LBA Performance Audit Report Summary:

Bureau of Elderly and Adult Services Medicaid Long-Term Care Program - July 2009

[Read the full report in PDF format - 3.49 MB]

The purpose of this audit was to assess the efficiency and effectiveness of the State’s Medicaid long-term care (LTC) program, which is administered by the Bureau of Elderly and Adult Services (BEAS). We focused on the eligibility determination process and service provision. The audit period was State fiscal year 2008.

Medicaid LTC can be provided in an institutional setting or, through waivers granted by the federal government, in a home and community setting. New Hampshire participates in the Home and Community Based Care for Elderly and Chronically Ill  (HCBC-ECI) waiver. The HCBC-ECI waiver program requires the cost of home and community-based care not exceed the costs incurred had clients been placed in a nursing facility. New Hampshire has utilized the HCBC-ECI waiver since first approved in 1984.

Results in Brief

We found the Medicaid LTC program administered by the BEAS is a multifaceted system involving the BEAS, Division of Family Assistance (DFA), ServiceLink, community support networks, stakeholders, LTC service providers, case management agencies, applicants, and recipients. The LTC program includes intake, eligibility determination, developing support plans, service provision (both institutional and home and community based), and management and oversight of service provision. 

Our audit presents 15 observations and recommendations to assist the Department and the Legislature in optimizing the efficiency and effectiveness of the BEAS long-term care system. Three observations would require legislative action. We found a complex eligibility process, involving the DFA and the BEAS, can extend for several months. While the DFA applies a 45-day time standard, the BEAS does not currently follow the same standard. We found the eligibility process can begin at the district office or a ServiceLink location and the medical and financial components may begin concurrently, may start separately, or one may be overlooked completely. We also found the look-back period used by the DFA for financial eligibility may not comply with federal or State requirements.

We found there is no consistent process for determining the appropriateness of provider rates and no regular assessment of the availability of services throughout the State. We found concern over the adequacy of provider rates and service availability as well as concern over the oversight and guidance pertaining to personal care services.

We found the program demands effective and continuous communication and information sharing; however, the BEAS has poor communication with those involved in the program and provides limited information with unclear reporting methodologies. Additionally, collaborations, partnerships, and feedback are not being utilized to maximize the efficiency and effectiveness of the LTC system. Finally, we found vulnerabilities and weaknesses exist in the BEAS management information system, Options.

This report recommends the DHHS follow federal timeliness guidelines for eligibility pertaining to both financial and medical eligibility, and streamline the application process. We further recommend the DHHS follow statutory requirements to assess and report on provider rates. We recommend the Department provide guidance on personal care services and financial eligibility look-back periods. Additionally, we recommend the BEAS improve communication, information sharing, and reporting while better involving stakeholders.