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
364,000 beneficiaries have questionable eligibility requiring county action, with an estimated monthly cost of $195 million.
Past audits identified significant weaknesses in eligibility processing, including $4 billion in questionable Medi-Cal payments (2018) and a 36% error rate in 2019 samples.
Focus reviews were not completed or reported for 2018-2019; limited corrective action plans and delays due to wildfires and emergencies.
View the Findings tab to see all 6 findings
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.
Audit Objectives
Assess Health Care Services' management of Medi-Cal eligibility during the COVID-19 public health emergency, including the handling of eligibility discrepancies and related potential federal reimbursements.
Evaluate whether Health Care Services and counties adequately address Medi-Cal eligibility alerts that could be resolved during the public health emergency and ensure readiness for redeterminations after the emergency.
Audit Findings (6)
364,000 beneficiaries have questionable eligibility requiring county action, with an estimated monthly cost of $195 million.
Past audits identified significant weaknesses in eligibility processing, including $4 billion in questionable Medi-Cal payments (2018) and a 36% error rate in 2019 samples.
Focus reviews were not completed or reported for 2018-2019; limited corrective action plans and delays due to wildfires and emergencies.
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.
2,400 beneficiaries had temporary eligibility for more than two months without final eligibility determinations, with 1,300 of these beneficiaries overdue for determinations since July 2019.
Recommendations (6)
Begin monitoring statewide alerts related to individuals identified as eligible for Medi-Cal in a county eligibility data system but not identified as eligible in the state eligibility system.
Instruct counties to resume processing overdue determinations for individuals who have received temporary eligibility and make a final determination.
Expand its planning efforts to address all high-risk eligibility alerts included in the pilot program.
Resume monitoring pilot program counties' progress in resolving high-risk eligibility alerts.
Review data collected during focus reviews conducted in 2018 and 2019 to identify policy gaps and share a written summary with all counties by September 1, 2021.
Resume focus reviews within four months of the end of the public health emergency.