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Information on the Federal Program: Assistance Listing 93.767 – Children’s Health Insurance Program (CHIP) Criteria or Specific Requirement (Including Statutory, Regulatory, or Other Citation): Title XXI of the Social Security Act requires that a child be placed in the health care coverage program for which the child is financially eligible. CHIP is one of the programs for which eligibility must be determined. A child is evaluated for CHIP eligibility when it is determined that the annual family income is above the income limit for Medicaid (MA) for the child’s age group. The Commonwealth of Pennsylvania’s Department of Human Services (PA DHS) is responsible for the management and oversight of the CHIP program. PA DHS has agreements with select private health care organizations, referred to as managed care organizations (MCOs), to provide the CHIP insurance coverage and to assist with enrollment and eligibility verification, renewals, terminations, and member assistance for case updates and questions on eligibility, coverage, etc. UPMC serves as an MCO for Pennsylvania’s CHIP program. As outlined in the PA DHS Children’s Health Insurance Program (CHIP) Procedures Handbook, MCOs are responsible for the following processes: a. Application Processing – The CHIP eligibility process starts when a parent or caregiver submits an application either electronically, via telephone call, or in paper form to a managed care organization (MCO). Applications may also be referred to the MCOs from other sources, such as a county assistance office (CAO). Any electronically submitted application that does not pass the CHIP eligibility requirements is routed to the MCO chosen by the parent or caregiver for manual processing. If no MCO is chosen, one is assigned. MCOs are also responsible for processing applications received through other sources (e.g., telephone, paper form, or CAO). Manual processing includes income verification if not previously verified by another party (e.g., PA DHS through MA application, CAO, or another MCO). The MCOs input the income data into CHIP Application Processing System (CAPS) (or verify data previously submitted) for CAPS to determine eligibility. MCOs are responsible for maintaining the source documentation provided by the enrollee. MCOs are also responsible for working with enrollees on incomplete applications and current members on renewals. b. Renewals – Renewal of CHIP coverage must occur prior to the end of the 12-month period of enrollment. Enrollees are automatically notified of renewal at 120 days prior to the expiration of the 12-month enrollment period. MCOs are required to send follow-up notifications to parents or caregivers at 90 and 60 calendar days prior to the expiration of the 12-month period of enrollment. The MCO is responsible for reviewing eligibility for continued coverage by verifying income. MCOs are encouraged to consider family circumstances that are also likely to change, including household income; age of child (as children age out of CHIP at 19 years old); number of household members (additions and deletions) that may impact income eligibility limits; MA eligibility and/or enrollment; enrollment in private health insurance; or other missing data. c. Ineligibility – MCOs are required to send notice of denial to applications or a notice of termination to enrollees. The notice must include the reason for ineligibility, the right to request an impartial review of the decision of ineligibility; and how to file a request for impartial review. d. Eligibility Review Process (ERP) – An applicant or enrollee may request an impartial eligibility review when a determination of an application or renewal results in denied or terminated coverage; a change in the coverage (e.g., from Free CHIP to Low-Cost or Full-Cost CHIP) or cost; applicant with income over eligibility thresholds disagrees with the determination of availability or affordability of private insurance; or MCO fails to make a timely eligibility determination. Requests for reviews are made directly to the MCO. Reviews must be completed within 2 business days, and, if the MCO cannot resolve the matter within this timeframe, the MCO must notify DHS. Coverage is required to be reinstated or continued during the review. MCOs must maintain a log of requests received and completed. e. Quality Management – MCOs must establish and implement an ongoing comprehensive quality assessment and performance improvement program that complies with requirements outlined by PA DHS. MCOs are also responsible for enrollee orientation, processing complaints and grievances, as well as other administrative processes. Condition: PA DHS utilized the CHIP Application Processing System (CAPS) to accumulate and process data associated with the CHIP program. The operation and management of CAPS, as well as the underlying data, was the responsibility of PA DHS. Beginning April 17, 2023, PA DHS decommissioned CAPS, transitioning the CHIP process to another application utilized by PA DHS. At this date, PA DHS began handling all applications, renewals, case updates, and eligibility questions for CHIP families, reducing the responsibility of MCOs. These functions were primarily performed in CAPS to capture application information and process eligibility determinations for CHIP. With the decommissioning of CAPS on April 17, 2023, the evidence to support UPMC’s completion of these processes is not available for the period January 1, 2023 to April 16, 2023. PA DHS is unable to provide all the required data from the archived version of CAPS, including certain enrollee or application data points; notes and commentary documented by the MCOs; and evidence of the date/time procedures were performed. This information is necessary to test internal controls over compliance and compliance over eligibility and special tests and provisions. Therefore, we were not able to support internal controls over compliance and compliance over the eligibility or the special tests and provisions compliance requirements through re-performance and have issued a disclaimer of opinion based on the scope limitation. Effect or Potential Effect: A disclaimer of opinion was issued for Assistance Listing 93.767 as we were unable to obtain sufficient documentation supporting the compliance of UPMC with eligibility and special tests and provisions compliance requirements. Questioned Costs: None. Context: Federal expenditures reported in the schedule of expenditures of federal awards for Assistance Listing 93.767 totaled $11,613,050 for the year ended December 31, 2023. Identification as a Repeat Finding, If Applicable: This is not a repeat finding. Recommendation: As UPMC has no further compliance responsibilities related to eligibility and special tests and provisions, not further follow-up is required. Views of Responsible Officials: As UPMC utilizes the Commonwealth of Pennsylvania’s system as described above, no further corrective action will be taken.

