M E M O R A N D U M

IM-161  12/16/03  MEDICAID ELIGIBILITY QUALITY CONTROL (MEQC) REVIEW

SUBJECT:
MEDICAID ELIGIBILITY QUALITY CONTROL (MEQC) REVIEW
DISCUSSION:
As an 1115 waiver state we have utilized alternative ways to do Federal Medicaid Eligibility Quality Control (MEQC) for the past several years.  We have operated our MEQC program by completing annual positive and negative reviews.  Effective with December 2003 we are engaging in monthly MEQC activity while still operating an alternative MEQC program.

Positive Review

We plan to do at minimum two positive MEQC projects for FFY 2004.  The positive review focuses on active Medicaid cases.  Our initial positive review project for FFY 2004 is to determine if timely and correct decisions are made when an individual receiving Medicaid enters an institution is switched to institutional care.  We also want to determine if transfers of assets are being properly evaluated.  To ensure correct eligibility is being determined and that we are providing good customer service Quality Assurance (QA) staff will review a sampling of cases to:

  • determine whether action was taken timely,
  • if not, what caused the delay,
  • what is the impact of the delay,
  • was a correct eligibility determination made.
A statistically valid sampling of case actions in which the type of care is changed to institutional care will be selected for review.  A sampling of October case actions has been selected and will be reviewed in December.  Another sampling consisting of November case actions will be obtained and reviewed in January.   We will target St. Louis City, St. Louis County, Jackson County and Greene County in completing the analysis of data.  These geographic areas make up a large percentage of the caseload and are areas in which QA staff is based.  Case actions completed and selected in other county offices in which QA staff is based or that QA staff travel to for other business will also be reviewed.

A new positive project as yet still in the planning phase will be initiated in February 2004.

Negative Review

The negative review project for FY 2004 is to review a sampling of Medical Assistance for Families, Medicaid for Children and SCHIP cases closed each month.  The focus of the review is to determine why the case was closed and if the closing was related to the annual review process.  The most prevalent reason for taking a negative action is non-cooperation.  A significant number of cases have a reason code of other, which may also be related to failing to complete the annual review process.  We want to determine if the household was ineligible or was the reason for the ineligibility process related (for example, failed to return review form).

A statistically valid sampling of negative case actions in which the reason entered in the system for the negative action is non-cooperation or other will be selected for review each month.  The review will consist of reviewing the paper file and contacting the household as needed to determine whether the household was ineligible for Medicaid.  We will target St. Louis City, St. Louis County, Jackson County and Greene County in reviewing these case actions.  These geographic areas make up a large percentage of the caseload and are areas in which QA staff is based.  Case actions completed and selected in other county offices in which QA staff is based or that QA staff travel to for other business will also be reviewed.

Please work with QA staff in providing requested case records and other information needed to complete the projects.
NECESSARY ACTION:
  • Review memorandum with all appropriate staff.
JC
IM-160
[ 2003 Memorandums ]
IM-162