assessment is underway. Security scanning and testing is complete, and security controls have been evaluated. Final report is due by 6/30/2026. Remediation of legitimate vulnerabilities is underway and defects are tracked on the RIBridges POAM. 2025-032c: EOHHS/Medicaid will work collaboratively with ETSS and their vendors to proactively assess critical risk areas planned for the review year. 2025-032d: For RIBridges, SOC engagements occur every other year. A third-party Attestation of the Arc-Ampe controls occurs annually. The state can evaluate the results of this year’s upcoming SOC audit to determine if an increased frequency of the SOC is needed. Anticipated Completion Dates: 2025-032a: EOHHS believes this item to be complete and will defer to OAG for resolution of this finding. 2025-032b: High findings – 30 days, moderate findings – 90 days, low findings – 365 days. July 31, 2027. 2025-032c: Ongoing 2025-032d: December 31, 2026 Contact Persons: Hector Rivera, Interdepartmental Project Manager, Executive Office of Health and Human Services hector.l.rivera@ohhs.ri.gov Deb Merrill, Security Officer, ETSS, Department of Administration deb.merrill@doit.ri.gov Brian Tichenor, Medicaid Systems Manager, Executive Office of Health and Human Services brian.tichenor@ohhs.ri.gov
EOHHS understands that this finding stems from two items. 1. Current limitations of the MMIS and the volume of manual transactions, including retroactive capitation adjustments and corrective journal entries related to CHIP funding 2. Lack of internal controls regarding CHIP draw downs and reporting...
EOHHS understands that this finding stems from two items. 1. Current limitations of the MMIS and the volume of manual transactions, including retroactive capitation adjustments and corrective journal entries related to CHIP funding 2. Lack of internal controls regarding CHIP draw downs and reporting. Management’s correction action plans for each item are below. 1. EOHHS will improve SOPs to include additional review of source data, collation of source data, and review of formula calculations for manual adjustment activities. These steps will be built into analyst training, and measures have been taken to include training and the creation/improvements of internal SOPs before the upcoming SFY 2026 closing activities occur. EOHHS will include within its forthcoming procurement of specific MMIS modules requirements to reduce the number of manual calculations and related entries. 2. Medicaid finance has and will take the following actions. a. Staff training. i. In May 2026, Medicaid Finance sent two employees to internal control training, which was sponsored by the Office of the Auditor General (OAG) ii. In July 2027, these two employees will train all Medicaid finance staff members on the importance of risk and internal controls using material from the OAG sponsored training. b. SOP tracker and dedicated work time i. Medicaid finance created an inventory of all finance-related SOPs to track assignments to ensure timely completion of high priority SOPs. ii. The Associate Director (Financial Management) has weekly worktime dedicated to the completion of high priority SOPs. iii. Each fiscal close, one staff member has been assigned to work with analysts to draft six SOPs (two from each finance unit—fee for service, managed care, and federal reporting) to continue to document all year end closing procedures. c. Post FFY-quarter end reconciliations i. Beginning in FFY 2026, the Associate Director (Financial Management) completes a post-quarter reconciliation of Medicaid draw down accounts (benefits, administrative claiming, and CHIP). ii. Staff email the Associate Director (Financial Management) after each federal draw down and include verification of the PMS draw down amount and account. iii. The Associate Director (Financial Management) enters this into a tracking sheet to ensure sufficient federal funds remain in each account during the quarter. Should additional funds be needed, Medicaid finance submits a supplemental budget request to CMS to prevent the shifting of funds between federal accounts benefits, administrative claiming, and CHIP accounts. iv. Shortly after the end of each FFY year quarter close, the Associate Director (Financial Management) completes the following: 1. Receives staff-run reports form the PMS system showing all draw downs in the previous quarter. 2. Checks that Medicaid Finance internal trackers (high level and detail trackers) accurately capture correct federal accounts and amounts. If variances, research is completed to reconcile to PMS. v. Associate Director (Financial Management) ensures that all CMS adjustments, such as Parts A, B, and D adjustments and TPL/AOR adjustments are included in the high-level fund tracker to match and verify CMS’ quarterly account balances. d. EOHHS acknowledges that many of the new checks and reviews implemented have not been formally codified. It will work to codify controls to document these reviews and checks. Anticipated Completion Date: Additional SOP and internal control development is ongoing and the date of procurement/implementation of the MMIS Finance module is still be determined. Contact Persons: Storm Lawrence, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health and Human Services storm.lawrence@ohhs.ri.gov Dezeree Hodish, Associate Director (Financial Management), Executive Office of Health and Human Services dezeree.hodish@ohhs.ri.gov
Medicaid deployed a system enhancement to automatically run eligibility on CHIP individuals for whom TPL information was received from MMIS. This enhancement went live in May 2026. This enhancement will improve the accuracy of eligibility determinations for the Medicaid and CHIP populations. In July...
