Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
E   O S
ARLY  UTCOMES  HOW 
 
L P
IMITED  ROGRESS FOR THE 
T M
RANSFORMED  EDICAID 
S I
TATISTICAL  NFORMATION 
S  
YSTEM 
 
Daniel R. Levinson   
Inspector General  
 
September 2013 
OEI-05-12-00610  EXECUTIVE SUMMARY:  Early Outcomes Show Limited Progress for the 
Transformed Medicaid Statistical Information System  
OEI-05-12-00610 
 
WHY WE DID THIS STUDY 
 
In response to a Congressional request, the Office of the Inspector General (OIG) agreed 
to determine the status of national Transformed Medicaid Statistical Information System  
(T-MSIS) implementation and determine whether early outcomes indicate that T-MSIS 
data will be complete, accurate, and timely upon national implementation. T-MSIS is 
designed to be a detailed national database of Medicaid and Childrens Health Insurance 
Program information to cover a broad range of user needs, including program integrity.   
T-MSIS is a continuation of the Centers for Medicare & Medicaid Services (CMS) past 
attempts to improve the current nationally available Medicaid data after OIG and others 
found that the current data were not complete, accurate, or timely.   
 
HOW WE DID THIS STUDY  
 
To complete this early implementation review, we analyzed project schedules, meeting 
minutes, and milestone achievements from 12 States that volunteered to work with CMS 
on the planning and development of T-MSIS.  These States were in a position to be some  
of the first States to implement T-MSIS.  We also analyzed CMSs T-MSIS 
documentation regarding States ability to report complete and accurate T-MSIS data.  
Finally, we conducted structured interviews with CMS staff.  
 
WHAT WE FOUND 
 
Overall, as of January 2013, CMS and the 12 volunteer States had made some progress in 
implementing T-MSIS.  However, most other States had not started implementing 
T-MSIS; and they reported varied timeframes for when they plan to begin.  CMS has not 
established a deadline for when national T-MSIS data will be available. 
 
Further, early T-MSIS implementation outcomes raised questions about the completeness 
and accuracy of T-MSIS data upon national implementation.  None of the 12 volunteer 
States can make all T-MSIS data elements available.  Further, both CMS and the 
12 States expressed concerns about the accuracy of the data they could provide upon 
implementation.   
 
WHAT WE RECOMMEND  
 
Although CMS and 12 volunteer States have made some progress with T-MSIS, it 
remains unclear whether T-MSIS will result in complete, accurate, and timely national 
Medicaid program integrity data upon implementation.  We recommend that CMS, to 
help create a fully functional T-MSIS:  (1) establish a deadline for when national T-MSIS 
data will be available; (2) ensure that States submit required T-MSIS data; and (3) ensure 
  that T-MSIS data are complete, accurate, and timely upon T-MSIS implementation.  
CMS concurred with our recommendations. 
  TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................8 

Findings......................................................................................................12 

Twelve volunteer States made some progress implementing 

T-MSIS; however, most other States had not started ....................12 

CMS has not established a deadline for when national T-MSIS 

data will be available .....................................................................14 

Volunteer States indicated that their data systems did not have 
all T-MSIS data elements...............................................................14 

CMS and volunteer States reported concerns about the accuracy 

of T-MSIS data ..............................................................................17 

Conclusion and Recommendations ............................................................19 

Agency Comments and Office of Inspector General Response .....22 

Appendixes ................................................................................................24 

A: Implementation Milestones ......................................................24 

B: Description of Documents Reviewed .......................................26 

C: Definitions of Office of Inspector General Completeness 

Categories ......................................................................................27 

D: Progress Toward Milestones ....................................................29 

E: Availability of  Transformed Medicaid Statistical Information 

System Data Elements by File for All Volunteer States .................32 

F: Transformed Medicaid Statistical Information System Data 
 
Elements Available in All Volunteer States ....................................35 

G: Agency Comments  ...................................................................37 

Acknowledgments......................................................................................44 

  OBJECTIVES 
1. 	  To determine the status of the Centers for Medicare & Medicaid 
Services (CMS) national implementation of the Transformed 
Medicaid Statistical Information System (T-MSIS). 
2.	   To determine the extent to which the early implementation outcomes 
and States and CMSs experiences implementing T-MSIS indicate 
that T-MSIS may result in complete, accurate, and timely national 
Medicaid program integrity data. 
BACKGROUND 
This early implementation review responds to a Congressional request that 
the Office of Inspector General (OIG) review T-MSIS to determine 
whether CMSs plans, milestones, metrics, goals, and data elements meet 
the needs of entities conducting program integrity activities.  In response 
to the request, OIG agreed to determine the status of national T-MSIS 
implementation and determine whether early outcomes indicate that 
T-MSIS data will be complete, accurate, and timely upon national 
implementation. 
Previous OIG work found problems with national Medicaid data and 
recommended that CMS improve the quality of data.1   T-MSIS is CMSs 
solution to the known problems in the current nationally available 
Medicaid data.2    
Medicaid Data Reporting Requirements 
States are mandated to report fee-for-service claims and individual 
encounter data for managed care enrollees to CMS.  The Patient Protection 
and Affordable Care Act (ACA) added a requirement that States report 
elements that the Secretary deems necessary for program integrity, 
oversight, and administration.  The Medicaid Statistical Information 
System (MSIS) is the mechanism by which CMS requires States to report 
these data.3  CMS requires States to report MSIS data quarterly. 4  
 
1 OIG,  Early Assessment of Audit Medicaid Integrity Contractors, OEI-05-10-00210, 
March 2012; OIG,  MSIS  Data Usefulness for Detecting Fraud, Waste, and Abuse, 
OEI-04-07-00240, August 2009; and  OIG,  Medicaid Managed Care Encounter Data:  
Collection and Use, OEI-07-06-00540, May 2009. 
2 OIG,  Early Assessment of Audit Medicaid Integrity Contractors. 

3 Social Security Act (SSA)    1903(r)(1)(F) as added by the Balanced Budget Act of
  
1997, P.L. 105-33  4753(a)(1), and amended by  the ACA, P.L. 111-148  6504, to 
 
include data elements the Secretary determines are necessary for program integrity, 

oversight, and administration.
  
4 CMS, State Medicaid Manual, Pub. No. 45,   2700.2. 

Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        1 
  CMSs statutory enforcement mechanisms for data reporting requirements 
vary.  CMS may withhold Federal matching payments for the use, 
maintenance, or modification of automated data systems from States that 
fail to report required data.5  For managed care enrollees, CMS may 
withhold Federal matching payments for medical assistance to those 
individuals when States fail to report required data.6  
Medicaid Statistical Information System  
MSIS is an extract of States Medicaid Management Information Systems 
(MMIS) and contains claims information from all 50 States and the 
District of Columbia (hereinafter referred to as States).7    
MSIS is composed of 5 data files and approximately 400 data elements.  
There is an eligibility file and there are four claims files (inpatient, 
long-term-care, pharmacy, and other). 
CMS intended MSIS as a detailed national database of Medicaid program 
information to cover a broad range of user needs.8   The database is used 
for analytical research, program  integrity, planning, budgeting, and policy 
analyses associated with Medicaid.  MSIS is the only nationwide 
Medicaid eligibility and claims database.  
Difficulties Using MSIS for National Medicaid Program Integrity  
In previous reports, OIG identified problems with missing or outdated 
MSIS data that make it an inadequate tool for national Medicaid program  
integrity data analysis strategies. OIG found that MSIS did not have all 
data elements necessary for conducting national Medicaid program  
integrity activities.9   Approximately half of a consolidated set of program  
integrity data elements identified by CMS and other Federal agencies were 
not collected from States for MSIS.10 Also, MSIS data were outdated.11   
OIG found that it took an average of 1.5 years to release MSIS data 
publicly from fiscal year (FY) 2004 to FY 2006; significant time was lost 
because States initial MSIS data submissions were late.12    
 
5  SSA  1903(r)(1)(F). 
 
6  SSA  1903(i)(25),  added by the ACA,  P.L. 111-148  6402 (c). 
 
7 Each State has its own unique MMIS.  States use MMIS to  process claims and monitor 

use of services. 

