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New CMS Guidance Issued to Enhance Medicaid Programs’ Integrity

June 20, 2019

The Centers for Medicare & Medicaid Services (CMS) recently issued guidance for state Medicaid agencies in an effort to continue enhancing the financial and programmatic integrity of each program. Information regarding necessary assurances based on a Medicaid program readiness checklist is among the renewed guidance issued.

Following the CMS Medicaid Program Integrity, which was introduced last year, efforts continue to reduce the amount of improper payments across states. The goal is to continue to protect tax payer dollars while enhancing the Medicaid program. Per the press release, the agency also plans examine nearly $1 billion backlog of impermissible state financial claims and conduct federal audits of state eligibility determinations and managed care financial reporting—ensuring that plans are not being over paid.

CMS points to recent concerns raised by the Office of the Inspector General which found that that several states did not adhere to federal regulations for determining Medicaid eligibility. The new renewed guidance signifies the agency’s commitment to Medicaid enrollees health and welfare.

Specific guidance included CMS’s expectations for states regarding Medicaid expansion; States should recognize the increased risk that comes with sharing federal costs, as well as be able to provide assurances of compliance with applicable program requirements when applying for state plan amendments.

The agency notes four main areas that state Medicaid programs should prioritize to ensure correct federal match claims. The program readiness checklist, included in CMS’s renewed guidance, is intended to help states prepare for potential audits and/or program reviews.

  • Development of necessary program integrity expectations for contractors;
  • Implementation of appropriate system and financial oversight controls;
  • State plans that continually assess the ongoing accuracy of eligibility determinations and claiming of federal funding; and  
  • State eligibility systems that are capable of, and ready to submit required performance indicator data to CMS, including information regarding the timeliness and accuracy of eligibility determinations. 

“We have seen a rapid increase in Medicaid spending in recent years and with this growth comes an increasing and urgent responsibility to ensure sound stewardship and oversight of our program resources, said CMS Administrator Seema Verma in a press release. “We are taking a strategic approach to managing improper payments, risks, and fraud as well as developing effective program integrity controls to ensure that government services aid their intended purposes.”

Edan Stanley


Centers for Medicare & Medicaid Services. CMS Issues Renewed Guidance in Effort to Ensure Medicaid Program Integrity, Signifies Agency’s Commitment to Safeguard Health and Welfare of Medicaid enrollees [press release.] 20 June 2019. Accessed June 20, 2019.

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