Finding 565372 (2024-002)

Criteria: The Federal requirement related to processing of an application requires the State to provide notice of its decision concerning eligibility and provide timely and adequate notice of the basis for denial or termination of assistance (42 USC 1320c-7(d)). According to the Colorado Department of Health Care Policy and Financing (HCPF), processing standards 8.100.3.D, the County is required to process an initial application for any program not requiring a disability determination no later than 45 days following receipt of application. In addition, per the Code of Colorado Regulations, in order to be an eligible participant in the Medicaid program one must be a citizen of the United States and meet certain income guidelines. Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: • One instance of non-compliance in which the County did not complete the eligibility determination and approve/deny the case within 45 days and no notice of action was sent to the client within the required timeframe. • Two instances of non-compliance in which the County did not ensure removal from the Medicaid program due to cases being ineligible, where eligibility is determined by a third party, because of over income or being undocumented. Cause: Due to the County’s ineffective monitoring, eligibility determinations were not completed in a timely manner and within the 45-day deadline and cases not removed from the program for being ineligible. Effect: Failure to process applications timely could result in participants that are delayed approval of Medicaid services. Failure to determine the appropriate eligibility will result in participants receiving benefits from the state in error. Questioned Costs: None reported Context/Sampling: A nonstatistical sample of 60 participants were selected for eligibility testing. Repeat Finding from Prior Year(s): No Recommendation: We recommend the County utilize available reports to determine which cases are nearing the exceeding processing guidelines. Further, we recommend the County strengthen its controls over approving cases as eligible.