8 CMS, MSIS Medicaid Statistical Information  System.   Accessed at 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-
Systems/MSIS/Medicaid-Statistical-Information-System.html on April 3, 2013.  See 
MSIS Procedures, as well. 
9 OIG,  MSIS Data Usefulness for Detecting Fraud,  Waste, and Abuse. 

10 Ibid. 

11 Ibid. 

12 Ibid. 

Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        2 
  Further, OIG identified MSIS accuracy concerns.  In a series of reports, 
OIG found that inaccurate MSIS data hindered the early results of 
Medicaid integrity contractors.13  Specifically, States invalidated more than 
one-third of sampled potential overpayments identified by Medicaid 
integrity contractors mainly because MSIS data were missing or 
inaccurate.14   Additionally, 81 percent of Medicaid integrity contractor 
audits reviewed by OIG either did not, or were unlikely to, identify 
overpayments; in nearly half of these audits, MSIS data were missing or 
inaccurate.15  
In addition, OIG found that the lack of complete, accurate, and timely 
national Medicaid data is also a barrier to CMSs own program integrity 
data initiatives, such as the Medicare-Medicaid Data Match Program  
(Medi-Medi) and the Integrated Data Repository (IDR).16  Specifically, 
CMS does not use MSIS data for the Medi-Medi program.17 Instead, 
CMSs contractors work with participating States to collect data directly 
from each States Medicaid program.  Additionally, CMS intends for the 
IDR to provide a central repository for Medicare and Medicaid data.18   
However, CMS has not integrated MSIS data into the IDR.  The OIG 
report notes that according to CMS Medicare program integrity staff, 
MSIS data in their current form are not appropriate to include in the IDR 
because the data are specific to each State and lack many of the 
standardized data elements needed for program integrity work.19  
Finally, in 2012, CMS testified that MSIS was not an effective data source 
for national Medicaid program integrity activities.20 CMS further stated 
 
13 OIG,  Early Assessment of Audit Medicaid Integrity Contractors; OIG,  Early 
 
Assessment of Review Medicaid Integrity Contractors, OEI-05-10-00200, February 2012. 

14 OIG,  Early Assessment of Review Medicaid Integrity Contractors. 

15 OIG,  Early Assessment of Audit Medicaid Integrity Contractors. 

16 OIG,  The Medicare-Medicaid (Medi-Medi) Data Match Program, OEI-09-08-00370, 

April 2012. 

17 CMS established the Medi-Medi program in 2001 as a way to identify improper billing  
patterns by matching Medicare and Medicaid claims information for providers and  
beneficiaries.  Section 6034 of the Deficit Reduction Act added section 1893  of the SSA,  
which permanently established the Medi-Medi program at section 1893(g), P.L.  109-171  
 6034.  
18 CMS established the IDR in 2006 as a central repository for Medicare and Medicaid 
data.  It is intended to  help CMS program integrity staff and contractors (including  
Medi-Medi contractors) prevent and detect improper payments across the Medicare and 
Medicaid programs.  Accessed at  http://www.cms.gov/Research-Statistics-Data-and-
Systems/Computer-Data-and-Systems/IDR/index.html  on March 5,  2013.  
19 OIG,  The Medicare-Medicaid (Medi-Medi) Data Match Program.  CMS indicated that 
the IDR would not contain Medicaid claims  data until at least 2015. 
20 Peter Budetti, M.D., J.D., Program Integrity Efforts in the Medicare and  Medicaid  
Programs, Testimony before  the United State House Committee on Oversight and 
Government Reform, Subcommittee on Government Organization, Efficiency, and  
Financial Management, June 7, 2012.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        3 
  that it was taking steps to create a more comprehensive information 
management strategy for Medicaid, the Childrens Health Insurance 
Program (CHIP), and State health systems.21   This included making 
improvements to MSIS. 
Transformed Medicaid Statistical Information System 
CMSs efforts to improve MSIS will result in a new national Medicaid 
dataset called T-MSIS.  Among CMSs goals for T-MSIS are improving 
the completeness, accuracy, and timeliness of the data.  CMS also intends 
for T-MSIS to be a way to limit the number of data requests States receive 
from CMS.  To accomplish these goals, CMS is working with contractors 
to implement T-MSIS. 
T-MSIS is a continuation of CMSs multiple past attempts to improve 
MSIS. In 2009, CMS conducted a pilot project for a national Medicaid 
database entitled MSIS Plus.22  CMS followed this with another pilot 
project for a database entitled MSIS Redesign in 2011.23  CMSs goals for 
both of these databases were to create a more complete, accurate, and 
timely national Medicaid dataset and to limit data requests to States.24  
T-MSIS pilot project. CMS conducted a pilot project between March 2011 
and June 2012 to inform the development of T-MSIS.  The pilot project, 
which incorporated lessons learned from the two previous attempts to 
improve MSIS, had two objectives:  (1) identify the data elements required  
by all stakeholders and (2) identify a technical platform and environment 
able to accommodate T-MSIS and run stakeholder analytics.   
At the conclusion of the pilot project, CMS determined that it identified 
appropriate T-MSIS data elements.  Internal CMS stakeholders confirmed 
that T-MSIS data elements were those that they need from States to 
conduct business functions and analysis, including national Medicaid 
program integrity activities.25  In addition, many data elements new to 
 
21 Ibid. 
22 Robb Miller & Yohannes Birre (CMS), MSISPLUS Pilot Project, presentation  at  
MMIS Conference, Chicago, IL, August 19, 2009.  Accessed at 
http://www.mmisconference.org/MMIS2009_Presentations_PDFs/Wednesday/The%20F 
uture%20of%20MSIS/Wednesday_MSIS_Birre.pdf on March 29, 2013. 
 
23 Federal IT Dashboard, MSIS Redesign. Accessed at 

http://www.itdashboard.gov/print/investment/project-summary/284  on March 5, 2013. 

24 Robb Miller & Yohannes Birre, MSISPLUS Pilot Project; Ibid. 

25 Internal  stakeholders include multiple divisions within CMS that may use T-MSIS  data 
 
in the future:   Center for Program Integrity, Center for Medicare & Medicaid Innovation, 

Financial Management Group, CHIP, Division of Pharmacy, and Center for Clinical
  
Standards and Quality. 

Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        4 
  T-MSIS address MSIS program integrity gaps identified by external 
stakeholders, such as OIG.26   
CMS also determined how to best construct a data platform to meet the 
data collection and analytic needs of CMSs internal stakeholders.   
T-MSIS Data. There are approximately 1,000 data elements in T-MSIS, 
an expansion of the approximately 400 data elements collected in MSIS.27   
In general, CMS created T-MSIS data elements that responded to gaps in 
MSIS data identified by OIG and other stakeholders.   
CMS organized T-MSIS into eight files.  T-MSIS files include eligibility,  
third-party liability, managed care plan information, provider, and four 
claims files (inpatient, long-term-care, outpatient, and pharmacy). 
CMS plans to make T-MSIS data files available approximately 60 days 
after the month in which the claims were processed.28 States will have 
1 month to submit T-MSIS data files (e.g., States will have until the end of  
February to submit January data).  CMS plans to upload files to a data 
platform within 1 month of receiving States  T-MSIS data files.    
National T-MSIS Implementation 
CMS has taken steps to establish the groundwork for States to begin 
implementing T-MSIS.  CMS completed a number of activities to design 
T-MSIS so that States could begin implementing it.  These activities 
include clarifying data elements, identifying critical data elements, 
completing some preliminary activities with States, and releasing data 
quality rules to States.  See Figure 1 for a timeline of these activities.  
   
