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F I S C A L I M P A C T R E P O R T

SPONSOR Lopez

ORIGINAL DATE

LAST UPDATED

02/22/07

HB

SHORT TITLE Medicaid Recertification Quality Control

SB SJM 20

ANALYST Weber

APPROPRIATION (dollars in thousands)

Appropriation

Recurring

or Non-Rec

Fund

Affected

FY07

FY08

NFI

(Parenthesis ( ) Indicate Expenditure Decreases)

Duplicates HJM17,

SOURCES OF INFORMATION

LFC Files

Responses Received From

Department of Finance and Administration (DFA)

Human Services Department (HSD)

SUMMARY

Synopsis of Bill

Senate Joint Memorial 20 requests the Human Services Department to implement a quality

control mechanism for its Medicaid recertification procedures, particularly related to the

automatic closure process. Automatic closure is a computer default so a Medicaid case that is

not updated by a caseworker by a specified date is electronically closed without action by the

caseworker. The quality control mechanism should include tracking the number of cases closed

and subsequently reinstated, providing an analysis of why Medicaid recipients are terminated

from the program, and performing a "point in time" tracking of the number of people enrolled in

Medicaid. Further, HSD is requested to implement performance measures that include the quality

of Medicaid recertification procedures and the percentage of eligible New Mexicans receiving

Medicaid.

HSD is asked to report on the results of its efforts to the Legislative Health and Human Services

Committee in November 2007 and again November 2008.

FISCAL IMPLICATIONS

HSD does not identify any fiscal implications. However, DFA estimates a cost of approximately

$70 thousand annually with half paid by the state and half by federal Medicaid funds to support

one full time FTE.

SIGNIFICANT ISSUES

DFA notes that by federal law, Medicaid eligibility must be recertified at lease once every twelve

months. Currently, in New Mexico the recertification period is the federal maximum of 12

months. At least 45 days prior to the end of a twelve month certification, HSD sends the

required recertification paper work to the Medicaid recipient asking that the documents be

returned within fifteen days.

Two events generally cause a Medicaid case to be closed during the recertification process.

Either the person being recertified does not respond or the response comes so late in the cycle the

case worker assigned to the case cannot finish the necessary paperwork by the close of the

twelve month period. There are many reasons why individuals may not respond; they have

moved, they do not wish to re-apply, they have died, etc. HSD has no realistic way of knowing

why an individual does not respond.

DFA continues that developing a quality control/ tracking system to determine why people drop

off the program simply is not feasible because more often than not, the "why" is simply not

identifiable. HSD performs extensive outreach to assure as much as possible that all individuals

eligible for Medicaid receive the services they need, but there simply is not much more the

agency can do to identify why people drop through the cracks. Only if the individual eventually

re-applies applies for certification will HSD be able to determine why there was a gap in

enrollment.

HSD offers a similar response.

OTHER SUBSTANTIVE ISSUES

A recent case was filed in United State District Court for the District of New Mexico regarding

the apparent same issues related to the HSD Medicaid re-certification process, specifically auto

closure. On September 29, 2006 the case against HSD was dismissed in its entirety and left

existing re-certification procedures, including automatic closure, intact.

MW/mt