Medicaid deployed a system enhancement to automatically run eligibility on CHIP individuals for whom TPL information was received from MMIS. This enhancement went live in May 2026. This enhancement will improve the accuracy of eligibility determinations for the Medicaid and CHIP populations. In July 2024, federal partners operating the PARIS interstate match informed the State of a hold on PARIS interstate matching files. PARIS lifted the hold in October 2024. In November 2024, the State identified several defects in the PARIS results and suppressed requests for verification. A temporary system enhancement was logged to address the deficiencies and ensure the process was only requesting residency verification from individuals believed to be receiving Medicaid in another State. Long-term enhancements to the PARIS interstate match process are scheduled for late 2027. Anticipated Completion Date: Q4 2027 Contact Person: Anthony Salvo, Implementation Director of Policy and Programs, Executive Office of Health and Human Services Anthony.Salvo@ohhs.ri.gov
DCYF has created separate GAP administrative and prevention services accounts since this deficiency was identified. Anticipated Completion Date: Complete Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
DCYF has created separate GAP administrative and prevention services accounts since this deficiency was identified. Anticipated Completion Date: Complete Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
2025-056a: Management and budget will work with team members to allow for proper separation of responsibilities, as well as, ensure that proper training is provided. 2025-056b: MARVIN will address this issue as the department will not be waiting 45 days after the QE for the RPT54. It is going to be ...
2025-056a: Management and budget will work with team members to allow for proper separation of responsibilities, as well as, ensure that proper training is provided. 2025-056b: MARVIN will address this issue as the department will not be waiting 45 days after the QE for the RPT54. It is going to be more real time. MARVIN is proposed to go live at the end of CY2027 which means that we will have this issue for both 2026 and 2027 fiscal close. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
DCYF will continue to work with Public Consulting Group to ensure that eligibility quality control reviews are performed in a timely manner. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families ...
DCYF will continue to work with Public Consulting Group to ensure that eligibility quality control reviews are performed in a timely manner. Anticipated Completion Date: Ongoing Contact Person: Kimberly Reynolds, Associate Director of Financial Management, Department of Children, Youth and Families kim.reynolds@dcyf.ri.gov
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some m...
