Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
P A
UBLIC  SSISTANCE 
 
R I
EPORTING  NFORMATION 
 
 
S :  S
YSTEM    TATE 
 
 
P
ARTICIPATION IN THE 
 
M  I
EDICAID  NTERSTATE 
 
M I L  
ATCH  S  IMITED 
 
Brian P. Ritchie  
Acting Deputy Inspector General for  
Evaluation and Inspections 
 
July 2014 
OEI-09-11-00780   
   
EXECUTIVE SUMMARY  PUBLIC ASSISTANCE REPORTING INFORMATION 
SYSTEM:  STATE PARTICIPATION IN THE MEDICAID INTERSTATE MATCH 
IS LIMITED, OEI-09-11-00780 
 
WHY WE DID THIS STUDY 
 
In 2013, eligibility errors caused an estimated 57 percent of improper Medicaid payments, 
representing approximately $8.2 billion in Federal expenditures.  One type of eligibility 
error occurs when beneficiaries remain enrolled in a States Medicaid program for which 
they are ineligible because they are no longer residents of the State and/or have failed to 
timely report a change in circumstances (i.e., address and residency) to the State.  The 
Public Assistance Information Reporting System (PARIS) Medicaid Interstate Match is an 
important tool that has the potential to reduce improper Medicaid payments by identifying 
beneficiaries who are enrolled in multiple State Medicaid programs.  Although the Social 
Security Act (SSA) mandates that States participate in the match, neither the SSA nor 
guidance from the Centers for Medicare & Medicaid Services (CMS) defines the meaning 
of such participation. 
 
HOW WE DID THIS STUDY  
 
We discuss participation in the Medicaid Interstate Match as four steps that States 
perform to reduce improper payments:  (1) submitting Medicaid enrollment data, 
(2) verifying matches, (3) discontinuing Medicaid benefits for ineligible beneficiaries, and 
(4) recovering any improper Medicaid payments.  To determine the extent to which States 
participate in the match, we gathered information from States for a random sample of 
300 matches from the August 2011 match.  We  conducted structured interviews with 
officials from CMS to determine the extent to which they provided guidance to States on 
the four steps. Finally, we conducted a survey of State Medicaid agencies and collected 
their match policies to determine the extent to which States have policies on the four steps.  
 
WHAT WE FOUND 
 
States participation in the Medicaid Interstate Match is limited.  CMS guidance to States 
for participating in the match is limited, and States reported that they needed more 
guidance. Most States had policies addressing at least one of the steps for participating in 
the match.   
 
WHAT WE RECOMMEND  
 
We recommend that CMS issue guidance to States on the requirement for participating in 
the Medicaid Interstate Match. CMS concurred with our recommendation. 
   
   
   
 
  
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 

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

Methodology................................................................................................5 

Findings........................................................................................................9 

States participation in the Medicaid Interstate Match is limited.....9 

CMS guidance to States for participating in the Medicaid      
Interstate Match is limited; States reported that they needed  
more guidance................................................................................11 
 
Most States had policies addressing at least one of the steps  
for participating in the Medicaid Interstate Match ........................12 

Conclusion and Recommendation .............................................................14 

Agency Comments and Office of Inspector General Response .................16 

Appendixes ................................................................................................17 

Appendix A:  Confidence Intervals................................................17 

Appendix B: Number of Projected Matches for the  
August 2011 Medicaid Interstate Match ........................................18 

Appendix C: Agency Comments ..................................................19 

Acknowledgments......................................................................................21 

 
   
