Comprehensive Medicaid Integrity Plan, FY 2019 – FY 2023 (PDF)
Explore the 5-year, comprehensive plan to protect taxpayer dollars in the Medicaid program by combatting fraud, waste and abuse.
Beneficiary Eligibility Reviews: As part of the Comprehensive Medicaid Integrity Plan for FYs 2019-2023 and the Medicaid Program Integrity Strategy, CMS is conducting beneficiary eligibility reviews. The primary goal of these reviews is to confirm that states’ Medicaid and Children’s Health Insurance Program (CHIP) beneficiary eligibility determinations are appropriate and that the federal match is correctly assessed.
Completed Medicaid and CHIP beneficiary eligibility review reports are included below:
California Medical Loss Ratio Examination Report (PDF)
A key component of CMS’ managed care program integrity work is to conduct targeted examinations of selected states’ Medicaid Managed Care Plans’ (MCPs) financial reporting. As part of this effort, CMS conducted an examination of the Medical Loss Ratio (MLR) reported by California’s 22 Medicaid MCPs to determine if the state’s previous review correctly identified findings and overpayments, and the documentation accepted by the state was reasonable to support the amounts included in the MLR calculation.
Strengthen safeguards in Personal Care Services: Read about noteworthy practices and CMS guidance in the CMS Medicaid Integrity Institute paper, Vulnerabilities and Mitigation Strategies in Medicaid Personal Care Services (PDF) and the CMS FAQ on Allowability of Using National Provider Identifiers (NPIs) for Medicaid Personal Care Attendants (PCAs) (PDF).
Join the fight against the opioid epidemic: The Medicaid Integrity Institute Compendium of Promising Practices explores how states are addressing program integrity vulnerabilities produced by opioid misuse and abuse. Learn more. (PDF)
Join the Healthcare Fraud Prevention Partnership: Learn how sharing data with others in the healthcare industry, both public and private entities, can help your organization identify and reduce fraud, waste, and abuse across the healthcare sector. Learn more about the HFPP and find out how to become a partner.
Learn the latest in fraud schemes and detection: The Medicaid Integrity Institute (MII) exists to educate and train our state partners. Located in Columbia, South Carolina and developed by CMS in partnership with the Department of Justice, MII brings together experts - including law enforcement - to deliver up-to-date information on trends and strategies. See the latest course offerings on the MII training page.
Find guidance on federal Medicaid enrollment standards: The Medicaid Provider Enrollment Compendium (MPEC) is one of many resources available to state Medicaid agencies on Medicaid.gov's Medicaid program integrity resources page. Specifically, the MPEC provides guidance and clarification to help Medicaid agencies comply with regulations around Disclosure of Information by Providers, and Fiscal Agents and Provider Screening and Enrollment.
Stay on top of Medicaid best practices and fraud prevention: Visit the Medicaid Integrity Program pages to find toolkits, videos, podcasts, and more to help eliminate fraud, waste, and abuse.