Management agrees with the finding regarding health and safety requirements for timely unannounced monitoring visits. While several providers identified in the audit did receive a monitoring visit within 60 days of the annual due date, the Licensing Department experienced delays in completing some monitoring visits due to staff shortages and employee leave. To address the backlog and prioritize oversight activities, The Department has implemented a team-based prioritization approach rather than individual caseload management. This approach allows the unit to prioritize providers with the greatest need for monitoring and ensure that available resources are directed toward the highest-risk areas. The Department is actively working to increase staffing capacity within the unit. The Department is currently onboarding four new staff members to address existing vacancies and has recently received two additional FTE positions to further support monitoring activities. The unit continues to manage the impact of two staff members being out on extended medical leave with undetermined return dates; however, despite these staffing challenges, the unit has completed 423 monitoring visits since January 1, 2026. The Department will continue to monitor progress toward eliminating the backlog, strengthening system processes, and ensuring timely completion and documentation of required unannounced monitoring visits. DHS has also implemented enhanced monitoring capabilities within RISES. The system now generates automated notifications to the Licensing Department at established intervals before monitoring visits are due for both child care centers and family child care programs. These automated reminders strengthen monitoring workflows, improve oversight of upcoming monitoring requirements, and support the timely completion of unannounced visits. In addition, RISES has strengthened the Department's ability to consistently track provider compliance, document corrective actions, and identify providers requiring increased oversight. These enhanced monitoring tools have improved accountability by providing greater visibility into provider compliance and enabling licensing staff to more effectively prioritize regulatory activities based on risk. Management does not concur with the findings related to corrective action plans and inspections but has implemented various enhancements to support streamlined processes in these areas since the audit time period. As discussed during the audit, several factors affect the timing and applicability of required inspections and do not necessarily indicate provider noncompliance. For example, radon testing may only be conducted during specific times of the year. Providers may make timely efforts to schedule testing but be unable to obtain an inspection due to limited inspector availability or because the request falls outside the allowable testing window. In these circumstances, DHS does not consider the provider to be out of compliance. Similarly, fire inspections must be completed by the State Fire Marshal's Office. In recent years, staffing challenges have affected the ability to complete inspections within standard timeframes, despite providers' efforts to obtain them. When a provider has a history of compliant fire inspections, the Licensing Department accepts documentation demonstrating the provider's attempt to schedule the required inspection and may proceed with license renewal while awaiting the inspection. Additionally, lead inspections are not required for facilities constructed after the applicable regulatory date and are not required for school-age programs. During the audit process, DHS identified several providers flagged for inspection concerns that appeared to fall into one or both of these exempt categories. To strengthen compliance monitoring, RISES now generates automated notifications beginning 90 days before inspection expiration dates. DHS has already observed improved provider responsiveness in renewing required inspections and will continue to use RISES to proactively monitor inspection status and work with providers to maintain current inspection documentation. Regarding corrective action plans, under the previous licensing system, providers submitted corrective action plans and supporting documentation directly to the assigned licensor. This is typically through email. As a result, documentation was often maintained outside of the licensing system and may not have been consistently reflected in the inspection record. If the corrective action or follow-up information was not documented within the system or the inspection status was not updated, the report could continue to appear as pending, even when the provider had submitted the required information. To address this limitation, DHS intentionally designed the RISES system to centralize the corrective action process. Following an inspection, the report is issued to the provider through RISES, where the provider is required to submit a corrective action plan directly within the system. The corrective action plan is then routed to DHS for review and approval, creating a documented workflow and improving the consistency and completeness of recordkeeping. If a provider does not submit a corrective action plan, DHS is able to identify the outstanding item within RISES and determine whether a follow-up inspection is warranted to verify that the noncompliance has been addressed. Currently, DHS prioritizes follow-up for high-risk noncompliance, including issues related to facilities, background checks, staff-to-child ratios and supervision, and infant and toddler care. Anticipated Completion Date: This corrective action has since been completed through the implementation of the 2026 requirement that all regulated providers utilize RISES. Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued prog...
