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Audit finds missing functional assessments in HCBS waivers; auditors estimate hundreds of millions in unsupported capitation payments
Summary
A follow‑up audit of home‑and‑community‑based services found required functional assessments were not completed for many waiver recipients; auditors cited roughly $238 million in capitation payments lacking required assessments and identified 721 beneficiaries with gaps longer than four years.
Auditors told the Public Health and Welfare committee they completed a follow‑up review of home‑and‑community‑based services (HCBS) waivers and found persistent problems with the CAMIS tracking system and with failure to complete required functional assessments.
The presenter said the 2022 audit findings were not fully corrected: CAMIS remains unchanged and many beneficiaries lacked annual assessments. Auditors estimated $238 million in capitation payments to managed care organizations that were not supported by required functional assessments. The presenter said 721 people had gone more than four years without an assessment and that, on the physically disabled (PD) waiver, 2,749 of 7,881 beneficiaries lacked required functional assessments.
Functional assessments — conducted by Aging and Disability Resource Centers (ADRCs) or contracted vendors such as Maximus — determine whether a beneficiary requires waiver services intended to keep people in home settings rather than institutions, the presenter said. The office recommended improving assessment completion and CAMIS tracking to reduce unnecessary waiver capitation payments.
Committee members asked about how savings would be calculated and the presenter explained the difference between waiver capitation (he cited figures over $5,000 per month) and non‑waiver Medicaid capitation (about $800 per month) as the basis for potential savings from appropriately assigning beneficiaries.
Next steps: the interim HCBS follow‑up report is available on the office website; auditors recommended process and IT fixes and further review of the remaining waivers.
