1. State of Minnesota Office of the Legislative Auditor _____________________________________ Department of Human Services Oversight of MNsure Eligibility Determinations for Public Health Care Programs Issued November 12, 2014 ________________ Health and Human Services Reform Committee Minnesota House of Representatives February 25, 2015 1

2. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ DHS is responsible for ensuring that the state correctly determines whether people are eligible to receive benefits from the state’s public health care programs 2

3. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Minnesota’s Public Health Care Programs –Medical Assistance (MA) –MinnesotaCare (MinnCare) –Children's Health Insurance Program (CHIP) 3

4. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ DHS has struggled to effectively oversee its eligibility determination responsibilities –OLA concerns for over 10 years –In the 5 most recent federal compliance audits we found that DHS did not have adequate internal controls to ensure compliance –In the 2 most recent federal compliance audits we found that DHS had not complied with eligibility requirements 4

5. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ In a 2014 report we stated that DHS “was ill prepared to determine how changes to its enrollment and eligibility verification processes” because of MNsure “either decreased or increased its risk of noncompliance with federal program requirements, or to identify the ways it needed to adjust its internal controls to address those risks.” 5

6. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Because of DHS’s history with eligibility determinations and the rough roll-out of MNsure, we thought it was important to test the eligibility of people enrolling in the state’s public health care programs through MNsure. 6

7. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Primary Objective To determine whether DHS ensured that 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. 7

8. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Conclusion DHS 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. 8

9. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Conclusion DHS 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. 9

10. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Methodology Using data from the state’s medical payment system (MMIS) we identified the 167,179 people who enrolled into MA, MinnCare, and CHIP through MNsure, from October 1, 2013 through April 30, 2014. 10

11. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ This included –People who enrolled through the website –People who worked with Mnsure, DHS, counties, navigators, brokers, or assisters to enroll through the website –People who submitted paper applications to MNsure, DHS, or counties 11

12. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ This DID NOT include –People who were already on one of the public health care programs on October 1, 2013 –People who were denied enrollment in a public health care program 12

13. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Methodology We met with staff from DHS, MNsure, MN.IT, and county human service offices to understand: –Problems resulting from MNsure’s implementation and how they were (or were not) resolved –Training provided to DHS and county human services staff to access and use MNsure 13

14. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Methodology Selected a sample of 100 cases –60 from Medical Assistance –25 from MinnesotaCare –15 from Children’s Health Insurance Program These 100 cases included 193 people 14

15. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Methodology Accessed data in MNsure about these cases and the people included in these cases Verified information to other sources –Tax filings –Wage and unemployment data –Other DHS and county data 15

16. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Methodology Where we could, we analyzed the entire population of public health care program enrollments through MNsure to determine the full scope of an exception 16

17. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Overall results Nearly 17% of the people we tested were not eligible for the public health care program in which they were enrolled –Some belonged in another public health care program –A few should not have been enrolled in any of the public health care programs 17

18. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Finding 1 (Page 7) –Overall finding, with some examples Findings 5 – 10 (Pages 14 – 29) –Further discussion of specific types of exceptions 18

19. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples MNsure provided applicants with wrong income information (Finding 1, page 7) Employer ID numbers were shown as income: Employer ID 41-5777140 was shown as $415,777,140 19

20. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples 24 enrollees (out of the whole population) had duplicate accounts (Finding 1, page 8) –Same Social Security Number –Same name and birthdate –Almost $45,000 in duplicate payments –A third of the duplicate accounts had not been detected 20

21. ProgramCitizenship / Immigration Status Social Security Numbers MA36%65% CHIP20%64% MinnCare88%75% DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples DHS and Counties had difficulty resolving certain discrepancies within 95 days (Finding 5, Page 14) 21

22. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples Enrollees’ incomes exceeded program limits (Finding 6, Page 17) At the time they applied After enrollment 22

23. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples Enrollees had errors in household size and family relationships Parents reported as children Spouse or children reported as “other” relatives Mother not included in household 23

24. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples Enrollees were in MinnesotaCare but should have been in Medical Assistance (Finding 8, Page 23) –Children –People whose income dropped –People whose reported income was not accurate 24

25. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Exception Examples MinnesotaCare recipients were also enrolled in Medicare (Finding 9, Page 27) Women still enrolled in Children’s Health Insurance Program more than 60 days after pregnancies end (Finding 10, Page 27) 25

26. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Other Findings County workers were not well trained (Finding 3, Page 10) County workers could not close cases (Finding 4, Page 12) 26

27. DHS Oversight of MNsure Eligibility Determinations for Public Health Care Programs _____________________________________ Other Findings DHS did not ensure that data accurately and securely transferred from MNsure to the state’s medical payment system (Finding 2, Page 9) DHS charged incorrect premium amounts to people who enrolled in MinnesotaCare through MNsure (Finding 11, Page 29) 27

28. State of Minnesota Office of the Legislative Auditor _____________________________________ Department of Human Services Oversight of MNsure Eligibility Determinations for Public Health Care Programs is available at: www.auditor.leg.state.mn.us 28