Finding Text
Information on the Federal Program U.S. Department of Health and Human Services, passed through New Jersey Department of Human Services, Division of Family Development and Division of Medical Assistance and Health Services – Medicaid Cluster, Grants to States for Medicaid, Assistance Listing No. 93.778; 1/1/2025 – 12/31/2025 Criteria or Specific Requirement Per 42 CFR § 435.945(a) and § 435.948, State Medicaid agencies are required to verify income using electronic data sources to the extent available, and must ensure that eligibility determinations are based on accurate and verified information. Condition The GCDSS did not consistently verify income reported on the Medicaid applications prior to granting program eligibility to individuals. Questioned Costs The GCDSS is responsible for determining Medicaid eligibility; Medicaid benefit payments are made by the State and are not included in the GCDSS’s Schedule of Expenditures of Federal Awards. Accordingly, no questioned costs applicable to the GCDSS's federal expenditures were identified. Context During our testing of 40 Medicaid eligibility determinations, we identified two instances in which income information was not properly verified or evaluated in accordance with program requirements. In both instances, the errors affected the eligibility determination and resulted in individuals being determined eligible who otherwise would have been ineligible. Effect or Potential Effect Improper eligibility determinations may result in ineligible individuals receiving benefits, leading to questioned costs and potential disallowance by the federal agency. Cause Procedures and review controls were not sufficient to ensure that discrepancies between self-attested and electronically verified income were properly resolved and that supporting income documentation was accurately interpreted when determining Medicaid eligibility. Identification as a Repeat Finding The condition existed in the immediately preceding fiscal year – see Finding No. 2024-001. Recommendation We recommend that the GCDSS strengthen its internal controls over Medicaid eligibility determinations to ensure that discrepancies between self-attested income and electronically obtained information are appropriately resolved and that income documentation is accurately interpreted and calculated. View of Responsible Officials and Planned Corrective Action The responsible officials agree with the finding and will address the matter as part of their corrective action plan.