 
26 OIG,  MSIS Data Usefulness for Detecting Fraud,  Waste, and Abuse.  
27 Jim Gorman (CMS), T-MSIS Pilot Overview, panel  presentation at Medicaid Enterprise  
Systems Conference, Boston, MA, August 20, 2012.  Accessed  at 
http://www.mesconference.org/wp-
content/uploads/2012/08/Monday_TMSIS_Gorman.pdf on  June 12, 2013.   
28 CMS, T-MSIS Implementation Tool Kit, version 2.0,   1.4, March 12, 2013. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        5 
  Figure 1: Timeline of T-MSIS Activities  
Pilot project 
Kickoff meetings (12 States) 
Planned implementation phase (all States) 
Status update meetings (12 States) 
Mapping exercise (12 States) 
Readiness assessments (39 States) 
Active 
 
Source:  OIG analysis of CMS documents and  structured interviews, 2013. 
Clarifying data elements and definitions. CMS published the T-MSIS 
data elements and definitions in a data dictionary.29   The data dictionary 
defines the data elements States must submit to CMS for T-MSIS.  Along 
with indicating new data elements for T-MSIS, the data dictionary 
changed some of the definitions for data elements that States had been 
submitting as part of MSIS to clarify the information CMS wants States to 
submit.  For example, one MSIS data element is national provider ID.  
CMS instructed the State on which provider identification number to 
submit for each claim file in the definition.  CMS changed this data 
element in T-MSIS to 10 data elements to reflect the different possible 
provider IDs.30   
Identifying critical data elements. Following the pilot project, CMS 
assessed which T-MSIS data elements would be critical to support 
Medicaid and CHIP business needs, including meetings with internal 
stakeholders. As a result, CMS identified a subset of T-MSIS data 
elements as critical for business needs.  Internal stakeholders identified the 
majority of T-MSIS data elements as critical.  For example, the Center for 
 
29 CMS has released three T-MSIS data dictionaries.  CMS released the first dictionary in  
February 2012, the second in  February 2013, and the third in  April 2013. 
30 The 10 T-MSIS data elements are:  admitting provider national provider identifier 
(NPI) number, billing provider NPI, dispensing  prescription drug provider NPI, health  
home provider NPI, operating provider NPI, prescribing provider NPI, referring provider  
NPI,  servicing provider  NPI, under direction  of provider  NPI, and under supervision  of  
provider NPI.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        6 
  Program Integrity identified more than two-thirds of T-MSIS data 
elements as critical.31   
Involving States. CMS partnered with 12 States (hereinafter referred to as  
volunteer States) that volunteered to work with CMS on the planning and 
development of T-MSIS.  These States were in a position to be some of 
the first States to implement T-MSIS.  CMS plans to phase in the 
remaining States in 2013.32  
CMS outlined 23 milestones to assist States in implementing T-MSIS.  
These milestones fall into four general stages:  (1) planning, (2) design, 
(3) development, and (4) testing.  CMS estimated that it would take States 
an average of 9 months to complete these milestones and implement 
T-MSIS.33  See Appendix A for a full list of these milestones.34    
Additionally, CMS held a series of meetings with volunteer States 
between April and December 2012.  These meetings focused on volunteer 
States progress in implementing T-MSIS, including discussion of any 
challenges they may face and possible solutions or strategies to overcome 
them. 
In November and December 2012, CMSs contractor worked with 
volunteer States to complete a data mapping exercise (hereinafter referred 
to as data matching exercise).35 This exercise consisted of volunteer 
States verbally confirming whether they could provide data that matched 
the T-MSIS data elements in the February 2012 T-MSIS data dictionary.  
The purpose of this exercise was to assess the status of the data dictionary 
and to identify any needed clarifications.  This exercise informed the 
development of subsequent data dictionaries.     
Lastly, in December 2012, CMS conducted readiness assessments with the 
remaining States.  CMS inquired about their readiness to begin 
implementing T-MSIS.   
 
31 CMSs Center for Program Integrity, which conducts national Medicaid program  
integrity activities, is one of the internal stakeholders.  See footnote 25. 

32 The volunteer States include Arizona, Arkansas, California, Michigan,  Minnesota, 

New Jersey, New Mexico, North Carolina,  Oregon, Tennessee, Texas, and Washington.  

These States represent approximately 40 percent of the Nations Medicaid expenditures.  

Jim Gorman (CMS), T-MSIS Pilot Overview; OIG analysis of data from  

http://kff.org/state-category/medicaid-chip/, accessed on November 21, 2012. 

33 CMS, Guidance for Automated Data Systems Requirements and Data  Elements 
Necessary for Program Integrity, Program Oversight, and Administration, Version 
1.0.  Provided  to OIG on  August 15, 2012. 
 
34 According to  CMS staff, States are not required to complete all milestones.  

Additionally, States may not need to complete all milestones in  order.  See Appendix  A 

for more details. 

35 CMS retained  a contractor to  assist with T-MSIS implementation.  

Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        7 
  Releasing data quality rules. CMS released data quality rules that 
addressed formatting T-MSIS data to all States on April 30, 2013.  CMS 
expects States to apply these rules prior to submitting their T-MSIS data to 
CMS. These rules address some data standardization concerns that made 
MSIS data unusable for many national data analysis strategies (e.g., some  
States submit five-digit ZIP Codes to MSIS while other States submit 
nine-digit ZIP Codes).  
T-MSIS Guidance.  CMS released a State Medicaid Director Letter on 
August 23, 2013.36   This letter provided an update to States on CMSs 
ongoing effort to improve Medicaid data through T-MSIS.37  
METHODOLOGY 
This early implementation review determines the status of T-MSIS 
implementation as of January 2013.  It also assesses the early outcomes 
from 12 States.  
Scope 
Our review focused primarily on the progress CMS and the 12 volunteer 
States had made. 
Our review also used the early outcomes from the 12 volunteer States to 
determine whether T-MSIS will provide complete and accurate national 
Medicaid program integrity data upon national implementation.  We did 
not assess the timeliness of T-MSIS data submissions.  Because the 
12 volunteer States were not submitting T-MSIS data at the time of our 
review, we could not determine States ability to report T-MSIS data a 
month after claims were processed or the ability of CMS to release 
T-MSIS data a month after receiving the data. 
Additionally, we did not assess individual State data elements or States 
capacity to modify their data to comply with T-MSIS requirements.  
Further, we did not assess the quality of States data or the usefulness of  
those data in conducting State program integrity activities.   
   
 
36 CMS, State Medicaid Director Letter, August 23, 2013, (SMD# 13-004).  Accessed at 
 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf on 
 
September 3, 2013. 

37 Included in this update was a change to CMSs implementation  deadline.  In the letter, 

CMS stated its goal is to  have  all States submitting monthly T-MSIS data by 

July 1, 2014.  This change  was made after OIG completed its analysis and has no effect 

on the findings of this report. 

Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        8 
  Data Sources 
Document Request. We requested from CMS all documents related to the 
status of T-MSIS implementation and CMSs plans for national 
implementation.  Primarily, these documents included:   
 	  meeting minutes between CMS and volunteer States (occurred 
between April and December 2012), 
 	  project schedules and status updates (as of January 2013), 
 	  State readiness assessment notes (occurred primarily in 
December 2012), 
 	  T-MSIS data dictionaries, and 
 	  T-MSIS Implementation Tool Kit. 
See Appendix B for a detailed description of these documents.  We  
received documents from CMS through April 2013. 
Data Matching Exercise. CMSs contractor conducted a data matching 
exercise with each volunteer State.  During this exercise, volunteer States 
verbally informed the contractor whether each T-MSIS data element that 
was in CMSs original February 2012 data dictionary was available in its  
data systems.  The contractor entered the results of this exercise into a 
spreadsheet. CMS provided the results spreadsheet to OIG. 
The exercise reviewed 769 data elements.  This is fewer than the 
approximately 1,000 data elements that CMS expects T-MSIS to have 
upon completion.  At the time of our data collection, CMS was still 
determining the final data elements.  For example, during the exercise, 
CMS identified 29 of the 769 data elements for removal.   
Structured Interviews. Between November 2012 and January 2013 we 
conducted multiple structured interviews with CMS officials and CMSs 
contractor responsible for designing and implementing T-MSIS.  We  
asked about the progress toward national T-MSIS implementation and 
CMSs plans. 
Determining the Status of T-MSIS Implementation 
To determine the status of T-MSIS implementation as of January 2013, we 
analyzed project schedules, meeting minutes, and information gathered 
during structured interviews with CMS and CMSs contractor.  We  
reviewed project schedules and meeting minutes to identify the volunteer 
States progress on completing the milestones.  We used the milestone 
checklist from the T-MSIS Implementation Tool Kit to identify the 
milestones that CMS laid out for States.  We reviewed the meeting 
minutes and information gathered during structured interviews to identify 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        9 
  steps CMS took to implement T-MSIS and move forward with additional 
States.  We also reviewed the meeting minutes and information from  
structured interviews for indications of which milestones States had 
completed.   
Determining Early Outcomes From Volunteer States 
We determine early outcomes from  volunteer States for two issues:  
completeness and accuracy.  
Completeness. We analyzed 740 data elements in the data matching 
exercise results spreadsheet to determine early outcomes from the 
volunteer States. We excluded the 29 data elements that CMS identified 
for removal.  Specifically, we reviewed volunteer States responses for 
indications of their ability to make T-MSIS data elements available to 
CMS. 
We calculated the percentage of all data elements in three categories for 
all volunteer States.  The three categories we created to reflect volunteer 
State responses to T-MSIS data element availability were:  (1) match 
available, (2) match available but data may have gaps, and (3) match not 
available. See Appendix C for a definition of each category.  We 
completed this calculation for each T-MSIS file and each volunteer State.   
Further, we calculated how many and what percentage of all T-MSIS data 
elements all volunteer States had available.  
We repeated these calculations for two subsets of T-MSIS data elements:  
(1) data elements deemed critical by CMS entities conducting program  
integrity work and (2) data elements that were included in MSIS.   
Accuracy. We analyzed the data matching exercise results spreadsheet 
and information from interviews with CMS to determine whether 
volunteer States early outcomes indicated potential accuracy concerns.  
We analyzed the spreadsheet and information from interviews with CMS 
to determine the extent to which early outcomes indicated that:  (1) data 
will reflect T-MSIS data dictionary definitions and (2) source data may be 
inaccurate.  
We analyzed notes in the spreadsheet in which CMS, CMSs contractor, 
or volunteer States indicated potential accuracy concerns.  When possible, 
we counted instances in which such notes indicated accuracy concerns and 
calculated the percentage of data elements with accuracy concerns.  
Limitations 
This study reports on CMSs plans for national implementation of 
T-MSIS, as well as the status and outcomes of national implementation as 
of January 2013. OIG recognizes that the status of implementation and 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        10 
  even CMSs plans may have changed by the time OIG releases this report.   
Further, given the early nature of national implementation, we were unable 
to assess the States ability to submit complete, accurate, and timely data.  
Rather, we used the volunteer States early implementation outcomes as 
indicators for what CMS and the remaining States might encounter during 
implementation.   
At the time of our data collection, the data matching exercise was the best 
available proxy for the data that volunteer States had available.  Because 
the exercise covered 740 of the 1,000 data elements in T-MSIS, it is a 
strong indicator of States ability to provide the T-MSIS data elements.  
However, the data elements in the exercise were not the final version of 
T-MSIS data elements that CMS will ask States to submit. Subsequent to 
this exercise, CMS made definitional changes and refined record layouts 
in an updated data dictionary. This means that States ability to submit the 
final data elements may differ from our results.  In addition, the data from 
the exercise are self-reported State data.  We did not verify whether States 
could actually provide the data that they reported they could.   
We could not calculate a percentage for all types of accuracy concerns 
mentioned by CMS and States.  When we could confidently interpret a 
comment on the data matching exercise results spreadsheet as a potential 
accuracy concern, we counted it and calculated a percentage.  In other 
instances, when we could not confidently interpret a comment as a 
potential accuracy concern, we relayed the nature of the concern. 
Standards 
This study was  conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        11 
  FINDINGS 
Twelve Volunteer States Made Some Progress 
Implementing T-MSIS; However, Most Other States 
Had Not Started 
As of January 2013, the 12 volunteer States had made progress toward 
T-MSIS implementation, but most of the remaining States had not started.  
The volunteer States completed, on average, 7 of the 23 T-MSIS 
milestones in the 6 months from when implementation began in July 2012.  
Seventeen additional States indicated that they were ready to start 
implementation in 2013.  The remaining 22 States did not have a 
timeframe for starting implementation. 
While volunteer States made some progress, they may exceed 
the estimated implementation time 
As of January 2013, all volunteer States had completed some of the 
T-MSIS implementation milestones but no volunteer State had completed 
all of them.   
Volunteer States made the most progress in the first stage, planning.  All 
volunteer States completed or partially completed the seven milestones 
associated with this stage.  However, only five volunteer States completed 
all of the milestones associated with this stage.   
No volunteer States completed the other three stagesdesign, 
development, and testing.  Further, four volunteer States have not started 
working on milestones associated with development and testing.  Table 1 
is a broad overview of the progress that volunteer States made in the 
four stages. For a complete breakdown of volunteer States progress by 
individual implementation milestone, see Appendix D. 
Table 1: Volunteer States Progress Toward T-MSIS Implementation 
Milestones  
Milestone Stages   Completed   Partially Completed   Not Started  
1. Planning (7 milestones)   5  7  0 
2. Design (6 milestones)   0  12  0 
3. Development (3 milestones)  0  8  4 
4. Testing (7 milestones)   0  7  5 
Source:  OIG analysis of T-MSIS project schedules and volunteer State status updates, 2013. 
Volunteer States experienced some delays that may have hindered their 
progress, including delays finalizing contracts to assist with T-MSIS 
implementation.  Securing contracts is part of identifying T-MSIS project 
resources, which is a stage 1 milestone, but delays in contracts also affect 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        12 
  States ability to complete other milestones, such as mapping their data 
elements to the T-MSIS data elements.  Five volunteer States indicated 
that they faced delays of this nature. 
Volunteer States also faced delays because CMS did not release needed 
information when it initially expected.  For instance, CMS initially 
expected that it would release the revised T-MSIS data dictionary in 
September or October 2012.  In fact, CMS did not release the revision 
until February 2013, delaying volunteer States ability to re-map their data 
elements to T-MSIS data elements.  Further, CMS did not release the data 
quality rules until April 2013.  Volunteer States need these rules to 
develop and test data verification/business rules and to validate 
successfully the eight T-MSIS data files.   
Possibly because of these delays volunteer States completed fewer 
milestones, on average, than would be expected at this point in CMSs 
estimated 9-month completion timeframe.  Volunteer States worked on 
milestones for at least 6 months by the time of our data collection, but 
were able to complete only between 3 and 13 of them, mainly in the 
planning phase. To stay on schedule to complete the milestones within the 
estimated 9-month completion time, States would have to complete the 
design, development, and testing of T-MSIS in 3 months.     
The remaining 39 States may not face the same challenges that volunteer 
States faced.  CMSs experiences with the volunteer States may enable it 
to work with the remaining States to avoid similar challenges and thus 
have fewer delays. In addition, CMS has released the data quality rules, 
so the remaining States will not have to wait for those as they begin 
implementing T-MSIS.  However, the remaining States may still 
experience delays, such as those related to finalizing contracts or 
challenges unique to their States.  
The remaining 39 States reported varied timeframes for when 
they can begin implementing T-MSIS 
As of the December 2012 readiness assessments, 17 of the remaining 
39 States indicated to CMS that they anticipate being ready to begin 
implementing T-MSIS in 2013.  The final 22 States did not indicate when 
they could begin implementing T-MSIS.38 These States listed various 
reasons for their hesitation, including lack of information about T-MSIS 
and competing demands for State resources.   
 
