Review of State Children's Health Insurance Program Eligibility in California

EXECUTIVE SUMMARY:

The California Department of Health Services and the Managed Risk Medical Insurance Board (referred to collectively as the State agencies) (1) made some State Children's Health Insurance Program (SCHIP) payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements and (2) did not always adequately document eligibility determinations.  Of the 191 payments in the statistical sample, 7 payments totaling $259 (Federal share) were unallowable because the beneficiaries were ineligible for SCHIP.  In addition, for 12 sampled payments totaling $410 (Federal share), the case files were missing or did not contain adequate documentation supporting eligibility determinations.  As a result, for the 6-month audit period, we estimated that the State agency made between 104,162 and 407,226 payments totaling between $2,081,901 and $14,248,148 (Federal share) on behalf of ineligible beneficiaries . We also estimated that case file documentation did not adequately support eligibility determinations for an additional 220,344 to 600,063 payments totaling between $4,996,337 and $20,829,931 (Federal share). 

We recommended that the State agencies use the results of this review to help ensure compliance with Federal and State SCHIP eligibility requirements by (1) reemphasizing to beneficiaries the need to provide accurate and timely information and (2) requiring employees of MAXIMUS, Inc., and the California county government offices to verify eligibility information and maintain appropriate documentation in all case files The State agencies agreed with the recommendation.