1 Medical Assistance Eligibility Determinations Legislative Audit Bureau December 2004

2 Overview u DHFS administers Wisconsin’s Medical Assistance program u The FY budget is $4.3 billion u Families with assets but limited incomes became eligible for benefits in July 2000 u In 2001, documentation of wages and other information used to determine eligibility was no longer required

3 Increases in Enrollment Total Enrollment for June

4 Program Expenditures u Expenditures for program benefits increased by 48.6 percent –Benefit expenditures increased from $2.9 billion in FY to $4.3 billion in FY u Administrative expenditures increased by 2.1 percent –Administrative expenditures totaled $169.6 million in FY

5 Comparisons with Other States u States have flexibility in designing coverage under Medical Assistance u At 185 percent of the federal poverty level, Wisconsin covers parents with higher incomes than any midwestern state except Minnesota u Wisconsin is one of only 12 states that do not require documentation of income

6 Worker Errors u Worker errors affected eligibility for 13 of 200 cases we reviewed u We found no instances of non-citizens or non-Wisconsin residents receiving benefits inappropriately

7 Income Discrepancies u We found 10 of 200 cases with income discrepancies that would have affected eligibility u In-person applications resulted in more accurate income estimates

8 Denied Applications u In 13 of 101 cases, applicants were inappropriately denied benefits u In January 2004, an estimated 1,100 individuals were inappropriately denied benefits as a result of the CARES problem u DHFS fixed the problem in July 2004 after we brought it to the Department’s attention

9 Program Integrity Efforts u Efforts to prevent fraud and abuse have been limited in recent years u Since 1998, approximately one-third of counties did not attempt to recover inappropriately granted benefits in any given year u Since 1995, funding for program integrity efforts declined 76 percent to $2.3 million in 2004

10 Obstacles to Benefit Recovery u Inconsistencies in statutes and policies have hampered benefit recovery efforts u Several counties reported having benefit recovery cases overturned at hearing because of these inconsistencies u We recommend inconsistencies in statutes and DHFS policies be corrected

11 Other Recommendations u We recommend DHFS: – report to the Audit Committee on additional CARES programming changes that could help to catch errors –make changes to the mail-in application form to improve clarity and reduce errors –clarify policies regarding when county workers can request documentation of income

12 Medical Assistance Eligibility Determinations Legislative Audit Bureau December 2004