38 Included in the group  of  22  States that did not  have a timeline for T-MSIS  
implementation are 4 States for which OIG did not receive records of their readiness 
assessments.  These States are Iowa, Missouri, New Hampshire, and  Wyoming.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        13 
  CMS Has Not Established a Deadline for When  
National T-MSIS Data Will Be Available 
CMS does not have a specific timeframe for when it will begin to rely on 
T-MSIS as the sole national Medicaid dataset.  Further, CMS does not 
have a timeline for switching completely from the use of MSIS data to 
T-MSIS data. Instead, the switch from MSIS to T-MSIS will happen over 
time on a State-by-State basis.  CMS staff indicated that each State will 
switch from MSIS to T-MSIS only after it demonstrates operational 
readiness to implement T-MSIS and successfully transmits T-MSIS data.  
Additionally, CMS has not clearly defined when it expects all States to 
complete T-MSIS implementation.  In August 2012, CMS staff stated that 
the goal was for all States to submit T-MSIS data as of January 1, 2014.  
In anticipation of that goal, CMS indicated that its goal was to be ready to 
accept data from States by that date. However, later, in 2013, CMS staff 
indicated that CMS modified its expectation for States by saying that all 
States should be either working on T-MSIS or committed to working on 
T-MSIS by January 1, 2014. CMS added terms and conditions on funding 
secured through an APD to reflect this shift.  CMS staff indicated that 
States that are not submitting T-MSIS data by January 1, 2014 must 
develop a work plan to submit T-MSIS data as soon as possible. 
What steps CMS might take to enforce any deadline is unclear.   When 
States asked whether there was flexibility in meeting the January 2014 
deadline or whether there were penalties for not doing so, CMS staff 
informed States that they were uncertain whether CMS would impose any 
penalties and what those penalties might be.  CMSs ability to enforce a 
deadline is a concern because 8 of the 39 remaining States asked CMS 
about the January 2014 deadline during the readiness assessments; 3 States 
asked specifically about potential penalties for not meeting the deadline.    
Volunteer States Indicated That Their Data Systems 
Did Not Have All T-MSIS Data Elements 
Upon implementation, T-MSIS will likely not contain all data elements 
across all volunteer States for two primary reasons.  First, volunteer States 
indicated that they do not have data available for all T-MSIS data elements 
in their State data systems. Second, CMSs T-MSIS processes allow 
States to submit a subset of T-MSIS data elements. 
Volunteer States do not have complete T-MSIS data available  
Results from the data matching exercise indicated that no volunteer State 
could make all of the 740 data elements available for T-MSIS.  In other 
words, States indicated that their data systems do not capture data that 
could match every T-MSIS data element. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        14 
  Volunteer States reported mixed abilities to make data available for 
T-MSIS data elements.  Data availability ranged from 9 percent of data 
elements to 81 percent; 11 of the 12 volunteer States reported data 
available for more than 50 percent of the data elements.  Data for the 
remaining data elements were either not currently available or available 
with indications of gaps in the data.39  T-MSIS data element availability by 
volunteer State is represented in Figure 2.  To see each volunteer States 
data element availability by file, see Appendix E. 
Figure 2: T-MSIS Data Availability by Volunteer State  
100% 
90% 
Match not 
80%  available 
70% 
60%  Match available 
but data may 
50% 
have gaps 
40% 
Match available 
30% 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
CMS faces similar challenges with data availability for T-MSIS data 
elements deemed critical for program integrity activities by the Center for 
Program Integrity as it does for T-MSIS data elements as a whole.  The 
percentage of data elements that were critical for program integrity was 
similar to the overall percentage of available T-MSIS data elements.  
Specifically, States individual abilities to make data available for critical  
program integrity data elements ranged from 9 percent to 84 percent; 11 of 
the volunteer States reported at least 50 percent of these critical T-MSIS 
elements as available.  This similarity is unsurprising because the Center 
for Program Integrity deemed two-thirds of the data elements as critical 
for conducting national Medicaid program integrity activities. 
States also indicated that data for T-MSIS data elements that were also 
required as part of MSIS may not be available.  Data for T-MSIS data 
elements that were also in MSIS (28 percent of T-MSIS data elements) 
 
39 Examples of  gaps in  data include:  notes saying that a volunteer State had certain data 
available only for fee-for-service claims  or notes indicating that a volunteer State had 
only a subset  of the values that CMS requested  for T-MSIS data elements.  Data that are 
not available are composed of all data elements for which volunteer States did not clearly  
have matches available.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        15 
  were slightly more available than T-MSIS data elements overall.  
Availability of these elements ranged from 13 percent to 87 percent; 11 
volunteer States reported at least 50 percent availability.  
A small percentage of the same T-MSIS data elements are available across  
all volunteer States. Approximately 4 percent (27 data elements) of 
T-MSIS data elements are available from all volunteer States.  The 
percentage of data elements available from volunteer States increased to 
25 percent when we excluded California from our analysis.  The results of 
Californias data matching exercise indicated an unusually high 
percentage of T-MSIS data elements for which matches were not 
available.40  For a list of the 27 data elements that all volunteer States can 
provide, see Appendix F. 
Upon implementation, CMS will accept, as complete, the data  
volunteer States have available 
CMS will create an individualized control file for each volunteer State.  
These files will specify the T-MSIS data elements that each volunteer 
State reports it is able to provide upon implementation.  These files will be 
created after States submit formal mapping documents to CMS and CMS 
reviews the results for completeness.41  States will need to justify their 
reasons for not providing specific data elements and provide an action 
plan to obtain the missing data elements.  CMS will use each volunteer 
States individualized files to determine whether their data submissions 
are complete.   
Modifications to volunteer States initial individualized control files after 
implementation depend on the State.  In some cases, the initial 
individualized files will represent a subset of T-MSIS that encompasses all 
of the data elements a State will be required to submit.  For example, 
Arkansas does not use managed care plans for its managed care program, 
so it does not have the data elements requested in the T-MSIS managed 
care plan information file, nor would CMS expect Arkansas to submit 
those data.  In other cases, CMS will alter States initial individualized 
control file to include additional data elements as the States expand the 
number of data elements they are able to provide.  
   
 
40 Specifically, California indicated that 81 percent of elements were TBD (i.e., to be 
determined).  California indicated that mapping its data to the T-MSIS data elements 
would involve reviewing 24 internal data  sources.   
41 States mapping documents indicate, in  writing, which data elements available in their 
State systems map to the T-MSIS data elements in the April 2013  data dictionary. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        16 
  CMS and Volunteer States Reported Concerns About 
the Accuracy of T-MSIS Data 
CMS and volunteer States raised concerns about States ability to submit 
accurate T-MSIS data. CMS, CMSs contractor, and volunteer States 
raised two types of concerns during the T-MSIS data matching exercise 
about whether the T-MSIS data submitted by States will be accurate.  The 
first concern is that data from States may not reflect the definition of the 
T-MSIS data element in question.  For example, while CMS requests that 
States report the data element for birth weight in grams, some States 
indicated that they would report birth weight in pounds.  The second 
concern is that State source data may be inaccurate.  For example, in some  
cases, State agencies other than the States Medicaid agencies collect and 
store the data necessary for T-MSIS.  Some volunteer States indicated 
concerns that they cannot guarantee the accuracy of data collected and 
stored by these other State agencies.  
CMS and its contractor described three reasons why T-MSIS data may not 
reflect the data element definitions:  (1) different derivation methods may 
cause inconsistent data reporting, (2) T-MSIS data element definitions 
may be unclear, and (3) States may submit data that do not match the data 
element definitions.   
CMS questioned whether volunteer States derivation methods when 
pulling or deriving T-MSIS data elements from sources outside MMIS 
would lead to inconsistent data reporting across volunteer States.  For 
example, CMS expressed concerns over whether the data elements 
indicating an individuals disability status were derived consistently across 
States because States may use and store disability codes in different ways.  
CMS had this concern for 19 percent of T-MSIS data elements. 
Additionally, CMSs contractor expressed concerns about whether CMS 
clearly defined some data elements.  Some data element definitions lacked 
specificity that could lead to the submission of inaccurate data.  For 
example, CMSs contractor noted that the definition for billing location 
needed clarification. CMSs contractor explained that volunteer States 
were unsure whether this data element asks for the location of where a 
service was performed or where the physicians main business office is 
located.42  
CMSs contractor also raised concerns that States may submit data that do 
not match CMS data element definitions.  CMSs contractor noted that 
many volunteer States collect data concerning beneficiary ethnicity and 
 
