Finding 512944 (2024-004)

U.S. Department of Health and Human Services Passed through the NC Department of Health and Human Services Program Name: Medical Assistance Program (Medicaid; Title XIX) AL #: 93.778 Finding: 2024-004 Untimely Review of SSI Terminations SIGNIFICANT DEFICENCY ELIGIBILITY Criteria: Condition: Questioned Costs: Context: Effect: Cause: Recommendation: Views of responsible officials and planned corrective actions: Section III. Federal Award Findings and Questioned Costs (continued) Ineffective communication between departments within the Department of Social Services. One area within DSS received State communications that applicants would no longer be eligible for SSI benefits and the County needed to conduct an ex-parte review. This information was not shared with other departments in DSS from which the recipient was also receiving benefits. Any State communications related to applicants/beneficiaries should be shared with all areas from which the participant receives benefits. State files should be reviewed internally to ensure all actions have been properly closed and the corrective action has been taken. Workers should be retrained on what process needs to be followed when State communications are received. The County agrees with the finding. See Corrective Action Plan in the following section. In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a participant is no longer eligible under a SSI determination. The County has a certain time period to initiate an ex-parte review to determine whether the recipient qualifies for Medicaid under any other coverage group, such as Family and Children's Medicaid, North Carolina Health Choice for Children, Work First Family Assistance, or Medicaid for the Aged, Blind and Disabled. There was 1 applicant/beneficiary not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated. There was no known affect to eligibility and there were no known questioned costs. We examined 60 cases from of a total of 1,176,385 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. The County did not initiate ex-parte review timely, therefore, no eligibility review was completed in the required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for which they were not eligible.