Finding Text
Finding 2021-002
Information on the Federal Program:
Medical Assistance Program (Medicaid, Title XIX), CFDA # 93.778, Grant Period 1/1/21 – 12/31/21.
Criteria or Specific Requirement:
According to the OMB Uniform Guidance Compliance Supplement, only medically needy individuals, or families whose incomes and resources are insufficient to meet the costs of necessary medical services may receive Medicaid to cover the claims supported by medical records.
Condition:
There were multiple instances where eligibility files selected for review were either incomplete, or unable to be presented for audit review.
Questioned Costs:
Unable to be determined.
Context:
Per the Federal OMB Uniform Guidance Compliance Supplement, each individual who receives benefits under the Medicaid program should have a completed eligibility determination on file which is available for audit review.
Effect:
By failing to provide documentation that each individual receiving Medicaid benefits was eligible for the program, there could be instances where ineligible program participants are receiving assistance.
Cause:
Controls were not in place to ensure that all required eligibility determinations and supporting documentation were on file and available for audit review.
Management’s Response:
The case record for all Medicaid cases is defined as the electronic or paper record of forms, narratives and documents upon which eligibility decisions are made. It reads:
10:90-7.1 Establishment and maintenance of case records
(a) The case record is the official file, whether computerized or hard copy, of forms, chronological narrative, correspondence, and other documents pertinent to the application and determination of eligibility for Medicaid benefits. It constitutes a complete record of the county/municipal agency’s decisions and actions concerning eligibility for assistance in each case. Since it is the record on which decisions to grant, deny or continue assistance in accordance with law and regulations are made, it is mandatory that a case record be established and maintained for every individual who applies for and/or receives Medicaid benefits.
Electronic records for all disbursement are created by PCBSS employees on the state operated systems commonly referred to as FAMIS and GAAS that record the issuance of benefits and ensure that the information recorded accords with state eligibility regulations.
The decision as to whether to maintain paper copies of all pertinent documents is left by regulation to local decision. At 10:90-7.2 the contents of the case file are described in more detail. There is no requirement that hard copies of documents be placed in each case file. Caseworkers are required to note the inspection of case files and in local practice those notes are maintained in the locally operated GUMP eligibility system.
The regulation reads:
A record of all pertinent verifications, such as, but not limited to, birth certificates, Social Security numbers, driver’s licenses, and so forth.
All TANF, SNAP and Medicaid assistance cases are tracked and recorded in the locally operated GUMP system and a permanent record of each is maintained. Paper records of all documents are not maintained and are not required by the Division of Family Development.