Finding Text
US Department of Health and Human Services
Passed through the NC Dept. of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL # 93.778
Finding: 2023-008 Untimely Review of SSI Termination
SIGNIFICANT DEFICIENCY
ELIGIBILITY
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL# 93.778
SIGNIFICANT DEFICIENCY/ NONCOMPLIANCE: Finding 2023-004, 2023-005, 2023-006, 2023-007, 2023-
008 also apply to State requirements and State Awards.
Questioned Costs: There was no known affect to eligibility and there were no known questioned costs.
Context: We examined 60 from a total of 911,554 Medicaid claims from the Medicaid beneficiary report provided
by NC Department of Health and Human Services to re-determine eligibility. These findings are being reported
with the financial statement audit as it relates to Medicaid administrative cost compliance audit.
Criteria: In accordance with the Medicaid Manual MA-3120, the State sends notification to the County when a
participant is no longer eligible under Supplemental Security Income (SSI) determination, the County is required
to initiate the ex parte review within 5 workdays of the date the termination appears on the SSI Termination
Report, and complete the redetermination within 4 months of the month the case appears on the SSI Termination
Report and notify the recipient about applicant's ongoing eligibility for Medicaid.
Condition: There were 1 applicant/beneficiaries not reviewed timely and determined to be eligible for Medicaid
when their SSI benefits were terminated.
Section IV. State Award Findings
Effect: The County did not initiate ex parte review timely, therefore, no eligibility review was completed in the
required time period. The lack of follow up and certification lead to applicants receiving Medicaid benefits for
which they were not eligible.
Cause: Ineffective communication between departments within the Department of Social Services. One area
within DSS received State communications that applicants would no longer be eligible for SSI benefits and the
County needed to conduct an application process. This information was not shared with other departments in DSS
from which the recipient was also receiving benefits.
Recommendation: Files should be reviewed internally to ensure proper documentation is in place for eligibility.
Workers should be retrained on what files should contain and the importance of complete and accurate record
keeping. We recommend that all files include online verifications, documented resources of income and those
amounts agree to information in NC FAST. The results found or documentation made in case notes should clearly
indicate what actions were performed and the results of those actions.
Views of responsible officials and planned corrective actions: The county agrees with the finding. Please refer
to the corrective action plan for details.
Identification of a repeat finding: This is a repeat finding from the immediate previous audit, 2022-007.