Finding 1220049 (2023-001)

Material Weakness Repeat Finding
Requirement
E
Questioned Costs
-
Year
2023
Accepted
2026-06-29

AI Summary

  • Core Issue: Incomplete or missing eligibility files for Medicaid recipients raise concerns about compliance with federal requirements.
  • Impacted Requirements: Each Medicaid recipient must have a complete eligibility determination on file for audit purposes, as outlined in the OMB Uniform Guidance.
  • Recommended Follow-up: Implement stronger controls to ensure all eligibility documentation is complete and readily available for future audits.

Finding Text

Finding 2023-001 Information on the Federal Program: Medical Assistance Program (Medicaid; Title XIX), ALN # 93.778, Grant Period 1/1/23 – 12/31/23. Criteria or Specific Requirement: According to the OMB Uniform Guidance Compliance Supplement, only medically needy individuals, or families whose incomes and resources are insufficient to meet the costs of necessary medical services may receive Medicaid to cover the claims supported by medical records. Condition: There were multiple instances where eligibility files selected for review were either incomplete, ineligible for benefits, or unable to be presented for audit review. Questioned Costs: Unable to be determined. Context: Per the Federal OMB Uniform Guidance Compliance Supplement, each individual who receives benefits under the Medicaid program should have a completed eligibility determination on file which is available for audit review. Effect: By failing to provide documentation that each individual receiving Medicaid benefits was eligible for the program, there could be instances where ineligible program participants are receiving assistance. Cause: Controls were not in place to ensure that all required eligibility determinations and supporting documentation were on file and available for audit review.

Corrective Action Plan

Medical Assistance Program (Medicaid, Title XIX), CFDA #93.778, Grant Period 1/1/23-12/31/23. Context: As per the Federal OMB Uniform Guidance Circular Compliance Supplement, each individual who receives benefits under the Medicaid program should have a complete eligibility determination on file, which is available for audit review. Corrective Action: PCBSS has implemented additional enhancements to support the DIMS Unit, where case files are scanned and electronically stored. The agency increased staffing dedicated to document scanning and streamlined the transfer process from worker units to the DIMS Unit. These improvements help ensure that cases are properly identified, organized, and maintained, and that supporting documentation is uploaded timely and accurately. Additionally, several Medicaid cases identified during the review were initially established by the State of New Jersey and/or third-party vendors contracted by the State prior to being transferred to the county for ongoing case management responsibilities. As a result, PCBSS did not possess the original applications or supporting eligibility documentation because the initial eligibility determination and enrollment process had already been completed before the cases were transferred to the county. Moving forward, PCBSS will provide auditors with system-generated portal documentation identifying the originating agency responsible for the initial case establishment. Implementation Date: Commenced in 2023 and ongoing.

Categories

Eligibility

Other Findings in this Audit

  • 1220050 2023-002
    Material Weakness Repeat
  • 1220051 2023-003
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.778 GRANTS TO STATES FOR MEDICAID $17.91M
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $12.96M
10.551 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $10.96M
93.563 CHILD SUPPORT SERVICES $3.30M
93.667 SOCIAL SERVICES BLOCK GRANT $1.73M
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $447,922
93.044 SPECIAL PROGRAMS FOR THE AGING, TITLE III, PART B, GRANTS FOR SUPPORTIVE SERVICES AND SENIOR CENTERS $415,906
93.568 LOW-INCOME HOME ENERGY ASSISTANCE $34,890