42 Not all medical services are provided at the physicians main business address; many 
physicians perform services in both an  office setting and a hospital setting.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        17 
  financial assistance through State agencies other than the State Medicaid 
agencies. These other State agencies may not code the data according to 
T-MSIS data element definitions.    
Volunteer States also expressed potential accuracy concerns for a small 
percentage of data elements.  Volunteer States comments indicated 
potential accuracy concerns related to their ability to submit data that 
reflected the data element definitions and the accuracy of their source data.  
Potential accuracy concerns ranged by State between 2 percent and 
9 percent of data elements for which they had matches available.  For a 
breakdown of available data elements with potential accuracy concerns by  
State, see Table 2.  
Table 2: Available T-MSIS Data Elements with Potential Accuracy  
Concerns Identified by Volunteer State  
Number  Number of  Accuracy   Percentage With  
States  
Available  Concerns   Accuracy Concerns  
AR  470  18  4%  
AZ  491  15  3%  
CA  69  5  7%  
MI  432  18  4%  
MN  479  43  9%  
NC  598  33  6%  
NJ  598  13  2%  
NM  479  15  3%  
OR  597  11  2%  
TN  547  27  5%  
TX  409  24  6%  
WA  575  42  7%  
Source:  OIG analysis of data matching  exercise results spreadsheet, 2013. 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        18 
  CONCLUSION AND RECOMMENDATIONS 
Although CMS and 12 volunteer States have made some progress with 
T-MSIS, early T-MSIS implementation outcomes raised questions about 
the completeness and accuracy of T-MSIS data upon national 
implementation.  Creating and obtaining a national Medicaid dataset is a 
complex endeavor given the structure of the Medicaid program.  To that 
end, CMS has planned and designed a dataset that appears to addresses 
various stakeholder data needs and concerns, including the planned 
collection of data elements important for national Medicaid program  
integrity strategies. However, early evidence raises concerns about 
volunteer States abilities to submit complete and accurate T-MSIS data; 
only 25 percent of T-MSIS data elements from the February 2012 data 
dictionary were available from all volunteer States.43  Additionally, limited 
implementation progress has delayed CMSs and States abilities to test  
monthly submission requirements. 
The early outcomes of volunteer States efforts to implement T-MSIS may 
also provide insight into the remaining 39 States abilities to implement 
T-MSIS. Specifically, the remaining States may also not have all T-MSIS 
data elements available in their data systems.  Further, many of the 
potential accuracy issues identified by CMS and volunteer States may also 
exist in the remaining States T-MSIS data.   
Complete, accurate, and timely national Medicaid data are essential to 
help protect the integrity of Medicaid.  CMS has multiple program  
integrity projects underway that require T-MSIS data to be fully 
functional. Additionally, OIG and other external stakeholders could more 
effectively protect Medicaid with complete, accurate, and timely national 
Medicaid data. 
The earlier T-MSIS is fully functional, the earlier CMS and others can 
support States by using advanced data analytics nationally to monitor 
Medicaid to prevent fraud, waste, and abuse.  To help create a fully 
functional T-MSIS, we make the following recommendations to CMS. 
CMS Should Establish a Deadline for When National T-MSIS 
Data Will Be Available 
CMS should provide a deadline so that stakeholders know when to expect 
data that is of sufficient completeness and quality that it can be effectively  
used for program integrity activities.  CMS should provide a deadline by 
which all States need to be submitting complete T-MSIS data.  As part of  
its effort to establish a deadline, CMS should provide a clear and 
 
43 Excluding California.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        19 
  transparent timeline for the rest of the implementation process so that 
States know what is expected of them.  The timeline should clearly 
identify when the remaining States must begin working on T-MSIS.   
To communicate a deadline and timeline to States and stakeholders, CMS 
could issue a State Medicaid Director letter or other policy guidance.  This 
letter or guidance could document what the deadline is for State 
implementation and what is required of States as they implement T-MSIS, 
as well as communicate to stakeholders when T-MSIS will be complete 
and usable for national Medicaid activities, including program integrity. 
To be more transparent about the status of T-MSIS implementation, CMS 
could provide periodic updates to stakeholders.  This could be 
accomplished in numerous ways, such as a regularly updated Web site or 
regular status updates sent to stakeholders.  Updates should include a 
status of each States T-MSIS implementation. 
CMS Should Ensure That States Submit Required T-MSIS Data 
CMS should clearly state that T-MSIS is required.  If States fail to begin 
submitting T-MSIS data by the implementation deadline, CMS should use 
its enforcement mechanisms to compel States to begin submitting required 
T-MSIS data. CMS has two statutory enforcement mechanisms (i.e., 
withhold matching payments for data systems or withhold matching 
payments for medical assistance for managed care enrollees) that could be  
used if States do not begin submitting T-MSIS data by the deadline.   
CMS may also want to seek legislative authority to employ alternative 
tools to compel State participation, such as interim sanctions for States 
that do not implement T-MSIS by the deadline.  Alternatively, CMS could 
seek legislative authority to encourage State participation through an 
incentive program.  
This recommendation builds on a past OIG recommendation that CMS 
enforce the Federal requirements that States submit managed care 
encounter data.44  CMS responded that it intended to review statutory and 
regulatory authorities to determine areas in which it could strengthen the 
reporting of managed care encounter data. 
CMS Should Ensure That T-MSIS Data Are Complete, Accurate, 
and Timely Upon T-MSIS Implementation 
CMS should ensure that the submitted T-MSIS data are complete, 
accurate, and timely.   The lack of complete, accurate, and timely MSIS 
data prevented it from being used effectively to protect the integrity of  
 
44 OIG,  Medicaid Managed Care Encounter  Data:  Collection and  Use. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        20 
  Medicaid. CMS should work to ensure that these problems are not 
repeated in T-MSIS.   
CMS could establish standards for the completeness, accuracy, and 
timeliness of T-MSIS data that States should meet once they have 
implemented T-MSIS.  These standards should establish specific 
expectations for the completeness, accuracy, and timeliness of the data.  
Establishing specific standards would allow CMS and other oversight 
bodies to hold States accountable for the quality and timeliness of their 
T-MSIS data. 
To enforce these standards, CMS could use existing accountability tools.  
Or CMS could seek legislative action for new tools that would compel 
States to submit data that are complete, accurate, and timely.  
CMS could work with States to ensure the submission of complete, 
accurate, and timely data.  For example, to improve the completeness of 
T-MSIS data, CMS could work with States to identify ways that States 
could collect information that they currently do not collect that is needed 
to meet T-MSIS data requirements.  To improve the accuracy of T-MSIS 
data, CMS could create standard derivation methods for States to use to 
ensure uniformly derived data elements.   
OIG has previously made a recommendation to CMS to improve the 
quality of nationally available Medicaid data so that better data are 
available for program integrity efforts.  Specifically, OIG recommended 
that CMS improve the quality of data that program integrity contractors 
can access for conducting data analysis.45 CMS responded that it intended 
to develop improved data systems for Medicaid program integrity and that 
T-MSIS was the chosen system.    
 
45 OIG,  Early Assessment of Review Medicaid Integrity Contractors.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        21 
  AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendations and provided details about 
ongoing activities in support of our recommendations.  OIG acknowledges 
CMSs already planned activities and encourages CMS to take the 
additional steps necessary to fulfill our recommendations and to ensure 
that T-MSIS is successful.  
For the first recommendation, CMS indicated that it is engaged in 
informing key internal stakeholders of when to expect data in the T-MSIS 
format.  CMS also stated that it is working to issue a State Medicaid 
Director Letter that it believes will reinforce the importance of meeting the 
T-MSIS compliance date. One week after providing comments to this 
report, CMS issued this letter and provided a deadline for when all States  
are expected to demonstrate operational readiness to submit T-MSIS files, 
transition to T-MSIS, and submit timely T-MSIS data.46 OIG reiterates 
that our recommendation is that CMS should establish a deadline for when 
T-MSIS data that is complete, accurate, and timely will be available.  This 
deadline may be different than a compliance deadline when States are 
capable of sending data to CMS in T-MSIS format.  In addition, OIG 
encourages CMS to think broadly about  T-MSIS stakeholders.  A number 
of external stakeholders who conduct program integrity work could 
benefit from better quality national Medicaid data.  They should also be 
updated as to the progress of T-MSIS and informed as to when T-MSIS 
data will be available. 
For the second recommendation, CMS believes that using the existing 
statutory enforcement mechanisms is an effective way to ensure timely 
T-MSIS data. OIG encourages CMS  to include information about its 
intent to use the statutory enforcement mechanisms to enforce T-MSIS 
deadlines in any T-MSIS guidance provided to States.  The State Medicaid 
Director Letter did not address T-MSIS enforcement mechanisms.    
For the third recommendation, CMS stated that it is working to create a set 
of data quality rules to govern T-MSIS data submission.  CMS also plans 
to monitor States progress to ensure improved data reporting when 
T-MSIS data are not available at implementation. OIG encourages CMS 
to hold States accountable to the data quality rules. 
Having access to complete, accurate, and timely national Medicaid 
program integrity data is critically important.  OIG will continue to 
 
