Minnesota Office of the Legislative Auditor
Financial Audit Division

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Report Summary
Department of Human Services'
Oversight of MNsure Eligibility Determinations for
Public Health Care Programs

 

Financial Audit Division Report 14-22 Released November 12, 2014

In fiscal year 2014, the state spent approximately $9.6 billion ($4.4 billion of state money and $5.2 billion of federal money) to pay for benefits provided under the state’s public health care programs. The programs—Medical Assistance (Minnesota’s Medicaid program); MinnesotaCare; and the Children’s Health Insurance Program—are available to residents with low incomes.1

The Department of Human Services (DHS) is responsible for ensuring that people who receive benefits through the state’s public health care programs meet federal and state eligibility requirements. For more than 10 years, the Office of the Legislative Auditor (OLA) has raised concerns about DHS’s ability to ensure that its eligibility decisions are correct.

Minnesota created a state-based health insurance exchange (MNsure) under the federal health care law, to help the state better manage its public health programs in two ways: (1) provide people with a convenient way to apply for benefits online, and (2) allow DHS to electronically determine who was eligible for coverage. MNsure began processing new applications for public health insurance programs on October 1, 2013. Through June 2014, the state paid $376 million of benefits for people MNsure enrolled in the state’s public health care programs.

The objective of this audit was to determine the effectiveness of DHS’s oversight of MNsure’s eligibility determinations to ensure people were eligible for the benefits they received and in compliance with federal and state legal requirements.

Conclusion

The Department of Human Services did not ensure that Medical Assistance, MinnesotaCare, and Children’s Health Insurance Program recipients who enrolled through MNsure were eligible for the benefits they received.

The department did not ensure that data accurately and securely transferred from MNsure into the state’s medical payment system.

The department had many instances where it did not comply with the federal and state legal requirements related to recipients’ eligibility for Medical Assistance, MinnesotaCare, and the Children’s Health Insurance Program. It also charged incorrect MinnesotaCare premium rates.

Key Findings

  • The Department of Human Services did not adequately verify that people who enrolled in public health care programs through MNsure were eligible for those programs.
  • The Department of Human Services lacked adequate controls to validate the completeness and accuracy of data transferred from MNsure to DHS’s medical payment system,2 and the department lacked monitoring controls to detect whether Office of MN.IT Services staff inappropriately accessed personal information.
  • Eligibility workers were unable to close cases when recipients had income and family relationship changes that made them ineligible for benefits or when recipients asked workers to close their cases.
  • The department did not verify critical criteria for eligibility – such as social security numbers, citizenship, income, and household sizes – which resulted in ineligible persons receiving public health care benefits, as discussed in Findings 5 through 7.

 


1 Medical Assistance (Minnesota’s Medicaid Program) and the Children’s Health Insurance Program provide low cost or free health coverage to low income residents. MinnesotaCare is available to low income Minnesotans who earn too much to qualify for Medical Assistance.

2 DHS’s medical payment system, the Medicaid Management Information System (MMIS), is a mechanized claims processing and information retrieval system required by the federal government.

More Information

Office of the Legislative Auditor ♦ Room 140, 658 Cedar St., St. Paul, MN 55155