Finding 2021-001 ? A. Activities Allowed or Unallowed and E. Eligibility Identification of the federal program: Federal Program: COVID-19 Testing for the Uninsured, Assistance Listing No. 93.461 (COVID-19 Uninsured Program) Federal Agency: U.S. Department of Health and Human Services (HHS) ? Health Resources and Services Administration (HRSA) Award Numbers: Various Award Period: January 1, 2021 through December 31, 2021 Criteria or specific requirement (including statutory, regulatory or other citation): Section 200.303 of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) states the following regarding internal control: ?The non-Federal entity must: (a) Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).? Health and Human Services (HHS) ? Health Resources and Services and Administrative (HRSA) issued Terms and Conditions for Participation in the HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (T&Cs) outlining requirements that recipients of funding from the HRSA COVID-19 Uninsured Program must comply. The HRSA COVID-19 Uninsured Program requires that services must be for individuals, who at the time the services were provided, were uninsured as described in the T&Cs. In order to be reimbursed through the HRSA COVID-19 Uninsured Program, the individual must be uninsured at the time the COVID-related testing, treatment, or diagnosis was provided. Condition: In testing internal controls over eligibility for one of UPMC?s central business offices administering the HRSA COVID-19 Uninsured Program for five UPMC facilities, we sampled 25 claims (totaling $7,901 in federal expenditures) for services occurring during the award period that were billed to the HRSA COVID-19 Uninsured Program, and we identified 3 claims for which uninsured/self-pay status were not performed timely. We noted that internal controls over the determination of uninsured/self-pay status were not operating effectively. In testing compliance over activities allowed or unallowed and eligibility, we sampled 60 claims (totaling $148,626 in federal expenditures) for services occurring during the award period that were billed to the HRSA COVID-19 Uninsured Program, and we identified 1 claim for which uninsured/self-pay status was not appropriately determined. For these 4 patient claims within this specific central business office, insurance coverage discoveries were not performed timely prior to billing to HRSA. Based on a retrospective evaluation of $1,600,343 in claims for the five UPMC facilities, which were reported as federal expenditures for the year ended December 31, 2021, it was subsequently determined, using an independent data source (FrontRunnerHC) that, for $49,500 of claims, there were other potential available sources of reimbursement. Total federal expenditures for Assistance Listing No. 93.461 totaled $3,182,904, for the year ended December 31, 2021. Cause: Policies, procedures, and internal controls over the review for patient insurance were designed to address the unique aspects of the HRSA COVID-19 Uninsured Program; however, such policies, procedures, and internal controls were not consistently performed timely. Effect or potential effect: A patient was not uninsured and, therefore, the related claim was ineligible for reimbursement under the HRSA COVID-19 Uninsured Program. Questioned costs: $49,500 Context: Internal controls over the determination of a patient?s uninsured/self-pay status were not being performed timely by a central business office administering the HRSA COVID-19 Uninsured Program for five UPMC facilities. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: The HRSA COVID-19 Uninsured Program ended in 2022. The HRSA COVID-19 Uninsured Program stopped adjudicating testing and treatment claims after March 22, 2022, and vaccine administration after April 5, 2022. Therefore, no further changes are required to the current internal controls over this program or the related documentation of the operation of internal controls. If the program were reinstated, UPMC should implement enhanced oversight to ensure that participating locations are administering the HRSA COVID-19 Uninsured Program in compliance with HRSA COVID-19 Uninsured Program terms and conditions. Views of responsible officials: UPMC believes it appropriately designed and implemented the standard policies, procedures, and internal controls over the review for patient insurance; however, UPMC agrees with the finding that such policies, procedures, and internal controls were not consistently performed timely as a result of the prioritization of patient care and safety during the public health emergency. UPMC will review the population of claims identified as questioned costs and refund HRSA for any claims found to be eligible for other sources of reimbursement.

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