Finding 570671 (2024-002)

U.S. Department of Health and Human Services Passed-through the Colorado Department of Human Services FFAL #93.778 Medicaid Cluster Eligibility Significant Deficiency in Internal Control Noncompliance 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 City and 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. Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: Four instances of non-compliance in which the City and 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. Cause: Due to the City and County’s ineffective monitoring, eligibility determinations were not completed in a timely manner and within the 45-day deadline. Effect: Failure to process applications timely could result in participants that are delayed approval of Medicaid services. Questioned Costs: None to report. Context/Sampling: A nonstatistical sample of 60 participants were selected for eligibility testing. Repeat Finding from Prior Years: Yes. Recommendation: We recommend the County utilize available COGNOS reports to determine which cases are nearing the exceeding processing guidelines. Views of Responsible Officials: Agree