Finding 1167850 (2025-002)

Edgecombe County, North Carolina Schedule of Findings and Questioned Costs For the Year Ended June 30, 2025 Section II. Financial Statement Findings (continued) Recommendation: The County should obtain recommendations regarding revisions of the schedule of services charges and improvements in the operation of or services rendered by the system so that they may meet the required debt coverage amounts in the future. Views of responsible officials: The County agrees with this finding. Please refer to the corrective action plan for details. US Department of Health and Human Services Passed through the NC Dept. of Health and Human Services Program Name: Medical Assistance Program (Medicaid) AL #: 93.778 Finding: 2025-002 SIGNIFICANT DEFICIENCY / NONCOMPLIANCE ELIGIBILITY Criteria:Federal regulations under 42 CFR § 435.956 require states to verify eligibility factors using electronic data sources where available, and to obtain documentation for unverifiable information. Additionally, the state's Medicaid manual (Aged, Blind and Disabled manual, Family and Children Medicaid manual and the Integrated Policy manual) mandates that all eligibility determinations include cross-verification of applicant-provided data against reliable external sources to ensure accuracy and prevent improper payments. Condition: There were a total of 25 errors found during our testing procedures: - There were 3 errors where income or household size was incorrectly calculated or inaccurate information was entered into the case file. In two notable instances, a failure resulted in a recipient being deemed eligible for Medicaid benefits when they were not, due to income exceeding the eligibility threshold. - There was 1 error where resources were incorrectly calculated or were not properly documented in the case file. - There were 15 errors where required information needed for eligibility determinations were not requested or not requested timely at applications or redeterminations. - There were 4 errors where applicants/beneficiaries not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. - There were 2 errors where a redetermination of eligibility was not performed in accordance with program requirements. Questioned Costs: Due to the nature of the populations provided from which the samples were chosen, we are unable to calculate questioned costs for the above mentioned potential eligibility and noncompliance errors. Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2024-002. Section III. Federal Award Findings 174Edgecombe County, North Carolina Schedule of Findings and Questioned Costs For the Year Ended June 30, 2025 Program Name: Medical Assistance Program (Medicaid) AL# 93.778 Section III. Federal Award Findings (continued) SIGNIFICANT DEFICIENCY/ NONCOMPLIANCE: Finding 2025-002 also apply to State requirements and State Awards. Views of responsible officials and planned corrective actions: The County agrees with the finding and is implementing actions to correct these issues, which are further discussed in the corrective action plan. Section IV. State Award Findings Recommendation: We recommend that management enhance internal controls by: (1) Providing comprehensive training to staff on the program's eligibility requirements and procedures outlined in the State's Medicaid manuals; (2) Ensuring that there is a formal internal review process and that it is adequately completed to identify and correct errors and monitor compliance; and (3) Communicating all program or policy changes clearly and timely across all departments who oversee eligibility determinations for federal funded programs. Context: We examined 60 cases from of a total of 588,500 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. Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2024-003, 2024- 004, 2024-005, 2024-006 and 2024-007. Note in FY 2025 Medicaid findings were combined into a single finding. Effect: For those certifications/re-certifications there was a chance that information was not properly documented and reconciled to North Carolina Families Accessing Services through Technology (NC FAST) and a participant could have been approved for benefits for which they were not eligible. Cause: These control deficiencies and noncompliance increase the risk of improper Medicaid payments, potentially resulting in overpayments to ineligible beneficiaries or underpayments to those who qualify. 175