Finding Text
US Department of Health and Human Services
Passed-through the NC Dept. of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
CFDA #: 93.778
Finding: 2024-2
SIGNIFICANT DEFICIENCY
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 21 instances of case records not containing the proper verifications,
documentation or computations as required by policy for the claim that we tested. Two cases were not
properly documented in evidence for liquid assets based on the verifications received. One claim did
not have proper verification and documentation for real property. One case did not contain proper
documentation and verification of living arrangement. Three cases did not contain proper verification
of vehicle ownership and value of vehicles. Two cases had a review that was not completed timely.
Five cases did not have proper verification and / or documentation of income. Of those cases four were
regarding earned income and one was regarding unearned income. Four cases did not properly
document household composition, relationships, and tax filing status. Two cases did not apply the
correct policy and rules for budgeting for things such as PLA vs long-term care budget and which
deductions from income are allowable. One case did not properly document residency for type of
verification used.
Questioned Costs: There were no known errors in our testing for claims being paid on an ineligible
recipient.
Context: Out of 680,717 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. The conditions noted above were noted in 15
of the 101 claims tested.
Effect: Case files not containing all required documentation results in a risk that services could be
provided to individuals not eligible and that individuals could be denied benefits for which they are
eligible. 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: Missing documentation/information has been a finding in previous
audits, 2023-2, 2022-2, 2021-1, 2020-2, 2019-1, 2017-1, 2017-2, 2016-2, and 2016-3. There has been
improvement in this area in recent years.
Cause: Missing information could result in improper determination of eligibility. The eligibility
determined by the caseworker in thirteen of the fifteen claims failed to ensure that all required items
were retained, that all calculations were accurate, and that all necessary information was entered into
NC FAST. In two of the fifteen claims, the review process was not completed in a timely manner.
Recommendations: 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. NC FAST 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 acknowledges the technical
and internal control errors noted and has ongoing measures in place to ensure that both initial
determination and ongoing redetermination in timeliness and accuracy of eligibility determination is in
the Medicaid program. The agency has measures in place with the Quality Assurance unit, who is solely
dedicated to second party reviews to identify any errors and determine needed training and/or
supervision for staff. The agency recognizes the critical importance of ensuring accuracy and timeliness
in the Medicaid program and strives to make efforts to ensure that all measures are in place for training,
second party reviews, and quality control to include Quality Assurance team, Medicaid Supervisors,
and Medicaid Lead Workers.