Finding 575688 (2024-004)

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, federal requirements as described at 42 CFR 435.139 and 435.350 requires state medical assistance programs to provide medical coverage for care and services that are necessary to treat a medical emergency for individuals who do not meet immigration or citizenship requirements for Medicaid through Health First Colorado (Colorado’s Medicaid Program). Per the Colorado Department of Health Care policy memo number HCPF PM 22-006, Emergency Medicaid only covers the treatment of emergency medical conditions that a physician determines (confirms) to be life- or limb-threatening and is coded as an emergency. Members who submit an initial application and are determined eligible for Emergency Medicaid Services will receive these services for up to a 12-month period or until the case is redetermined at the end of their renewal period. A 12-month period does not guarantee paid services: all services must be considered emergency treatment by a physician to be covered. Condition: We tested eligibility determination and controls over this process for sixty case files. We noted the following in our testing: • Six instances 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. • One instance of non-compliance in which the County did not identify that the participant no longer qualified for Emergency Medicaid Services and continued to provide benefits to the participant. Cause: Due to the 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, 2023-008 Recommendation: We recommend the County utilize available COGNOS reports to determine which cases are nearing the exceeding processing guidelines and which cases are life- or limb-threatening related and ensure re-determinations are completed accurately. Views of Responsible Officials: Agree