Office of the Legislative Auditor - Financial Audit Division

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

 

Financial Audit Division Report 16-02

Released January 28, 2016

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In fiscal year 2015, the state spent approximately $11 billion ($4.6 billion of state money and $6.4 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) and MinnesotaCare—are available to residents with low incomes.¹

The Department of Human Services is responsible for ensuring that people who receive benefits through the state’s public health care programs meet federal and state eligibility requirements. In November 2014, we issued a report on the department’s oversight responsibility for ensuring people who enrolled in a state public health care program through MNsure met federal and state eligibility requirements for the program in which they were enrolled.² Because that report contained significant findings, we decided to do this follow-up audit.

Only a portion of the people enrolled in the Medical Assistance and MinnesotaCare programs had their eligibility determined through MNsure. As of March 31, 2015, about 470,000 of the 870,000 people enrolled in a public health care program enrolled through MNsure.³

The primary objective of this audit was to determine whether the department’s oversight of MNsure’s eligibility determinations ensured people were eligible for the health care benefits they received. Another objective was to determine if the department complied with eligibility requirements in federal and state regulations for the Medical Assistance and MinnesotaCare enrollees, whose income calculations were based on the new federal requirements.

Conclusion

The Department of Human Services did not ensure that all of the people enrolled in Medical Assistance and MinnesotaCare met the federal and state eligibility requirements for the program in which they were enrolled. As a result, the department paid benefits for ineligible people enrolled in public health care programs.

The Department of Human Services did not ensure that data accurately and securely transferred from MNsure to the state’s medical payment system.

As detailed in Appendix A, the Department of Human Services did not resolve 9 of 11 prior findings included in our Oversight of MNsure Eligibility Determinations for Public Health Care Programs report we issued in November 2014.

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. This is a repeat finding.
• The Department of Human Services lacked adequate controls to ensure the accurate and complete transfer of enrollee data from MNsure to the department’s medical payment system and to detect whether Office of MN.IT Services’ staff inappropriately accessed enrollees’ personal information. This is a repeat finding.
• The Department of Human Services did not reverify that Medical Assistance and MinnesotaCare enrollees who enrolled through MNsure remained eligible for the program within the required timeframes established in federal and state laws.
• The department did not adequately verify critical criteria for eligibility, such as social security numbers, citizenship, incomes, and household sizes, which resulted in ineligible persons receiving public health care benefits, as discussed in Findings 5 through 7. These are repeat findings.

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¹ Medical Assistance (Minnesota’s Medicaid program) provides 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 Office of the Legislative Auditor, Financial Audit Division Report 14-22, Department of Human Services Oversight of MNsure Eligibility Determinations for Public Health Care Programs, issued November 12, 2014.

³ The department used its legacy eligibility system, MAXIS, to enroll the other 400,000 Medical Assistance enrollees.