46 CMS, State Medicaid Director Letter. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        22 
  monitor T-MSIS beyond the early implementation phase to determine 
whether the identified vulnerabilities have been addressed. 
We did not make any changes to the report based on CMSs comments.  
For the full text of CMSs comments, see Appendix G. 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        23 
  APPENDIX A 
Implementation Milestones 
The Centers for Medicare & Medicaid Services (CMS) created the 
implementation milestones for States as a high-level list of major 
milestones that States should consider within their schedule for successful 
implementation.47    
States may not have to complete all of the milestones.  In fact, States may 
not need to complete at least 2 of the 23 milestones.  Specifically, not all 
States will need to complete milestones 5 and 6 (stage 1).  Some States 
may not have to complete milestone 5submitting an advanced planning  
document (APD) to CMSbecause they may not require financial 
assistance to implement the Transformed Medicaid Statistical Information 
System (T-MSIS.)48  Some States may not need to complete milestone 6 
hardware and software procurement completedif they plan to use 
existing hardware and software. 
Additionally, CMS staff explained that States might not need to complete 
the milestones in order.  For example, States may test their ability to send 
a sample of data to CMS (milestone 19) prior to completely mapping their 
State data elements to T-MSIS data elements (milestone 9).   
Planning 
1. 	  T-MSIS on-boarding/orientations completed 
2. 	  T-MSIS State-level project approvals obtained 
3. 	  T-MSIS detailed project schedule developed  
4. 	  T-MSIS project team identified  
5. 	  APD submitted to CMS  
6. 	  Hardware and software procurement completed 
7.   T-MSIS project planning activities completed  
Design 
8. 	  Data dictionary/data file/business rules review completed  
9. 	  Data mapping for all eight files completed and base lined with 
CMS 
 
47 CMS, T-MSIS Implementation Tool Kit, version 2.0,   3.4, March 12, 2013. 
48 CMS requires States to submit APDs when they request financial assistance to make 
changes to their Medicaid Management Information Systems.  See 42 CFR  433.112.  
States use the APD to outline any changes they are making, the rationale for them, and  
their expected  costs. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        24 
  10.  Software development life cycle (SDLC) T-MSIS requirements 
phase completed 
11.  Operational structure of data files defined 
12.  Extract validation and format design defined 
13.  SDLC T-MSIS design phase completed 
Development 
14.  Data extraction process developed and tested (if applicable) 
15.  Data verification/business rules developed and tested 
16.  SDLC T-MSIS development phase completed 
Testing  
17.  End-to-end data verification test planning complete  at State level 
18.  SDLC end-to-end integration testing complete  at State level 
19.  Successful transmission of test data to CMS  
20.  Successful transmission of data file (all four claims files, 

eligibility, provider, managed care, third-party liability) 
 
21.  Successful validation of all data files (all four claims files, 
eligibility, provider, managed care, third-party liability) per 
business rules 
22.  Production readiness approved by CMS (email to State) 
23.  Submission of first set of monthly production file 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        25 
  APPENDIX B 
Description of Documents Reviewed 
Meeting minutes: 	 Records of status update meetings 
that occurred between the Centers 
for Medicare & Medicaid Services 
(CMS), its contractor, and the 
volunteer States. 
Project schedules and status updates: CMS records of initial schedules for 
the Transformed Medicaid Statistical 
Information System (T-MSIS) 
implementation and the status of 
implementation activities in the 
volunteer States. 
State Readiness Assessment Notes: 	  Records of CMSs readiness 
assessment calls with the remaining 
39 States to determine their ability to  
implement T-MSIS.   
T-MSIS Data Dictionaries: 	 Documents containing the names, 
definitions, and format for T-MSIS 
data elements.   
T-MSIS Implementation Tool Kit: 	 Roadmap for States to follow as they 
continue, or begin, implementing 
T-MSIS.  Developed from CMSs 
experience with the volunteer States, 
it contains milestones, guidance, and 
best practices. CMS expected to 
release this to all States in May 2013. 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        26 
  APPENDIX C 
Definitions of Office of Inspector General Completeness 
Categories 
Match Available:  
Available: 	 Volunteer State indicated that it has this data 
element. 
Derivable: 	 Volunteer State indicated that it could obtain the 
data element by performing a calculation, pulling 
from another file, or creating a crosswalk between 
existing data. For example, if a volunteer State 
indicated that a data element was stored in a 
different data system and required a crosswalk to 
fulfill the Transformed Medicaid Statistical 
Information System (T-MSIS) definition and 
format, we considered the data element derived. 
Match Available But Data May Have Gaps:   
Partially available: 	 Volunteer State indicated that it may not have all of 
the information requested in the T-MSIS data 
dictionary definition. For example, if a volunteer 
State indicated that it could provide a certain data 
element for only fee-for-service claims, we 
considered the data element to be partially 
available. 
Match Not Available:  
Not available: 	 Volunteer State indicated that it did not have the 
requested data element. 
To be determined: 	 Volunteer State indicated that the requested data 
element was TBD or that it was still working to 
determine whether the requested data element was 
available.  
Unknown: 	 We could not determine the availability of the data 
element using information from the data matching  
exercise results spreadsheet, or the volunteer State 
did not provide a response to the requested data 
element. 
Not applicable: 	 Volunteer State indicated that a data element does 
not apply to it. For example, Arkansas has a limited 
managed care program and indicated that almost all 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        27 
  of the data elements in the managed care file were 
not applicable.49  
 
49 Arkansas operates its Medicaid program through a primary care case management 
program.  This means that providers are reimbursed on  a fee-for-service basis for 
treatment and that the State does not have managed care plan information.  Very  few of  
the managed care plan information file data elements apply to Arkansass managed care  
program.    
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        28 
  APPENDIX D 
Progress Toward Milestones 
Table D-1:  Individual States' Progress Toward T-MSIS* Milestones 
-
IV 
Milestone  <.IIIIIt.lVV.lll:.:ll        <IN0t;V::      (g(.cI.i.VJ:.j      ::Iu0tEeV:1      :I0ICtteVl::l ll     ..0(zt..IE0:.cV.:J.::         .zI.CCC~>..l,lll. llll     .  ":zu:>0QC~!l!(  ll       000tf!: !1     1IIQCCttCll::lllllllll        1IIC>Vl<lll    :~cIt0Etl::l ,      
1.  T-MSIS 
onboarding/orientations 
completed 
2. T-MSIS State-Level 
project approvals 
obtained 
3. T-MSIS detailed 
project schedule 
developed 
4 . T-MSIS project team 
identified 
5. Advanced planning 
document submitted to 
CMS** 
6.  Hardware and 
software procurement 
completed 
7.  T-MSIS project 