   
OBJECTIVES 
To determine the extent to which:  
1. 	  States participate in the Public  Assistance Reporting Information 
System (PARIS) Medicaid Interstate Match,  
2. 	  the Centers for Medicare & Medicaid Services (CMS) provides 
guidance to States for participating in the PARIS Medicaid Interstate 
Match, and 
3. 	  States have policies and procedures for participating in the PARIS 
Medicaid Interstate Match. 
BACKGROUND 
CMS estimates that nationally, 5.8 percent of Medicaid payments made in 
fiscal year 2013 were improper, representing $14.4 billion in Federal 
expenditures.1  Eligibility errors caused an estimated 57 percent of these 
improper payments,2 representing approximately $8.2 billion in Federal 
expenditures.3 One type of eligibility error occurs when beneficiaries 
remain enrolled in a States Medicaid program for which they are ineligible 
because they are no longer residents  of the State and/or have failed to 
timely report a change in circumstances (i.e., address and residency) to the 
State. Therefore,  procedures to capture and share State residency changes  
are essential for reducing improper payments resulting from beneficiary 
enrollment in multiple State Medicaid programs.4   PARIS is an important 
tool that has the potential to reduce improper Medicaid payments by 
identifying beneficiaries who are enrolled in multiple State Medicaid 
programs.  
PARIS 
PARIS provides all 50 States, the District of Columbia, and Puerto Rico5  
(States) with information to aid them in detecting and preventing improper 
payments in the administration of public assistance and medical assistance 
 
1 Department of Health and Human Services (HHS),  Fiscal Year 2013 Agency Financial  
Report, December 16, 2013,  p. 173. 

2 For the purpose of this report, we use the term improper payments to encompass both 

erroneous payments caused  by eligibility errors and improper payments resulting from  

potential fraud.  

3  Office of  Inspector General (OIG)  analysis based on  CMS numbers,  Fiscal Year 2013  
Agency Financial Report, December 16, 2013,  p. 173. 

4 There are conditions under which States may pay for services received by a beneficiary  

in more than  one State, which include, but are not limited to, medical emergencies.   

42  CFR  431.52. 
  
5 Puerto Rico is the only United States territory participating in PARIS. 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   1 
   
   
programs.  PARIS consists of three types of matchesa Federal Match,6 a 
Veterans Affairs Match,7 and an Interstate Match. The Interstate Match 
provides States with information about individuals who are enrolled in 
various types of State health and public assistance programs in multiple 
States. One type of Interstate Match is the Medicaid Interstate Match, 
which takes Medicaid enrollment data from one State and matches it to 
Medicaid enrollment data from other States to identify beneficiaries who 
are enrolled in multiple State Medicaid programs.8  
The Administration for Children and Families (ACF).  ACF, an agency 
within HHS, facilitates the PARIS matches and provides information to 
States about PARIS. As part of its responsibilities for Federal programs 
that promote the economic and social well-being of children, families, and 
communities, ACF coordinates with States to ensure that they sign the 
required annual memorandums of understanding to participate in the 
PARIS matches.9   ACF also maintains a Web site and sponsors an annual 
conference to provide information to States regarding PARIS.  
Federal Requirements for the Medicaid Interstate Match 
State participation in the Medicaid Interstate Match is required by the 
Social Security Act (SSA) as a condition of receiving Medicaid funding for 
automated data systems.10 Effective October 1, 2009, the SSA required 
States to have a system for determining Medicaid eligibility that provides  
for data matching through PARIS or any successor system.11, 12    
 
6 The Federal match provides States with information by matching State data with 
 
information from  the Department of  Defense  and the Office of Personnel  Management.  

This match determines whether beneficiaries receive income from either of these sources 

or are eligible for Federal health care coverage.  PARIS, Federal Match Files: User 

Manual, December 2008, p. 1. 

7 The Veterans  Affairs match provides States with information on the eligibility of their 

public and medical assistance beneficiaries for veterans benefits and allows States to
  
confirm whether their beneficiaries receive  income and/or medical assistance payments 

from the Department of  Veterans  Affairs.  Altarum Institute, PARIS Cost-Benefit 

AnalysisFinal Report,  December 2008, p.  3. 
 
8 The Interstate Match also matches enrollment data from the following public assistance 

programs:  Temporary Assistance for Needy Families, the Supplemental Nutritional 

Assistance Program, the Childcare  program,  and Workers Compensation. 

9  The annual memorandum of understanding certifies States compliance with  procedures 

for information technology security.  ACF, Memorandum  of Understanding Interstate 

Data Matching by State Public Assistance Agencies. Accessed at 

http://www.acf.hhs.gov/programs/paris/appendix-3m  on November 5, 2013.  
 
10 SSA  1903(r)(3).  States may receive payments for automated data systems authorized 
 
by SSA    1903(a)(3)  only if they meet the requirements of  SSA  1903(r)(3). 

