Finding Text
Significant Deficiency Finding 2022-002 Eligibility U.S. Department of Health and Human Services HIV CARE Formula Grants CFDA No. 93.917 Condition During our audit, we selected a sample of 60 clients receiving assistance under the RWB program to ascertain whether those clients met the RWB program eligibility requirements. We noted that documentation supporting compliance with eligibility requirements for certain clients were incorrect, incomplete, or not provided. Specifically, we found that: - For 16 of the 60 clients selected, the file contained insufficient documentation to verify that the payer of last resort requirement was met. - For three of the 60 client files selected, the file did not have annual or semi-annual certification forms dated prior to certain dates of services, indicating that eligibility determinations were not performed prior to billing the Ryan White program. - For one of the 60 client files selected, the file contained certification forms that were more than 6 months apart. During that gap in certifications, services for the client were billed. - For one of the 60 clients selected, a bank statement was used for income determination. A bank statement alone does not document gross income as required to determine eligibility. Criteria Clients receiving assistance under the RWB program are subject to eligibility requirements contained in the Health Resources and Services Administration?s HIV/AIDS Bureau Policy Clarification Notice No. 13-02 Clarifications on Ryan White Program Client Eligibility Determinations and Recertification Requirements. To be eligible, clients must have a medical diagnosis of HIV/AIDS and be (a) a low-income individual, (b) a resident of the state, and (c) uninsured or underinsured, as defined by the state. Eligibility determination is required before participation in the RWB program during the in-take process. Re-assessments are performed at least once every 6 months thereafter. Per HHHRC?s Ryan White Eligibility Policy, these eligibility criteria are to be documented in their Annual Certification forms, and their Six-Month Semi-Annual Certification forms. HIV status must be documented by a written statement from a medical provider. Lab results may only be used on an interim basis. Residency must be documented with a State ID card or a driver?s license, lease agreement, utility bill, official government mail, bank statement, pay stub, or a verification letter from an agency providing the client with housing. Income levels must be documented with the most recent pay stubs covering 30 consecutive days, benefit statements, IRS tax transcripts, or a signed statement from the client attesting to no income or very low income. For the payer of last resort criteria, HHHRC?s policy states that they must, at a minimum, assess and re-assess the client?s eligibility for benefits such as MedQuest. In addition, HHHRC must make reasonable efforts to secure funding, besides the Ryan White program, including pursuing enrollment into health care coverage. Cause HHHRC did not adhere to established policies and procedures requiring that appropriate documentation be received and maintained to evidence compliance with eligibility requirements during the in-take and re-assessment process for the RWB program. As described in Finding 2022-001, HHHRC updated their formal policies and procedures effective April 1, 2022 to ensure that eligibility determinations performed by case managers during the in-take and re-assessment process are reviewed by a manager or knowledgeable employee other than the case manager. Effect HHHRC did not comply with the RWB program eligibility requirements for the instances noted above. Questioned Costs No questioned or known costs were identified. Identification of a Repeat Finding This finding was reported as a federal award finding in the immediate previous audit as Finding 2021-002. Recommendation We again recommend that HHHRC adhere to established policies and procedures requiring that appropriate documentation be received and maintained to evidence compliance with eligibility requirements during the in-take and re-assessment process for the RWB program. HHHRC should also consider expanding on their policies for payer of last resort, with more specific criteria for documentation required to support compliance with this requirement.