State Program Integrity Reviews

State Program Integrity Reviews

Medicaid and the Children's Health Insurance Program (CHIP) are required to have a fraud detection and investigation program that meets certain federal standards. To assist the states with these requirements, CMS offers the Medicaid Program Integrity Manual.
To help oversee this requirement, CMS conducts focused program integrity reviews on high-risk areas in the Medicaid program:

  • Case tracking and referrals
  • Managed care
  • New statutory and regulatory compliance
  • Overpayment identification and recovery  
  • Personal Care Services
  • Pre-payment and post-payment review
  • Surveillance and utilization systems
  • Territory oversight operations

As a companion to the comprehensive reviews, CMS created Frequent Findings reports. These toolkits were designed to help states better understand requirements and improve compliance with regulations for provider disclosures, federal database checks, and reporting adverse actions taken against providers to HHS-OIG.

Beginning in 2014, CMS began conducting focused reviews. Focused reviews are conducted to determine the extent of program integrity (PI) oversight of the Medicaid program by the States. Traditionally, these reviews have focused on high risk areas of managed care, Affordable Care Act provisions, personal care services and non-emergency medical transportation.

These reviews are designed to identify risks and vulnerabilities to the Medicaid program and assist states with strengthening program integrity operations. The significance and value of performing onsite program integrity reviews include:

  • Assess the effectiveness of the state’s PI efforts, including compliance with certain Federal statutory and regulatory requirements
  • Identify risks and vulnerabilities to the Medicaid program and assist states to strengthen PI operations
  • Help inform CMS in developing future guidance to states
  • Help prepare states with the tools to improve PI operations and performance

Annual Summary Reports

Search below for comprehensive and focused reports by state or year.

State / Territory Fiscal Year Date of Report Focus Area
Tennessee
2015
2015-12-31
Focused: Managed Care
Delaware
2015
2016-02-16
Focused: Managed Care
Nevada
2015
2016-03-01
Focused: Managed Care
Pennsylvania
2015
2016-03-01
Focused: Managed Care
North Carolina
2015
2016-05-03
Focused: Managed Care
Missouri
2015
2016-05-03
Focused: Managed Care
Connecticut
2015
2016-05-03
Focused: Personal Care Services
Wisconsin
2015
2016-07-05
Focused: Managed Care
Puerto Rico
2016
2016-08-02
Focused: Managed Care
Vermont
2015
2016-10-04
Focused: Managed Care
Texas
2015
2016-12-01
Focused: Managed Care
Virginia
2016
2017-02-01
Focused: Managed Care
Maryland
2016
2017-03-07
Focused: Managed Care
Kentucky
2016
2017-05-01
Focused: Managed Care
New Hampshire
2016
2017-05-31
Focused: Managed Care
South Carolina
2016
2017-06-01
Focused: Managed Care
Utah
2016
2017-06-01
Focused: Managed Care
Rhode Island
2016
2017-06-01
Focused: Managed Care
West Virginia
2016
2017-06-01
Focused: Managed Care
Nebraska
2016
2017-06-01
Focused: Managed Care
Arizona
2017
2017-07-28
Focused: Managed Care
Alabama
2016
2017-07-28
Focused: Managed Care
District of Columbia
2017
2017-08-01
Focused: Managed Care
Louisiana
2017
2017-08-01
Focused: Managed Care
Colorado
2017
2017-10-02
Focused: Managed Care
Indiana
2017
2017-11-01
Focused: Managed Care
Iowa
2017
2018-01-01
Focused: Personal Care Services
Florida
2017
2018-01-03
Focused: Managed Care
South Dakota
2017
2018-02-01
Focused: Personal Care Services
Mississippi
2017
2018-03-30
Focused: Managed Care
New York
2017
2018-04-30
Focused: Personal Care Services
Oregon
2018
2018-11-01
Focused: Managed Care
Georgia
2018
2018-11-30
Focused: Managed Care
Arkansas
2018
2018-12-03
Focused: Personal Care Services
Wyoming
2018
2018-12-03
Focused: Personal Care Services
Kansas
2018
2019-01-01
Focused: Managed Care
Washington
2018
2019-01-04
Focused: Managed Care
Idaho
2018
2019-01-08
Focused: Managed Care
Illinois
2018
2019-01-08
Focused: Managed Care
Minnesota
2018
2019-01-09
Focused: Personal Care Services
Delaware
2018
2019-01-31
Focused: Personal Care Services
Oklahoma
2018
2019-01-31
Focused: Personal Care Services
Texas
2018
2019-01-31
Focused: Personal Care Services
North Dakota
2019
2019-07-01
Focused: Personal Care Services
Tennessee
2019
2019-07-01
Focused: Personal Care Services
Ohio
2019
2019-10-01
Focused: Managed Care
Connecticut
2019
2019-10-31
Focused: Personal Care Services
Maine
2019
2019-11-01
Focused: Personal Care Services
Massachusetts
2019
2020-02-01
Focused: Managed Care
Pennsylvania
2019
2020-02-01
Focused: Managed Care
Montana
2019
2020-02-01
Focused: Personal Care Services
New Jersey
2019
2020-03-01
Focused: Managed Care
Vermont
2019
2020-03-01
Focused: Managed Care
Missouri
2019
2020-03-02
Focused: Managed Care
New Mexico
2019
2020-03-02
Focused: Managed Care
New Jersey
2019
2020-03-02
Focused: Managed Care
Alabama
2021
2021-12-01
Focused: Personal Care Services
Iowa
2021
2022-01-01
Focused: Managed Care
West Virginia
2021
2022-02-01
Focused: Personal Care Services
Rhode Island
2021
2022-04-01
Focused: Managed Care
Kentucky
2021
2022-05-01
Focused: Managed Care
Wisconsin
2021
2022-05-01
Focused: Managed Care
Michigan
2021
2022-06-01
Focused: Managed Care
Utah
2021
2022-06-01
Focused: Managed Care
Maryland
2021
2022-10-17
Focused: Managed Care
Nevada
2021
2022-10-17
Focused: Managed Care
Virginia
2021
2022-10-17
Focused: Managed Care
South Carolina
2021
2022-10-18
Focused: Managed Care
Nebraska
2022
2023-04-03
Focused: Managed Care
Hawaii
2022
2023-04-05
Focused: Managed Care
Arizona
2022
2023-05-17
Focused: Managed Care
Colorado
2022
2023-05-17
Focused: Managed Care
Mississippi
2022
2023-06-01
Focused: Managed Care
New Hampshire
2022
2023-06-01
Focused: Managed Care
District of Columbia
2022
2023-08-01
Focused: Managed Care
California
2022
2023-09-01
Focused: Managed Care
Indiana
2022
2023-10-10
Focused: Managed Care
Louisiana
2022
2023-10-10
Focused: Managed Care
South Dakota
2022
2023-10-10
Focused: Personal Care Services
Alaska
2022
2024-02-08
Comprehensive
North Carolina
2022
2024-03-13
Focused: Personal Care Services
Washington
2023
2024-05-29
Focused: Managed Care
Illinois
2023
2024-07-01
Focused: Managed Care
Minnesota
2023
2024-10-16
Focused: Managed Care
Page Last Modified:
11/20/2024 11:13 AM