2025-604 State High Risk: Department of Health Care Services — Medi-Cal Eligibility

Audit Scope and Objectives

This audit of the Department of Health Care Services’ Medi-Cal Eligibility determination process is conducted pursuant to Government Code section 8546.5, which authorizes the State Auditor to identify, audit, and issue reports on any agency of the State or any statewide issue that it identifies as being at high risk for the potential of waste, fraud, abuse, or mismanagement or that has major challenges associated with its economy, efficiency, or effectiveness. The State Auditor developed the following objectives to guide the performance of this audit. Consistent with generally accepted government auditing standards, the State Auditor may refine or adjust these objectives as work is performed if he determines such changes are necessary.

1. Review and evaluate the laws, rules, and regulations significant to the audit objectives.

2. Evaluate trends in the number and type of Medi-Cal eligibility discrepancies. To the extent possible, determine the amount of questionable costs associated with these discrepancies.

3. Evaluate Health Care Services’ monitoring of counties’ resolution of Medi-Cal eligibility discrepancies. Determine whether its process is sufficient to control or eliminate the risks associated with these discrepancies.

4. Review and assess any other issues that are significant to the audit.