11 As of the date of this report, a successor system does not exist for PARIS. 

12  SSA  1903(r)(3).   

PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   2 
   
   
CMS Guidance for the Medicaid Interstate Match. CMS administers the 
Medicaid program and has the responsibility to issue guidance regarding 
States participation in the Medicaid Interstate Match.  In June 2010, CMS 
issued a State Medicaid Director  Letter (SMDL) to provide formal 
guidance to State Medicaid agencies  on complying with the requirement at 
section 1903(r)(3) of the SSA that requires States to participate in PARIS  
. 
According to the guidance, each State mustto demonstrate compliance 
with the requirementamend its Medicaid State plan to document its 
participation in PARIS.13  However, neither the SSA nor the SMDL  
defines the meaning of participation as it relates to the match.  
Medicaid Interstate Match Process 
States submit Medicaid enrollment data to the Defense Manpower Data 
Center (DMDC), which conducts the Medicaid Interstate Match.14 DMDC 
conducts quarterly matches in February, May,  August, and November of 
each year.  For each quarterly match, DMDC uses the enrollment data 
submitted by States and compares the Social Security Numbers (SSNs) of  
enrolled beneficiaries from one State to those of beneficiaries enrolled in 
other States, thereby identifying beneficiaries who are enrolled in multiple 
State Medicaid programs. For these beneficiaries, DMDC then generates 
matches that contain enrollment data from the States with Medicaid 
programs in which the beneficiary is enrolled.  DMDC compiles the 
matches into a match file and sends it to the appropriate States.  
Reducing Improper Payments Through Participation in the 
Medicaid Interstate Match 
Although neither the SSA nor the June 2010 SMDL defines what 
constitutes State participation in the Medicaid Interstate Match, we 
identified four steps that States perform to reduce improper payments 
through their participation in the match.  The four steps include 
(1) submitting Medicaid enrollment data to DMDC, (2) verifying matches 
(i.e., determining the Medicaid eligibility of the beneficiaries listed in the 
match file), (3) discontinuing Medicaid benefits for ineligible 
beneficiaries, and (4) recovering any improper Medicaid payments.   
Submitting Medicaid Enrollment Data.  States receive an email from  ACF 
that provides the deadline for submitting Medicaid beneficiaries  
enrollment data for each quarterly Medicaid Interstate Match. States 
participating in that quarterly match must electronically submit their 
 
13 CMS, SMDL:   Public Assistance Reporting Information System (PARIS), 

SMDL#10-009, June 21, 2010. 

14 DMDC is a Department of Defense contractor that conducts all the PARIS matches. 

PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   3 
   
   
enrollment data to DMDC by the deadline.15   At a minimum, States are 
expected to submit enrollment data for the quarterly match conducted in 
August of each year.16  Neither the SSA nor the SMDL indicates whether 
States are required to submit enrollment data for all of their Medicaid 
beneficiaries. 
The Medicaid enrollment data that States submit to DMDC for the 
Medicaid Interstate Match include a variety of information.  Examples of 
the information include the beneficiarys name, SSN, date of birth, 
address, sex, marital status, and Medicaid eligibility dates (i.e., the start 
and end dates of Medicaid coverage).17    
Verifying Matches. After State Medicaid agencies receive their match 
information from DMDC, agency staff may verify the matches 
(i.e., determine whether the beneficiary is eligible to receive benefits in 
their State). Because DMDC uses only the SSNs to identify beneficiaries  
who are enrolled in multiple State Medicaid programs, State Medicaid 
agency staff use the Medicaid eligibility dates in the match file to 
determine whether the beneficiaries coverage periods for their State 
overlap with those for other States.18 Overlapping coverage periods 
indicate that the beneficiary is simultaneously enrolled in multiple State 
Medicaid programs.  Other verification activities can include requiring a 
beneficiary to come into the State Medicaid agencys office to show proof 
of residency, mailing a residency verification letter to the beneficiary,  
and/or contacting another State to determine whether the beneficiary is 
still enrolled in that States Medicaid program.   
Discontinuing Medicaid Benefits. If State Medicaid agency staff verify a 
match and determine that a beneficiary is ineligible to receive Medicaid 
benefits in that State, they may initiate action to discontinue the 
beneficiarys benefits.19  By discontinuing such benefits, States can reduce 
improper payments to the managed care organizations and fee-for-service 
providers that participate in their Medicaid programs.   
Recovering Improper Medicaid Payments. If State Medicaid agency staff 
determine that their program made improper payments for a beneficiary 
whose Medicaid benefits were discontinued, the State may attempt to 
recover these improper payments.  States may treat these improper 
 
