Despite the COVID-19 Public Health Emergency, the Department Can Do More to Address Chronic Medi-Cal Eligibility Problems
Learn how the AI-generated research projects were createdOverall Conclusion
Health Care Services halted efforts to resolve hundreds of thousands of known Medi-Cal eligibility discrepancies during the public health emergency, leading to a growing backlog and increased risk of improper payments and federal penalties; some emergency waivers and communications were implemented, but more action is needed.
Source Document
Audit Scope
The audit covers Health Care Services' management of Medi-Cal eligibility and related processes during the COVID-19 public health emergency, including discrepancies between state and county data systems, eligibility alerts, waivers, and redetermination preparations.
Key Findings Summary
Health Care Services halted the pilot program and paused eligibility work, causing a 22% increase in eligibility discrepancies over the previous year and a backlog exceeding 500,000 as of March 2021.
More than 37,000 Medi-Cal beneficiaries are identified as eligible in county data systems but not in the state data system, risking access to care.
364,000 beneficiaries have questionable eligibility requiring county action, with an estimated monthly cost of $195 million.
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AI-Assisted
AI Scope Summary
Future Medicaid audits should assess whether Health Care Services and counties implement the recommended actions to monitor cross-system eligibility data, resume overdue determinations, expand focus reviews, and ensure robust redetermination processes as the public health emergency ends and post-emergency operations resume.
AI-Generated Insight
During the COVID-19 emergency, the department paused key eligibility work, creating a growing backlog of discrepancies and elevated risk of improper Medi-Cal payments and federal penalties. Addressing high-risk alerts, resuming focus reviews, and enhancing county guidance are critical to stabilize eligibility determinations post-emergency.