ISSUE AREA: OF THE CASES REVIEWED, MEDICAID ELIGIBILITY POLICY AND PROCEDURES WERE NOT FOLLOWED IN 16.5% OF THE CASES
To determine whether eligibility decisions are being made correctly, a sample of 455 cases was taken. These cases were evaluated based on Federal and State guidelines provided field staff in the Income Maintenance Manual. This Manual serves as the authority for all eligibility decisions. Of the 455 cases sampled, 77 cases (or 17%) were found to contain errors as follows: incorrect eligibility decisions (10 cases representing 13.3% of the total errors); lack of verification such that a proper determination of eligibility could not be made (51 cases representing 68% of the total errors); or the entire file or relevant application had been lost (14 cases representing 18.7% of the total errors). Expenditures for cases determined to be in error totaled $146,343, accounting for about 12% of expenditures for cases in the sample. Insufficient training, a complex reference manual and insufficient case review combine to cause errors in Medicaid eligibility decisions.