15 ACF,  Instructions for DMDC electronic file transmission  on the PARIS project. 

Accessed at http://www.acf.hhs.gov/programs/paris/instructions-for-dmdc-electronic-file-
transmission on September 16, 2013.  

16 Ibid.  

17  70  Fed.  Reg. 40690 (July 14, 2005). 

18 A coverage  period is the period during  which an individual is entitled to benefits.  
 
19 Government Accountability Office (GAO), PARIS Project Can Help States Reduce 

Improper Benefit Payments, GAO-01-935, September  2001, p.  5. 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   4 
   
   
payments to managed care organizations and fee-for-service providers as 
overpayments, and recover them accordingly.20   Once an improper 
payment is identified, State Medicaid agency staff refer the matter to the  
appropriate State component to recover these Medicaid payments.  The 
criteria for recovering improper Medicaid payments vary by State; 
therefore, not all improper payments may result in recoveries.  
Related Work 
In 2008, a series of OIG audits found that millions of dollars were paid for 
Medicaid services on behalf of beneficiaries who should not have been 
eligible because of their residency.  One of these audits found that the 
District of Columbia paid $1.9 million from July 2005 to June 2006 for 
Medicaid services provided to beneficiaries who should not have been 
eligible because of their residency in Maryland.21    
Other reports have been issued saying that there are issues with how States 
verify matches from the PARIS Interstate Match.  For example, in 2001, a 
GAO report found that States participating in PARIS gave little or no 
attention to interstate matches, allowing matches to go unresolved.22   Also, 
an ACF-commissioned report that looked at a sample of 14 States found 
that not all 14 were verifying the majority of the matches from the PARIS 
Interstate Match.23    
METHODOLOGY 
Scope 
Our evaluation is national in scope and focuses on States participation in 
the Medicaid Interstate Match.   We used DMDCs match files from the 
August 2011 match because States are expected to, at a minimum,  
 
20 SSA  1128J, added by the Patient Protection and Affordable Care Act, P.L. 
No. 111-148  6402 (March 23, 2010), as amended by  the Health  Care Reconciliation 
Act of 2010, P.L. No. 111-152 (March 30, 2010), collectively known  as the ACA.   
Overpayments are funds that a person receives or retains under the Medicaid program, to 
which the person, after applicable reconciliation, is not entitled.   Once an  overpayment is 
identified and not returned within  the deadlines in SSA    1128J(d)(2), the overpayment 
becomes a debt owed to the Federal  Government.  Under SSA  1128J, beneficiaries are 
not liable for overpayments.  
21 OIG,  Medicaid Payments for Services Provided to Beneficiaries With Concurrent 

Eligibility in the District of Columbia  and  Maryland for July 1, 2005, Through 
 
June 30, 2006:  The District of Columbia  Department of  Health, A-03-07-00214, 

April 2008, p. 3.  

22 GAO,  PARIS Project Can Help  States Reduce Improper Benefit Payments, 
GAO-01-935, September  2001, p.  15. 

23 Health Systems Research, Inc., an  Altarum Company, Evaluation to Determine the 

Effectiveness of the Public Assistance Reporting and Information SystemFinal Report, 

June 2007, p.  34.  Accessed at http://www.acf.hhs.gov/sites/default/files/files/ 

PARISFinal082007.pdf on  September  18, 2013.  

PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   5 
   
   
participate in this quarterly match.24, 25  To allow States adequate time to 
verify matches from the August 2011 match, we continued to collect data 
through November 2012.  The findings in this report are projected to all 
the matches in the August 2011 match.   
Data Collection and Analysis 
We used three data sources for our analysis:  (1) DMDC match files from 
the August 2011 match, (2) structured interviews with CMS officials, and 
(3) a survey of the 52 State Medicaid agencies.   
DMDC Match Files From the August 2011 Medicaid Interstate Match. To  
determine the extent to which States participate in the Medicaid Interstate 
Match, we obtained from DMDC all match files from the August 2011 
match and selected a simple random sample of 300 matches.  Overall, the 
August 2011 match files identified 159,964 matches from all States.  The 
sample of 300 matches allows us to project the results of our analysis 
nationally to all the matches in the Medicaid Interstate Match for that 
quarter.  We are projecting only to those Medicaid beneficiaries whose 
enrollment data was submitted for the quarterly Medicaid Interstate Match 
conducted in August 2011.  For the statistics we project in this report, the 
estimates and 95-percent confidence intervals are listed in Appendix A.  
For each match in the sample, we gathered information from all States that 
submitted Medicaid enrollment data for the beneficiary.  For the 
beneficiaries in our sample of matches, we asked States whether they had 
verified the match(es) to determine the beneficiaries eligibility. If a State 
 
had done so and determined that a beneficiary was no longer eligible for 
benefits in its State, we asked whether the State discontinued the 
beneficiarys benefits.  If the State had discontinued the benefits, we asked 
it to provide the amount of improper Medicaid payments it made on behalf 
of the beneficiary and whether it recovered any of this amount.    
From the sample of matches and States responses, we projected the 
following information: 
	   the percentage of matches from  the August 2011 match that States 
verified; and  
 
24 ACF,  Instructions for DMDC electronic file transmission  on the PARIS project. 
Accessed at http://www.acf.hhs.gov/programs/paris/instructions-for-dmdc-electronic-file-
transmission on September 16, 2013. 
25  We  did not  use DMDCs match files from the August  2012 Medicaid Interstate Match.  
Using  DMDC match files from  that period  would not have allowed sufficient time for 
States to verify the matches. 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   6 
   
   
   the percentage of beneficiaries from the August 2011 match whose 
benefits were discontinued because their State determined that they 
were ineligible to receive Medicaid benefits in the State.  
We were unable to project the total amount of improper Medicaid 
payments made and recovered by States because States reported improper 
payments for only a limited number of matches.  Therefore, our findings 
are limited to presenting the actual amounts of improper payments and of 
recoveries that States reported making based on our sample of 
300 matches from the August 2011 match.  
To identify issues that States encounter when verifying matches, we asked 
States to explain their reasons for not verifying each beneficiarys 
Medicaid eligibility in our sample.  We analyzed their responses and 
described the reasons States did not verify the eligibility of the 
beneficiaries. 
Structured Interviews With CMS Officials. We conducted structured 
interviews with CMS officials to determine the extent to which they 
provided guidance to States, beyond the SMDL, for participating in the 
Medicaid Interstate Match. We asked them to describe any guidance that 
they provided to States related to participating in the match, and we 
analyzed their responses. 
State Medicaid Agency Survey.  We administered an electronic survey to 
Medicaid agency staff in all States to determine, for each of the four steps 
listed on pages 34, the extent to which they (1) have policies and 
procedures (policies), (2) experience barriers, and (3) receive guidance 
from CMS.  If States reported that they had polices for any of the four 
steps, we asked them to provide their policies to us.  We reviewed the 
policies to validate States responses and determined the number of States 
that had policies for each step. We  asked States to describe any barriers 
they experienced for each of the four steps, and we analyzed their 
responses to determine the type of any such barriers.  We asked States 
what type of additional guidance, if any, they would like to receive related 
to the Medicaid Interstate Match. We analyzed survey responses to 
calculate the number of States that wanted to receive such guidance and to  
determine the types of such guidance.  
We asked States to provide us with copies of their amendment to their 
Medicaid State plan that documents their participation in PARIS.  We  
calculated the number of States that submitted such an amendment.  We  
reviewed the amendments to determine the extent to which States 
addressed one or more steps related to participating in the Medicaid 
Interstate Match.   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   7 
   
