Finding Text
U.S. Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-004 Untimely Review of SSI Terminations
SIGNIFICANT DEFICENCY
ELIGIBILITY
Criteria:
Condition:
Questioned Costs:
Context:
Effect:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
Section III. Federal Award Findings and Questioned Costs (continued)
Ineffective communication between departments within the Department of Social
Services. One area within DSS received State communications that applicants would no
longer be eligible for SSI benefits and the County needed to conduct an ex-parte review.
This information was not shared with other departments in DSS from which the
recipient was also receiving benefits.
Any State communications related to applicants/beneficiaries should be shared with all
areas from which the participant receives benefits. State files should be reviewed
internally to ensure all actions have been properly closed and the corrective action has
been taken. Workers should be retrained on what process needs to be followed when
State communications are received.
The County agrees with the finding. See Corrective Action Plan in the following section.
In accordance with the Medicaid Manual MA-3120, the State sends notification to the
County when a participant is no longer eligible under a SSI determination. The County
has a certain time period to initiate an ex-parte review to determine whether the recipient
qualifies for Medicaid under any other coverage group, such as Family and Children's
Medicaid, North Carolina Health Choice for Children, Work First Family Assistance, or
Medicaid for the Aged, Blind and Disabled.
There was 1 applicant/beneficiary not reviewed timely and determined to be eligible for
Medicaid when their SSI benefits were terminated.
There was no known affect to eligibility and there were no known questioned costs.
We examined 60 cases from of a total of 1,176,385 Medicaid claims from the Medicaid
beneficiary report provided by NC Department of Health and Human Services to redetermine
eligibility. These findings are being reported with the financial statement audit
as it relates to Medicaid administrative cost compliance audit.
The County did not initiate ex-parte review timely, therefore, no eligibility review was
completed in the required time period. The lack of follow up and certification lead to
applicants receiving Medicaid benefits for which they were not eligible.