Finding 583599 (2023-001)

2023-001: Compliance Qualification and Material Weakness - Eligibility for Medical Assistance Program - Medicaid Cluster (AL Number 93.778) - U.S. Department of Health and Human Services - Virginia Department of Social Services (Repeat finding 2021-001). Criteria: Per the Virginia Medical Assistance Eligibility Manual, an annual review of all of the enrollee’s eligibility requirements is called a renewal. A renewal of the enrollee’s eligibility must be completed at least once every 12 months. The renewal can be initiated in the 10th month to ensure timely completion of the renewal (Subchapter M1520.001) A signed application for medical assistance is required for all initial request for medical assistance (Subchapter M0120.300) and the renewal must be signed by the enrollee or authorized representative (Subchapter M1520.200). An application for medical assistance must be signed to be valid (Subchapter M0120.150). The case records must contain facts essential to the determination of initial and continuing eligibility (Subchapter M0110.400). It also states that the agency must include in the case record documentation to support the agency’s decision on his application (Subchapter M0110.000). Condition: Of the sixty (60) participants selected for testing, one (1) participant did not have either a renewal or an original application located in the physical participant case file or in the electronic Medicaid system. Consequently, the initial or required re-determination of the participants eligibility could not be verified through our testwork. Cause: Prior to a clarification received in August of 2019, the Newport News Department of Human Services had been operating under an interpretation of policy that supported retaining three years of Medicaid record documents. While case record materials for Medicaid began being scanned into the VaCMS/DMIS system at application in 2015, paper records were maintained for previously approved, ongoing cases. In an effort to keep paper records manageable, they were frequently purged of materials that were sent to closed files. These files were noted with a destroy date of three years from date of purge. Due to the undeterminable number of missing records, the City implemented a plan to obtain new applications as the need arose. Effect: The City’s non-compliance could result in cost disallowed by the grantor or a reduction in future funding for this program. Questioned Cost: Undeterminable. Recommendation: The City should continue executing its corrective action plan to enhance internal controls related to participant eligibility to ensure that participant files contain adequate supporting documentation in accordance with Medicaid requirements. Views of Responsible Officials and Planned Corrective Actions: The Department of Human Services is in agreement with the findings related to missing application/renewal forms for the noted cases. Refer to the City’s corrective action plan for further details.