   
To determine whether States submitted Medicaid enrollment data for all of 
their beneficiaries, we asked each State to provide us with (for the 
August 2011 match) (1) the total number of beneficiaries enrolled in its 
State Medicaid program and (2) the total number of such beneficiaries for 
whom it submitted enrollment data for the match.  To determine how 
many States did not submit enrollment data for all of their beneficiaries, 
we took the total number of beneficiaries enrolled in each States 
Medicaid program and subtracted the total number of beneficiaries for 
whom the State submitted data for the match. 
We received survey responses from all States.   
Limitations 
We did not determine the validity of the matches from the August 2011 
Medicaid Interstate Match. Our analysis of the survey of State Medicaid 
agencies and the information we gathered on our sample of matches is 
based on self-reported data as of November 2012.  We did not 
independently verify the accuracy of the survey data.  We could not 
determine States full compliance with the SSA because neither the SSA  
nor CMS guidance defines the meaning of participation as it relates to 
the Medicaid Interstate Match.  
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.  
   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   8 
   
   
FINDINGS 
States participation in the Medicaid Interstate Match is 
limited 
State participation in the Medicaid Interstate Match is required  as a 
condition of receiving Medicaid funding for automated data systems. This 
match has the potential to identify beneficiaries who may be enrolled in 
multiple State Medicaid programs and thus to enable States to reduce 
improper payments.  In analyzing how States perform the four steps to 
reduce improper payments through the match, we found that States 
participation in the August 2011 match was limited.  Specifically, States 
did not (1) submit Medicaid enrollment data for all beneficiaries; 
(2) verify more than half the matches (to determine beneficiaries 
Medicaid eligibility); (3) discontinue beneficiaries benefits for over half 
the verified matches; or (4) recover any improper payments.     
Fourteen States did not submit Medicaid enrollment data for 
all beneficiaries in their State; five States reported that barriers 
related to resources or technical capability limited their ability 
to submit Medicaid enrollment data 
While all States submitted Medicaid enrollment data for the August 2011 
match, 14 States did not submit enrollment data for all of their 
beneficiaries.  These 14 States did not submit between 1 and 85 percent 
with an average of 46 percent and a median of 11 percentof the 
Medicaid enrollment data for their beneficiaries.  For example, one State 
did not submit enrollment data for 79 percent of its Medicaid beneficiaries 
(7 million of 9 million).26  Another State did not submit enrollment data 
for 66 percent of its beneficiaries (650,000 of 988,000).  To maximize the 
potential for the Medicaid Interstate Match to identify beneficiaries who 
may be enrolled in multiple State Medicaid programs, each State needs to 
submit complete enrollment data for all of its beneficiaries.   
Among the 14 States that did not submit Medicaid enrollment data for all 
of their beneficiaries, 5 States reported that barriers related to resources or 
to technical capability limited their ability to submit data to DMDC.  For 
example, one State Medicaid agency reported that it lacked staff to prepare  
the enrollment data for submission.  Another State reported that it does not 
submit enrollment data from one of its two Medicaid enrollment systems 
because the system does not have the technical capability to display 
information that it receives from DMDC.  
 
26 Medicaid enrollment figures provided  by the State are rounded.  
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   9 
   
   
States did not verify almost 70 percent of the matches because 
of issues with the enrollment data 
States did not verify 68 percent of the matches from the August 2011 
match because issues with the enrollment data led States to determine that 
the matches no longer merited verification.  The most common reason that 
States did not verify matches was that States submitted enrollment data for 
beneficiaries who were no longer enrolled inor soon to be no longer 
enrolled intheir Medicaid programs.  The second most common reason 
that States did not verify matches was that States submitted incomplete or 
inaccurate enrollment data (e.g., incorrect SSNs).   
With regard to the matches that were not verified, States did not verify 
56 percent of those because the Medicaid eligibility dates for the 
beneficiaries indicated that they were no longer enrolled inor would 
soon no longer be enrolled inthe program for at least one of the States 
for which there was a match.  When a State submits Medicaid eligibility 
dates that indicate that the beneficiary is no longer enrolled in its Medicaid 
program, it can create a false positive match.  When another State 
examines this match and finds that the eligibility dates indicate that the 
beneficiary will soon no longer be enrolled in at least one of the States 
Medicaid programs, that State may conclude that the match does not merit 
the resources for verification. 
Of the matches that were not verified, States did not verify 17 percent of 
those because the match was associated with incomplete or inaccurate 
Medicaid eligibility dates or inaccurate SSNs.  When a State submits 
incomplete or inaccurate eligibility dates for beneficiaries who are 
included on the match file, it is difficult for other States to determine 
whether such beneficiaries have an overlapping Medicaid coverage period.  
States must then conduct resource-intensive followup activities, which 
may include obtaining additional information from other States.  
Therefore, given their limited information and resources, States may 
 