Management concurs with the findings related to controls over child care eligibility determinations and provider payments. Management notes that the number and scope of findings identified in the current audit have been substantially reduced compared to prior Single Audits, reflecting continued progress in strengthening internal controls. The Office of Child Care remains committed to enhancing eligibility determination processes and related internal controls, including ensuring that required eligibility documentation is consistently maintained in the electronic case record. Corrective actions to address the remaining findings, along with the anticipated completion dates, are outlined below. [See Corrective Action Plans for table.] In addition to the corrective actions outlined above, the Department is strengthening supervisory oversight through implementation of routine pre-authorization quality reviews and standardized supervisory monitoring practices. Supervisors will utilize these tools as part of ongoing quality assurance activities to verify that required eligibility documentation is complete prior to authorization, identify recurring error trends, and provide targeted coaching, training, and process improvements to strengthen program integrity and reduce future eligibility errors. Management agrees with the recommendation to evaluate modifications to the existing eligibility system to support eligibility determinations under the CCAP Child Care Staff program. The Department previously assessed the feasibility of modifying RIBridges to accommodate eligibility determinations for the CCAP Child Care Educators and Child Care Staff pilot program. At that time, implementation was not feasible due to competing system development priorities, limited vendor development capacity, and the pilot status of the program. Since the period covered by the audit, the Department has implemented a requirement that participants in the pilot program also apply for the traditional CCAP program. This change has strengthened documentation requirements and helped mitigate risks associated with incomplete eligibility documentation. While these interim measures have improved program administration, the Department recognizes that administering eligibility determinations outside of the primary eligibility system is not a sustainable long-term approach. Accordingly, the Department is reassessing the future administration of the pilot program and evaluating options to incorporate eligibility determinations into RIBridges or, alternatively, to develop the functionality within RISES and integrate it with RIBridges. The Department will determine the most appropriate path forward based on program needs, system capabilities, and available resources to ensure a sustainable and well-controlled eligibility process. Additionally, the Department has strengthened controls over provider payments for the CCAP Child Care Staff pilot program since the audit period. Prior to each payment, the CCAP program team reviews the copayment workbook to identify and resolve discrepancies between pilot program payments and traditional CCAP benefits. In addition, the CCAP Finance team performs a formal review of each payment workbook before payments are processed. The vendor supporting the pilot has also enhanced its payment file process by implementing an additional level of financial review by the project team prior to submission and incorporating safeguards to identify attendance records that may have been previously paid, reducing the risk of duplicate payments. The Department has established procedures to recover identified overpayments, including both one-time recoveries through withholding from future pilot payments, where appropriate, and a formal recoupment process for providers who are no longer participating in the pilot program. These enhanced controls are intended to strengthen payment accuracy and support effective stewardship of program funds. Anticipated Completion Dates: See table above Contact Person: Nicole Chiello, Associate Director, Office of Child Care, Department of Human Services nicole.chiello@dhs.ri.gov
Although the Department remained in compliance with applicable CCDF earmarking requirements, DHS will strengthen its review procedures to ensure that only expenditures applicable to the reporting period are included in quarterly earmarking calculations. These procedures will include verification tha...
Although the Department remained in compliance with applicable CCDF earmarking requirements, DHS will strengthen its review procedures to ensure that only expenditures applicable to the reporting period are included in quarterly earmarking calculations. These procedures will include verification that expenditures are reported within the appropriate reporting period, reconciliation of source expenditure reports to supporting accounting records, documented supervisory review of quarterly earmarking calculations to verify the accuracy, completeness, and appropriateness of expenditures included in the calculation prior to finalization, and formal approval prior to finalization. In addition, DHS will update written procedures and provide training to staff responsible for preparing and reviewing quarterly earmarking calculations to ensure the enhanced controls are consistently applied. The corrective actions implemented in response to Finding 2025-051 will further strengthen the reliability of the expenditure data used in quarterly earmarking calculations and support effective monitoring of compliance with CCDF earmarking requirements. These enhancements will strengthen the reliability of quarterly compliance calculations, improve management oversight, and provide greater assurance that CCDF earmarking requirements continue to be accurately monitored and documented. Anticipated Completion Date: June 30, 2027 Contact Person: Eileen Asselin, Assistant Director, Financial and Contract Management, Department of Human Services eileen.asselin@dhs.ri.gov
The Department is developing standardized written procedures for the preparation, reconciliation, review, and submission of required federal financial reports. The procedures will include reconciliation of reported expenditures to the State accounting system, identification of applicable appropriati...
