Finding 1095070 (2024-004)

US 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 Termination SIGNIFICANT DEFICENCY Eligibility Criteria: Condition: Questioned Costs: Context: Effect: Identification of a repeat finding: Cause: In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination Report and notify the recipient about applicant's ongoing eligibility for Medicaid. The County agrees with the finding. See Corrective Action Plan in the following section. 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 application process. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. 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. This is a repeat finding from the immediate previous audit, 2023-003. Section III. Federal Award Findings and Questioned Costs (continued) As a result of the lack of a proper eligibility determination, federal funds were distributed to ineligible recipients. Due to the nature of these types of eligibility determinations and the lack of a proper review by the department, the auditor is unable to determine the known or likely questioned costs. There were 2 applicants/beneficiaries not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. Of these 2 errors, one was determined to be an eligibility error with potential questioned costs. We examined 60 cases from of a total of 454,445 Medicaid claims from the Medicaid beneficiary report provided by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported with the financial statement audit as it relates to Medicaid administrative cost compliance audit.