Finding Text
MATERIAL WEAKNESS
Required verifications and documentation for Eligibility
Criteria: Per the North Carolina Medicaid Assistance Program Compliance Supplement, the DSS
manuals (Aged, Blind and Disabled manual and the Family and
Children Medicaid manual), and Administrative Letters from the Division of
Health Benefits case files for individuals or families receiving assistance are required to retain
documentation to evidence appropriate eligibility determination, including verifications of and support
for:
Age
Citizenship/Identity
State residency
Household composition and relationship
Living arrangement
Social Security Number
Pregnancy (if applicable)
Disability, Blindness (if applicable)
Medicare
Cooperation with Child Support
Liquid Assets
Vehicles and Other Personal Property
Real Property
Deductibles
Income (Self-employment, Other earned income, Unearned income)
Accurate computation of countable income and resources.
Reviews/Applications must be completed timely.
The DSS manuals and Administrative Letters also provide income maintenance amounts and resource
limits for the respective Medicaid program and budget unit size. The computed countable income
and resources must be under these limits for the person / family to be eligible for the Medicaid
program.
Condition: We noted 64 instances of case records not containing the proper verifications or proper
computations as required by policy. The files for twelve claims did not contain appropriate
verification of real property ownership with the Register of Deeds Office and the Tax Office resulting
in 13 errors. Files for 4 claims did not properly verify or document vehicles per policy. Vehicles
were not rebutted timely, not keyed into evidence timely or not keyed into evidence at all. Nine of
the claims had files that did not properly verify or document bank accounts, correctly document
ownership of liquid resources, and enter information in to evidence correctly or timely for liquid
resources resulting in 16 errors. There were 9 cases where disability information was not properly
entered into evidence. 6 claims did not properly verify and document the living arrangement of the
applicant. There 8 claims where the corresponding files show that policy was not followed and
verified correctly including exparte reviews not being completed timely, citizenship, household
composition was not properly documented, incompetency entered into evidence, and unmet medical
needs documented. There were files related to seven claims that income was not counted correctly or
not updated in evidence which resulted in 8 errors.
Questioned Costs: There were no known errors in our testing for claims being paid on an ineligible
recipient.
Context: Out of $47,704,603 Medicaid claims paid during the year, we tested the Medicaid
certification of eligibility (initial application or recertification of eligibility) that related to the period
that included the date of service for the claim being tested for 101 claims that totaled $37,978. The
conditions noted above were noted in 31 of the 101 claims tested.
Effect: Case files not containing all required documentation result in a risk that the County could
provide services to individuals not eligible to receive such services or that such individuals could be
denied access to eligible benefits. Upon notification of the missing documentation or the errors in
calculations in the case files, the County was able to obtain documentation and provide corrected
calculations to substantiate that the recipients tested were eligible to receive benefits in all cases.
Identification of a repeat finding: This is a repeat finding from previous audits, 2022-4, 2021-5,
2020-1, 2019-1, 2017-1, 2017-2, 2016-1, 2016-2, 2016-3, 2016-4, 2016-5, and 2016-6.
Cause: The County did not obtain or retain required documentation in case files at the time that
eligibility was determined. The review performed by the caseworker was ineffective in determining
that all required items were retained, that all calculations were accurate, and that all necessary
information was entered into NCFast.
Recommendation: We recommend that the County train and monitor employees on the eligibility
determination process, specifically those areas noted to have errors above. Files should be reviewed
internally to ensure proper documentation is in place for eligibility. Work aids for areas such as
resources may be helpful for Caseworkers as they document the eligibility process. NCFast should be
reviewed to determine that information gathered during the review is properly input into the system
and that system driven calculations are utilizing the available information.
Views of responsible officials and planned corrective actions: The County will continue to train
employees on a monthly basis and as needed when new and updated policies are received.
Supervisors and lead workers will continue to conduct second party reviews and utilizing any
findings to aid in training staff on any necessary policy information. The department will continue to
implement changes as necessary to achieve the overall improvement of eligibility determinations.