The Department is developing standardized written procedures for the preparation, reconciliation, review, and submission of required federal financial reports. The procedures will include reconciliation of reported expenditures to the State accounting system, identification of applicable appropriation accounts, reporting thresholds, required documentation, submission deadlines, and documented supervisory review and approval prior to submission. The Department will also review previously identified reporting discrepancies and amend reports, as appropriate, to ensure compliance with federal reporting requirements. Development of these standardized procedures was temporarily delayed due to implementation of the State's Enterprise Resource Planning (ERP) system. DHS anticipates resuming this work during State Fiscal Year 2027 and incorporating lessons learned from the ERP implementation into its reporting procedures to strengthen financial reporting controls. Anticipated Completion Date: June 30, 2027 Contact Person: Ben Quattrucci, Assistant Director, Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov
During the audit period, responsibility for FFATA reporting transitioned among multiple staff due to staffing changes, which contributed to untimely reporting. To strengthen internal controls and ensure continuity of operations, DHS will cross-train multiple employees on FFATA reporting requirements...
During the audit period, responsibility for FFATA reporting transitioned among multiple staff due to staffing changes, which contributed to untimely reporting. To strengthen internal controls and ensure continuity of operations, DHS will cross-train multiple employees on FFATA reporting requirements and reporting procedures. In addition, DHS will establish a standardized reporting calendar, designate primary and backup staff responsible for FFATA submissions, and implement a supervisory review process to verify that all required subaward reports are submitted timely and in accordance with federal reporting requirements. These actions are intended to strengthen monitoring controls, reduce the risk of reporting delays, and ensure ongoing compliance with FFATA reporting requirements. Anticipated Completion Date: July 31, 2026 Contact Person: Ben Quattrucci, Assistant Director, Financial Contract Management, Department of Human Services benjamin.a.quattrucci@dhs.ri.gov
The RI Works unit has completed a comprehensive revision of the State's Work Verification Plan. The revised plan is currently undergoing an internal quality review to ensure consistency, appropriate terminology, removal of legacy references, and alignment with current program operations. Upon comple...
The RI Works unit has completed a comprehensive revision of the State's Work Verification Plan. The revised plan is currently undergoing an internal quality review to ensure consistency, appropriate terminology, removal of legacy references, and alignment with current program operations. Upon completion of this review, the Work Verification Plan will be submitted to the Administration for Children and Families (ACF) for review and approval. To strengthen ongoing compliance with the Work Verification Plan, DHS will implement documented supervisory quality assurance reviews to verify work participation documentation, ensure compliance with established verification procedures, and confirm the accuracy of work participation data reported to ACF. In addition, the Multi-Program Eligibility Review Tool referenced in Finding 2025-046 will be incorporated into the Department's supervisory monitoring process. Supervisors will utilize the tool to conduct routine case reviews to verify eligibility accuracy, work verification documentation, and compliance with federal and State requirements. Review results will be used to identify trends, provide targeted coaching, and strengthen ongoing quality assurance activities. Anticipated Completion Date: October 1, 2026 Contact Person: Donna Rook, Administrator, Family & Adult Services, Department of Human Services donna.m.rook@dhs.ri.gov
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a docu...
The Department has worked with the ACF Data Unit and the system vendor to identify the required coding corrections and implement updates consistent with current ACF reporting guidance. System enhancements are underway to address the identified coding issues. The Department will also implement a documented quality assurance review process for each quarterly ACF-199 submission. Prior to submission, designated staff will validate report data against RIBridges case information, verify compliance with current ACF reporting guidance, and document supervisory review and approval. DHS has incorporated updated ACF reporting guidance into its reporting procedures and will provide training and technical assistance to staff responsible for preparing and reviewing ACF-199 reports to ensure consistent application of federal reporting requirements. The Department will also obtain documentation on a quality assurance review for the quarterly 199 reports. Anticipated Completion Date: Ongoing Contact Person: Nikolaos Petropoulos, Data Analyst III, Office of Performance Analytics & Continuous Improvement, Department of Human Services nikolaos.petropoulos@dhs.ri.gov
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