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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-09-16-02023
Report Description

The Patient Protection and Affordable Care Act gave States the option to expand Medicaid coverage to low-income adults without dependent children. It also mandated changes to Medicaid eligibility rules and established a higher Federal reimbursement rate for services provided to these beneficiaries, which led us to review whether States were correctly determining eligibility for these newly eligible beneficiaries. California was one of 31 States, along with the District of Columbia, that chose to expand Medicaid coverage.

Report Type
Audit
Location

CA
United States

Number of Recommendations
7
Additional Details
https://oig.hhs.gov/oas/reports/region9/91602023.asp

Open Recommendations

This report has 6 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
262778 No $0 $0

We recommend that the State agency develop and implement written policies and procedures to ensure that applicants who did not want or did not intend to apply for Medicaid are not determined eligible.

262775 No $0 $0

We recommend that the State agency ensure that all eligibility requirements are properly verified.

262774 No $0 $0

We recommend that the State agency ensure that eligibility caseworkers properly input applicant information.

262773 No $0 $0

We recommend that the State agency ensure that CalHEERS and SAWS have the system functionality to: deny or discontinue Medicaid for an ineligible beneficiary after a previous determination has already been made on the basis of the beneficiary’s MAGI, properly process cases for beneficiaries who were formerly in the foster-care youth program, use SSA data to verify whether a beneficiary is entitled to or enrolled in Medicare, properly redetermine eligibility when a beneficiary is no longer a child, and retrieve and use information from the Department of Homeland Security to determine whether a beneficiary has met the 5-year-bar requirement to be eligible to receive full-scope Medicaid services.

262776 No $0 $0

We recommend that the State agency ensure that eligibility determinations are made in accordance with Federal and State requirements for beneficiaries: who do not provide the required information, e.g., citizenship or lawful presence status, whose presumptive eligibility period has ended, and who may not have met the residency requirement.

262777 No $0 $0

We recommend that the State agency develop and implement written policies and procedures, as necessary, to ensure that all payments for nonemergency and non-pregnancy-related services are adjusted for beneficiaries who are subject to the 5-year bar.

Department of Health & Human Services OIG

United States