Reports & Guidance
Medicaid Program Integrity Reports
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:
- New York Medicaid Eligibility Determinations (PDF)
- Kentucky Medicaid Eligibility Determinations (PDF)
- Louisiana Medicaid Eligibility Determinations (PDF)
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.
State Program Integrity Review Reports, 2007 – 2019
State program integrity (PI) review reports, and respective follow-up review reports, provide CMS' assessment of the effectiveness of States' Medicaid PI efforts, including compliance with Federal statutory & regulatory requirements.
Other Program Integrity Reports
Fraud Prevention System Return on Investment, 2015 (PDF)
A one-time high-level summary of the Fraud Prevention System (FPS) savings and return on investment. The FPS helps identify and prevent inappropriate payments.