Finding Text
Hertford County, North Carolina Schedule of Findings and Questioned Costs For the Year Ended June 30, 2025 U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid) AL #: 93.778 Finding: 2025-003 MATERIAL WEAKNESS/MATERIAL NONCOMPLIANCE Eligibility Criteria: Condition: Questioned Costs: Section III. Federal Award Findings and Questioned Costs 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. There were a total of 28 errors found during our testing procedures: - There were 7 errors where income or household size was incorrectly calculated or inaccurate information was entered into the case file. In 4 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 3 error where resources were incorrectly calculated or were not properly documented in the case file. In 1 instance, a failure resulted in a recipient being deemed eligible for Medicaid benefits when they were not, due to resources exceeding the eligibility threshold. - There were 8 errors where required information needed for eligibility determinations were not requested or not requested timely at applications or redeterminations. In 1 instance, a failure resulted in a recipient being deemed eligible for Medicaid benefits when they were not, due to resources exceeding the eligibility threshold. - 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 6 errors where a redetermination of eligibility was not performed within Medicaid guidelines. In all 6 cases the County is not in compliance with program requirements. 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. 113Hertford County, North Carolina Schedule of Findings and Questioned Costs For the Year Ended June 30, 2025 Context: Effect: Identification of a repeat finding: Cause: Recommendation: Views of responsible officials and planned corrective actions: Program Name: Medical Assistance Program (Medicaid) AL # 93.778 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. The County agrees with the finding and is implementing actions to correct these issues, which are further discussed in the corrective action plan. MATERIAL WEAKNESS/MATERIAL NONCOMPLIANCE: Finding 2025-003 also apply to State requirements and State Awards. Section IV. State Award Findings and Questioned Costs Section III. Federal Award Findings and Questioned Costs (continued) We examined 60 cases from of a total of 625,001 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. 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. This is a repeat finding from the immediate previous audit, 2024-006, 2024-007, 2024-008, and 2024-009. Note in FY 2025 Medicaid findings were combined into a single finding. The deficiencies and noncompliance reported above are caused from ineffective record keeping and case review processes due to insufficient training of staff, lack of oversight from management, and/or inadequate communication between departments resulting in inconsistencies in data sharing and delayed information exchanges. 114