| (a) The Health and Human Services Commission (HHSC),
through the Medicaid and CHIP Services Division, the Office of Inspector
General (OIG), and Health and Human Services (HHS) Internal Audit
Division, is responsible for audits of MCOs and any entity with which
an MCO contracts.
(b) For purposes of this rule, "MCO" includes any entity
with which an MCO contracts.
(c) HHSC conducts audits of MCOs, including financial
audits, performance audits, compliance audits, and agreed upon procedures:
(1) with the scope and frequency necessary to provide
information to allow for the effective oversight and control of the
MCOs; and
(2) as necessary to comply with all federal and state
laws.
(d) Medicaid and CHIP Services Division's roles and
responsibilities for audits of MCOs include:
(1) determining, based on coordination with OIG about
MCO audits, which audits to assign to contracted audit firms in order
to eliminate duplication of audit effort and reduce the impact of
potentially duplicative audits on the MCOs;
(2) coordinating with HHS Internal Audit Division to
obtain delegated authority, from the State Auditor's Office (SAO),
to procure audit services as required by Texas Government Code §321.020;
(3) facilitating and determining the extent of work
to be performed in agreed upon procedures and audits of MCOs, through
the use of contracted audit firms as part of the integrated business
processes used to oversee and monitor MCOs;
(4) providing final reports of agreed upon procedures
and audits to OIG, along with other information relevant to quantifying
MCO performance under the contract with HHSC, including results of
on-site monitoring visits, and other relevant MCO-related performance
information;
(5) providing all deliverables, such as contracts,
contract amendments, and audit reports, for contracted audit related
engagements to HHS Internal Audit Division for delivery to the SAO;
and
(6) ensuring actions planned to address audit recommendations
are implemented, including actions planned by the Medicaid and CHIP
Services Division or by an MCO.
(e) The OIG's roles and responsibilities, related to
performing audits of MCOs, are as outlined in §371.37 of this
title (relating to Audit of Managed Care Organizations).
(f) HHS Internal Audit Division's roles and responsibilities,
related to audits of MCOs, are:
(1) auditing the Medicaid and CHIP Services Division
and OIG, as part of its established audit authority and risk-based
audit coverage, including auditing the effectiveness of coordination
between the Medicaid and CHIP Services Division and OIG on the performance
of MCO audits;
(2) notifying and conferring with the Medicaid and
CHIP Services Division and OIG before initiating an audit of an MCO
contained in the audit plan approved by the HHS Executive Commissioner;
(3) coordinating with Medicaid and CHIP Services Division
when audit services need to be procured to ensure HHSC obtains the
appropriate authority to procure audit services from the SAO; and
(4) coordinating with Medicaid and CHIP Services Division
to ensure that all appropriate documents related to contracted audit
services are obtained and provided to the SAO. These documents include
executed contracts, contract amendments, and audit reports.
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