planning activities 

completed 

8.  Data dictionary/data 

file/business rules 

review completed 

9.  Data mapping for all 

eight fi les completed 

and base lined with 

CMS 

*T-MSIS =Transformed Medicaid Statistical Information System; **CMS =Centers for Medicare & Medicaid Services 
Note: Y = Completed milestone; P = Milestone in progress; X = Milestone not necessary; U = Progress unknown by Office of 
Inspector General (OIG); N = Milestone not complete. 
continued on next page 
Early Outcomes Show Limited Progress for T-MSIS (OEI-05-12 -0061 0)  29  Table D-1:  Individual States' Progress Toward T-MSIS Milestones, 
continued 
ns 
Milestone  <.l.sttnnl.:ii::ss.:ll:        <s0nN;::s: :     ig'0.2ni. si.     :isnC(2 :,:s):)      i0ssQtn ::i::s)l::      00.z1..sn0r.:: :s:.:  ::      .z!>QQQ~.!, !)))      :z:(;0QQ~!c,1)  )):      0s0C~::  :)    1ssQQQQtt::ii::))))ll::        1)Qtni(s)l     :~sCst2::i::::l )      
10. Software 
Development Life 
Cycle (SDLC) T-MSIS  N  p  p  p  N  N  p  p  p  p  N  p 
requirements phase 
completed 
11 . Operational 
structure of data files  N  p  p  p  N  N  p  p  p  p  N  p 
defined 
12. Extract validation 
and format design  N  N  N  p  N  N  p  p  p  p  N  p 
defined 
I  I  I  I 
13. SDLC T-MSIS 
design phase  N  p  p  N  N  p  p  N 
completed 
I  I 
14.  Data extraction 
process developed and  N  p  p  p  N  N  p  p  p  N 
tested (If applicable) 
15. Data  
verification/business  N  p  N  N  p  p  p  p  N  p 
rules developed and 
tested 
16. SDLC T-MSIS 
development phase  N  p  p  p  N  N  p  p  p  p  N  p 
completed 
17. End-to-end data 
verification test  N  N  N  p  N  N  p  p  p  p  p 
planning complete -at 
State level 
18. SDLC end-to-end 
integration testing  N  N  N  p  N  N  p  p  p  p  p 
complete -at State 
level 
Note: Y = Completed milestone; P = Milestone in progress; X = Milestone not necessary; U = Progress unknown by Office of 
Inspector General (OIG); N =Milestone not complete. 
continued on next page 
Early Outcomes Show Limited Progress for T-MSIS (OEI-05-12-0061 0)  30  Table D-1 : Individual States' Progress Toward T-MSIS Milestones, 
continued 
Milestone  <.11cCCI..I//.ll: )).ll        <;cC0N:l:  l     g"ui.Ci2..li. l      :~cCC02l  l  l   -~1cc0CQ/l  )) l    u0.zts.cCC0:.:.::  ll   ..ll      .zI>QQQ=,!= !)))     :z;:00QQ=::!c=  :))     0c0C~   l   111QQQccQ//))))))         11CQ>/<l))l    :-31ccC0c/) l   
19. Successful 
transmission of test data 
toCMS 
20. Successful 
transmission of data file 
(all four claims files, 
eligibility, provider, 
managed care, third
party liability) 
21.  Successful 
validation of all data files 
(all four claims files, 
eligibility, provider, 
managed care, third
party liability) per 
business rules 
22.  Production 
readiness approved by 
CMS (email to State) 
23 . Submission of first 
set of monthly 
production file 
Source: OIG analysis of T-MSIS project schedules and volunteer State updates, 2013 . 
= = =
Note: Y  Completed milestone; P  Milestone in progress; X = Milestone not necessary; U  Progress unknown by Office of 
Inspector General (OIG); N =Milestone not complete . 
Early Outcomes Show Limited Progress for T-MSIS (OEI-05-12 -0061 0)  31  APPENDIX E 
Availability of Transformed Medicaid Statistical Information 
System Data Elements by File for All Volunteer States 
 
Table E-1: Availability of Inpatient Claim File, by State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  Office of  Inspector General (OIG) analysis of data matching exercise results spreadsheet, 2013. 
 
Table E-2: Availability of Long-Term-Care Claim File, by  State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        32 
  Table E-3: Availability of Outpatient Claim File, by  State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
 
Table E-4: Availability of Pharmacy Claim File, by  State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
 
Table E-5: Availability of Eligibility File, by State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        33 
  Table E-6: Availability of Managed Care File, by  State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
 
Table E-7: Availability of Provider File, by  State 
100% 
90% 
80% 
70%  Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
 
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
 
Table E-8: Availability of Third-Party  Liability File, by State 
100% 
90% 
80% 
70% 
Match not available 
60% 
50%  Match available but data may have 
gaps 
40% 
30%  Match available 
20% 
10% 
0% 
CA  TX  MI  AR  NM  MN  AZ  TN  WA  OR  NC  NJ 
 
     
Source:  OIG analysis of data matching exercise results spreadsheet, 2013. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        34 
  APPENDIX F 
Transformed Medicaid Statistical Information System (T-MSIS) 
Data Elements Available in All Volunteer States 
 
Table F-1: T-MSIS Data Elements That All Volunteer States Reported as 
Match Available 
T-MSIS File   Data element 
Claim: Inpatient  Revenue units 
Claim: Pharmacy  Medicaid Statistical Information System (MSIS) identification number 
Claim: Pharmacy  Prescription fill date 
Claim: Pharmacy  Prescription number  
Eligibility   Basis of eligibility code 
Eligibility  Childrens Health Insurance Program code 
Eligibility   County code  
Eligibility   County name  
Eligibility   Date of birth  
Eligibility   Days of eligibility  
Eligibility   Eligible ZIP Code 
Eligibility   Eligibility status end date  
Eligibility   Eligibility status start date 
Eligibility   Federal fiscal year month  
Eligibility   First name  
Eligibility   Health insurance coverage  
Eligibility   Last name  
Eligibility   Maintenance assistance status 
Eligibility  Managed care plan enrollment end dates 
Eligibility  Managed care plan enrollment start dates  
Eligibility   Middle initial 
Eligibility   MSIS case number  
Eligibility   Restricted benefits code 
Eligibility   Sex 
Eligibility   Social Security Number  
Eligibility   State 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        35 
  Table F-1: T-MSIS Data Elements That All Volunteer States Reported as 
Match Available, continued  
T-MSIS File   Data element 
Eligibility   ZIP Code50  
 
Source:  Office of  Inspector General analysis of data matching exercise results spreadsheet, 2013. 
   
 
50 In the data matching exercise results spreadsheet, this data element was indicated as 
duplicative.  Notes in the spreadsheet indicate that it was to  be  removed  from  the 
February 2013  data dictionary. 
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        36 
  APPENDIXG 
Agency Comments 
\....4-	
/"'''<qt.
DEPARTMENT OF HEALTH &'HUMAN SERVICES  Centern for Medicare & Medicaid Services 
Administrator 
Washington, DC 20201 
DATE:  AUG 15  2013 
TO: 	 Daniel R. Levinson 

!~spector General 

FROM: 	 Nlari~ T~e; 

Adminislratm: 

SUBJECT: 	 Office oflnspector General (OIG) Draft Report: "Early Outcomes Show Limited 
Progress for the Transformed Medicaid Statistical Information System" (OEI-05
12-00610) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the above-referenced draft report. CMS concurs with all recommendations and is 
actively engaged in tasks to address these recommendations as part of the normal course of 
project activities. Please review additional details below relating to the recommendations, which 
have been broken out by topic area to more succinctly address the recommendation areas. 
OIG Recommendation 1 
The OIG recommends that CMS Should Establish a Deadline for When National T-MSIS Data 
Will Be Available. 
CMS shouldprovide a deadline so that stakeholders know when to expect data that is of 
sufficient completeness and quality that it can be effectively used for program integrity activities. 
CMS should provide a deadline by which all States need to be submitting complete T-MSIS data. 
As part ofits effort to establish a deadline, CMS should provide a clear and transparent timeline 
for the rest ofthe implementation process so that States know what is expected ofthem.  The 
time line should clearly identify when the remaining States must begin working on T-MSIS. 
CMS Response 
We concur. CMS is actively engaged in informing key stakeholders via CMS senior leadership 
data councils ofwhen to expect Medicaid and Children's Health Insurance Program (CHIP) 
operational data in the Transformed Medicaid Statistical Information System (T-MSIS) format. 
Standardized reports reflecting critical milestones in T-MSIS implementation activities are 
distributed and reviewed by said councils.  In addition, all ofthe states have been instructed to 
add a series ofcritical milestones that are to be integrated into their internal project work plans . 
Early Outcomes Show Limited Progress for T-MSIS (OEI-05-12-0061 0)  37   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        38 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        39 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        40 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        41 
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        42 
   
   
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        43 
  ACKNOWLEDGMENTS 
This report was prepared under the direction of Ann Maxwell, Regional 
Inspector General for Evaluation and Inspections in the Chicago regional 
office, and Thomas Komaniecki, Deputy Regional Inspector General.  
Nicole Hrycyk served as the team  leader for this study, and Carolyn 
Pichert served as the lead analyst.  Other Office of Evaluation and 
Inspections staff from the Chicago regional office who conducted the 
study include Emily Rowe and Cassie Yarbrough.  Central office staff who 
provided support include Kevin Farber and Kevin Manley.  
Early  Outcomes Show Limited Progress for T-MSIS (OEI-05-12-00610)        44 
  Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs  and operations and providing all 
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.