REPORT HIGHLIGHTS MEDICAID ELIGIBILITY DETERMINATIONS FOR LONG-TERM CARE PERFORMANCE AUDIT Release Date: July 16, 2025 State of Illinois, Office of the Auditor General FRANK J. MAUTINO, AUDITOR GENERAL To obtain a copy of the Report contact: Office of the Auditor General, 400 West Monroe, Suite 306, Springfield, IL 62704-9849 (217) 782-6046 or TTY (888) 261-2887 This Report Digest and Full Report are also available on the worldwide web at www.auditor.illinois.gov BACKGROUND: On August 25, 2017, the Governor signed into law Public Act 100-380 which amended the Illinois Public Aid Code. This amendment to the Illinois Public Aid Code requires that beginning July 1, 2017, the Auditor General is to report every three years to the General Assembly on the performance and compliance of the Department of Healthcare and Family Services (HFS), the Department of Human Services (DHS), and the Department on Aging (DoA) in meeting the requirements placed upon them by Section 11-5.4 of the Illinois Public Aid Code and federal requirements concerning eligibility determinations for Medicaid long-term care services and supports (see Appendix A). This is the third audit (CY21-CY23) on their performance and compliance related to Medicaid eligibility determinations for long-term care. The first audit (CY15-CY17) was released in March 2019 and contained eight recommendations. The second audit (CY18-CY20) was released in September 2022 and contained five recommendations. Key Findings: • During this audit, issues related to the Integrated Eligibility System (IES) continued to be identified. These issues surrounded the system’s internal controls as well as the completeness of the data provided. Due to these issues, we determined reviewing the entire population of the applications data would not provide accurate results for the purposes of this audit and instead performed sample testing. • For the 50 applications tested, we found that 11 applications (22%) were pending past the required number of days. On average, it took 41 days from receipt of application to decision. Three different reports produced by HFS (backlog reports, monthly reports, and weekly reports) all indicated applicants were not receiving their determinations of eligibility in a timely manner, particularly after the end of the Public Health Emergency. Consequently, the status of the prior recommendation on the timeliness of eligibility determinations was determined to be partially implemented. • DHS and HFS noted that an IES system enhancement was established to address the processing delays related to OIG asset investigations. However, applications involving HFS OIG asset discovery investigations continued to be overdue during this audit period. The prior audit found that all 16 applications involving asset discovery investigations were not completed in a timely manner. For this audit, we tested 17 cases referred to the HFS OIG in calendar year 2023 to follow up on this recommendation. During this testing, we found that 8 of the 17 applications were not completed in a timely manner, ranging from 14 to 156 days overdue. • In addition, multiple issues were identified for these HFS OIG cases during our review. These issues included incorrect information in IES and a lack of controls in IES. As a result, the status of the recommendation on processing delays related to HFS OIG asset discovery investigations was determined to be partially implemented. • Although HFS noted that a system enhancement was implemented in IES to address the prior audit recommendation regarding extension tracking, the testing results showed the enhancement was not fully effective. For the 10 extension cases reviewed, 5 applications (50%) had issues with inaccurate IES data, including granting one 60-day extension. While there continued to be cases with inaccurate IES data, there was improvement over the prior audit. Also, we found no examples of more than two extensions or extensions that were not in IES. As a result, the status of the recommendation on extension tracking was determined to be partially implemented. • HFS is not posting the LTC reports on a monthly basis as required by the Illinois Public Aid Code. HFS completed reports for 28 of the 36 months (78%) during the audit period. We also requested documentation to support the posting of the monthly reports completed during calendar years 2021 to 2023. HFS was only able to provide documentation for 5 of the 28 (18%) reports. • The prior audit found the LTC monthly reports did not contain all elements as required by statute. We reviewed the LTC monthly reports for calendar years 2021 to 2023 and found some required elements were still not included. As a result, the status of this recommendation on the LTC monthly report completeness was determined to be partially implemented. • During the prior audit, we found the LTC monthly reports were not accurate due to duplicate entries and other issues with the source data. During this audit, we reviewed the monthly reports for calendar years 2021 to 2023 and found similar issues with accuracy that were identified during the prior audit. We also found 19 of 50 applicants tested (38%) had a reported disability, which would allow 60 days for processing those applications. • We requested LTC data on the total number of redeterminations completed during the audit and found the redeterminations data in the monthly reports did not have any issues with the totals matching. The only remaining issue involved multiple entries, and no reports after February 2023 contained multiple entries. Therefore, the status of the recommendation on the LTC monthly report accuracy was determined to be partially implemented. • Public Act 100-380 requested the Auditor General to review and evaluate the efficacy and efficiency of the task-based process used for making eligibility determinations in the centralized offices of DHS for LTC services. During this audit period, DHS moved away from the task-based system to a new facility-based system. During the current audit period, the IES reports used to identify work were designed to identify tasks. However, work is assigned to teams based on facilities rather than tasks. After the end of the audit period DHS began re-assessing the reports. Since the reports were not re-designed until after the end of the current audit period, we could not fully assess the efficacy and efficiency of the facility-based approach. Therefore, additional follow-up will need to be conducted during the next audit period. Key Recommendations: The audit report contains six recommendations directed to HFS and DHS, including: • HFS, including the HFS OIG, and DHS should work together to implement controls to improve the timeliness of long-term care eligibility determinations to comply with timelines contained in federal regulations and the Illinois Administrative Code. • HFS, including the HFS OIG, and DHS should, in order to decrease the opportunity for application processing delays, work together to implement changes to improve the process of: referring applications to the HFS OIG to ensure referrals are received by the HFS OIG, and receiving and acting upon recommendations from the HFS OIG upon completion of its asset investigations. • HFS, including the HFS OIG, and DHS should ensure extensions are tracked so processing times can be tolled, as required by the Illinois Public Aid Code, for extension days granted. Specifically, the agencies should ensure: extensions are captured in a usable manner; extensions are captured accurately; and the length of extensions granted by IES are in accordance with statute. • HFS and DHS should complete the monthly reports and post the reports to each Department’s website as required by the Illinois Public Aid Code. • HFS and DHS should ensure monthly reports contain all elements required by the Illinois Public Aid Code. • HFS and DHS should develop controls to ensure monthly reports required by the Illinois Public Aid Code are accurate. This performance audit was conducted by the staff of the Office of the Auditor General. HFS and DHS agreed with the recommendations.