| Medical Assistance Program |
Eligibility. Out of 140 beneficiaries tested, there were 47 beneficiaries with eligibility exceptions. In addition to these exceptions, the U.S Department of Health and Human Services Office of Inspector General (OIG) issued a report in February 2018. OIG sampled 150 beneficiaries and found California made Medicaid payments on behalf of 112 eligible beneficiaries. However, for the remaining 38 beneficiaries, California made payments on behalf of ineligible and potentially ineligible beneficiaries. These deficiencies occurred because California's eligibility determination systems lacked the necessary system functionality, and because county welfare agencies' eligibility caseworkers made errors.
Health Care Services should continue its practice of performing regular focus reviews on county welfare agencies to identify factors contributing to the delays and errors in the redetermination process and then work with county welfare agencies to provide appropriate training and/or creating corrective action plans.
Health Care Services should complete the development of and implement a quality control process to monitor all critical and urgent level Medi-Cal Eligibility Data System (MEDS) alerts to be able to quickly identify county welfare agencies that are not resolving MEDS alerts in a timely manner. Health Care Services should also incorporate into the MEDS alert functionality the ability to alert county welfare agencies when eligibility redeterminations are required or overdue. Health Care Services should then work directly with those county welfare agencies that are not performing eligibility redeterminations in a timely manner and who may not be
correctly verifying eligibility through training and site visits to implement policies and procedures to improve its compliance status. |
2014-15 |
| Partially Corrected – repeat finding – refer to 2019-005. Health Care Services performs site visits/focus reviews on counties to identify factors contributing to delays/errors in renewal processing. Health Care Services continues to conduct regular focused reviews of counties to ensure eligibility determinations are performed in accordance with federal/state regulations. Health Care Services completed focus reviews for 39 counties and planned to review the remaining 19 counties by December 31, 2020. Due to the COVID-19 pandemic, Health Care Services has temporarily suspended the 2020 site visits and focus reviews. Health Care Services will resume effort upon termination of the pandemic. Health Care Services is working to develop two new Medi-Cal Eligibility Data System (MEDS) alerts, which will be used to notify counties of past due renewals and track the number of months since the last renewal. Alerts will be used by Health Care Services’ quality control staff to monitor overdue renewals and quickly identify counties accruing a high volume of past due renewal alerts. Health Care Services will work with counties to implement processes/procedures that are effective in reducing the number of renewals processed in excess of federal/state timeframes. |
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| Medical Assistance Program |
Activities Allowed or Unallowed. Twenty-three of the 56 contractor counties of Short-Doyle funding were tested and eight had not submitted their cost reports timely. Although the Mental Health Division of Health Care Services did take the required action of notifying the eight subrecipients in writing within 30 days of the noncompliance, it has not taken any additional action necessary to ensure contract and performance compliance.
The Mental Health Division should develop and follow policies and procedures to take additional action for significantly late annual cost reports. These policies and procedures should include imposing sanctions, including, but not limited to, fines, penalties, the withholding of payments, probationary or corrective actions, or any other actions deemed necessary to promptly ensure contract and performance compliance. |
2015-16 |
| Partially Corrected – repeat finding – refer to 2019-003. Health Care Services drafted policies and procedures prior to the end of the 2019 legislative session, to impose administrative and financial sanctions, such as but not limited to, fines, penalties,
and corrective actions, when a county does not comply with existing requirements for submitted cost reports. Before the new policies and procedures can be implemented, additional work is required to confirm they do not conflict with state or federal laws and regulations, contract provisions, or other applicable guidance and requirements adopted during the 2019 legislative session. Estimated implementation date is December 31, 2020. |
25 |
| SCHIP (State Children's Insurance Program) |
Activities Allowed or Unallowed. Twenty-three of the 56 contractor counties of Short-Doyle funding were tested and eight had not submitted their cost reports timely. Although the Mental Health Division of Health Care Services did take the required action of notifying the eight subrecipients in writing
within 30 days of the noncompliance, it has not taken any additional action necessary to ensure contract and performance compliance.
The Mental Health Division should develop and follow policies and procedures to take additional action for significantly late annual cost reports. These policies and procedures should include imposing sanctions, including, but not limited to, fines, penalties, the withholding of payments, probationary or corrective actions, or any other actions deemed necessary to promptly ensure contract and performance compliance. |
2015-16 |
| Partially Corrected – repeat finding – refer to 2019-003. Health Care Services drafted policies and procedures prior to the end of the 2019 legislative session, to impose administrative and financial sanctions, such as but not limited to, fines, penalties,
and corrective actions, when a county does not comply with existing requirements for submitted cost reports. Before the new policies and procedures can be implemented, additional work is required to confirm they do not conflict with state or federal laws and regulations, contract provisions, or other applicable guidance and requirements adopted during the 2019 legislative session. Estimated implementation date is December 31, 2020. |
25 |
| Medical Assistance Program |
Special Tests and Provisions – Risk Analysis and System Security Review. The California Medicaid Management Information System (CA-MMIS) Division of Health Care Services uses a service organization/fiscal intermediary to perform many fiscal components of the administration of the program. CA-MMIS obtained from the fiscal intermediary, an independent service auditor's Service Organization Control (SOC) report on the suitability of the design and operating effectiveness of controls for the period of July 1, 2015 to June
30, 2016. The report included a number of deficiencies, three of which were significant enough to warrant the service auditor to modify its opinion on controls. During the biennial period July 1, 2016 - June 30, 2018, the CA-MMIS Division continuously monitored the fiscal intermediary's efforts to implement required corrective actions to resolve these deficiencies. However the fiscal intermediary has demonstrated its inability to implement the required corrective actions.
Since the fiscal intermediary has not been effective in implementing the CA-MMIS Division's corrective actions required to resolve significant deficiencies noted for general controls over logical access to systems, programs and data, the CA-MMIS Division should evaluate the continued risks associated with these deficiencies and consider further actions permitted under its contract to remediate the deficiencies or consider alternate service providers. |
2017-18 |
| Remains Uncorrected – repeat finding – refer to 2019-009. Adoption of the new services management framework and assumption of operations to the new IBM contract occurred on October 1, 2019. Some Health Care Services’ owned access control activities have started. Further improvements, such as automated workflows, will evolve over time as we mature in our Information Technology Services Management operating model. Estimated implementation date is July 1, 2020. |
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