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YELLOW SHEET Office of the State Auditor of Missouri |
Report No. 2004-29
April 27, 2004
Management Weaknesses Increase the Risk Ineligible Recipients Remain Active in the Medicaid Program
This
audit reviewed the controls and procedures used by the Department of Social Services
to determine Medicaid eligibility.�
Auditors also focused on the potential unnecessary Medicaid program costs
paid by the state when recipients were incorrectly determined eligible for
benefits or remained eligible beyond limits established in state and federal
regulations.
More than 40
percent of Medicaid recipients had no recent eligibility reevaluation
Caseworkers
are not performing annual eligibility redeterminations as required by federal
and state regulations.� As of June 30,
2003, eligibility had not been redetermined for a year or more for 383,004 of
934,453 recipients (41 percent).� In July
2002, caseworkers were notified they could stop doing routine eligibility
redeterminations.� Officials said
caseworkers could not keep up with their current workload given staffing available
under current budget limits. �Instead,
these caseworkers were to use various computer-generated data matches and
exception reports to identify changes for recipients that could impact
eligibility and focus on those cases. ��However, our analysis identified numerous
weaknesses in the match and report processes impacting identification and
review of recipient eligibility status. �(See page 3)
Social security numbers not being
obtained on all recipients
Federal
regulations require a Medicaid recipient furnish a valid social security number
(SSN) to receive benefits, but auditors found caseworkers were not obtaining
valid SSNs on all recipients.� As of June
30, 2003, auditors identified nearly 45,000 �active Medicaid recipients without a SSN or an
invalid SSN in department computer systems.�
Federal regulations do not allow states to deny or delay benefits
pending obtaining or verification of a SSN, but auditors found 67 percent of
these recipient's cases had been open at least a year.� Review of case documentation for a sample of
these recipients indicated 30 percent of recipients with no reported SSN did
not have one noted in their case file and nearly 50 percent of invalid SSNs
were the result of caseworker input errors. �In addition, auditors found a monthly
exception report listing recipients with no or an invalid SSN was inadvertently
discontinued, which went unnoticed until auditors identified it. �Obtaining valid SSNs for all recipients (including
children) is an important step in ensuring only eligible individuals receive
Medicaid services.� (See page 5)
State allowing some recipients to remain
Medicaid eligible beyond their age limit
Children
who are 19 are normally no longer eligible for Medicaid. �As of July 2003, auditors identified 2,510
recipients over age 19 who received nearly $1.3 million in �Medicaid services after they became ineligible.� Caseworkers have access to a report showing
�recipients reaching age limits, but they
said they have no time to review the report or did not receive it timely.� (See page 6)
Some deceased recipients are not being identified
Procedures
to identify recipients who have died are not as effective as possible.� Auditors identified 1,112 active recipients
the department's death match analysis had not identified.� Medicaid payments totaling at least $144,000
were made for these recipients after their death. �Auditors used historic death records and different
match criteria to identify the deceased recipients.� (See page 7)
Matches to
wages and unemployment benefits not being done
Computer
matches to verify wages and unemployment benefits on active Medicaid employees
were stopped in July 2000 unbeknownst to officials until auditors identified it.� Federal regulations require state officials
to verify wages when a person applies for Medicaid and quarterly thereafter,
and verify unemployment benefits. �A
recipient's unreported job or wage changes would likely be missed by
caseworkers without these matches.� (See
page 10)
Faulty edit causes unnecessary program
costs
Auditors
identified 111 recipients who were active on Medicaid as of June 30, 2003,
whose Medicaid eligibility start date preceded their birth date.� This problem resulted in unnecessary costs of
at least $35,000. �A system edit is
supposed to ensure Medicaid eligibility is not started before a recipient's
birth date; however, starting in March 2000, this edit was not being applied to
newborns being added to the mother's case.�
As of January 2004, division officials were working to correct the edit problem.
�(See page 10)