conclude that these matches also do not merit verification.  One State said: 
When the data is not accurate or reliable, [conducting verification] is not 
an efficient use of [State Medicaid agency] staff time.     
Less than half the verified matches resulted in States  
discontinuing beneficiaries benefits  
States reduce improper payments through participation in the Medicaid 
Interstate Match when one or more States discontinue the Medicaid 
benefits of beneficiaries who are found to be enrolled in multiple State 
Medicaid programs.  While States verified 32 percent of the matches from 
the August 2011 match, only 41 percent of those matches resulted in a 
discontinuation of benefits. Forty-nine percent of the matches verified did 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   10 
   
   
not result in a discontinuation of benefits because they were verified by 
only one of the States in which the beneficiary was enrolled, and that State 
was not the one that needed to discontinue benefits.27  For the process to 
accurately identify beneficiaries who are improperly enrolled in multiple 
State Medicaid programs, each State that is flagged in a given match must  
verify the match to determine whether it needs to discontinue the 
beneficiarys benefits. 
See Appendix B for the number of projected matches for the August 2011 
match that are associated with the above percentages for verified and 
unverified matches.   
States did not recover any improper Medicaid payments 
To maximize the potential for reducing improper payments through 
participation in the Medicaid Interstate Match, States may recover 
improper payments made on behalf of beneficiaries found to be ineligible.  
For 41 percent of the verified matches from the August 2011 match that 
resulted in a discontinuation of benefits, States had made improper 
payments on behalf of beneficiaries.  However, States provided the 
amount of improper payments for only 18 percent of these matches,28  
which totaled $6,200 in improper Medicaid payments.  Although this 
amount is small, we do not know the amount of improper payments for the 
other 82 percent of the verified matches that resulted in a discontinuation 
of benefits. Furthermore, all of the beneficiaries associated with the 
$6,200 in improper payments were enrolled in Medicaid managed care 
programs.  States reported that in these cases, they did not recover any 
improper payments from the managed care organizations because of 
barriers such as lack of resources and length of time needed to recover 
improper payments.  This suggests that if the States had not discontinued 
these beneficiaries benefits, they potentially would have made additional  
unrecoverable improper payments.   
CMS guidance to States for participating in the 
Medicaid Interstate Match is limited; States reported 
that they needed more guidance 
In June 2010, CMS issued an SMDL to provide guidance to State 
Medicaid agencies on complying with the SSAs requirement that States 
participate in PARIS.  The guidance requires States to amend their 
respective Medicaid State plans to document their participation in PARIS, 
 
27 For 10 percent of the matches that were verified, States did  not  provide us  with  
information to  determine whether the beneficiaries Medicaid benefits were discontinued. 
28 States did not  provide the amounts of improper payments for enough matches to  
project the total amount of improper payments for the August 2011 match. 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   11 
   
   
but it does not address any of the four steps related to reducing improper 
payments through participation in the Medicaid Interstate Match.  In the 
absence of specific guidance, only four States have amended their 
respective State plans to include language that addresses one or more of 
the four steps.29    
Twenty-two of the fifty-two States reported they would like additional 
guidance related to one or more of the steps for participating in the 
Medicaid Interstate Match.  See Table 1 for each step and the 
corresponding number of States that would like additional guidance.   
Table 1. Number of States That Would Like To Receive Guidance 
Regarding Steps Related to Participation in the Medicaid Interstate Match  
  Number of States 
Step Related to  Participation in the  That Would Like To 
Medicaid Interstate Match  Receive Guidance 
Regarding Step  
Submitting Medicaid enrollment data  7 
Verifying matches   20 
Discontinuing benefits  22 
Recovering improper payments   21 
Source:  OIG analysis of  survey data, 2013. 

Note: Categories are not mutually exclusive.  Therefore, the total number of
  
States exceeds 52.  

 
Most States had policies addressing at least one of
the steps for participating in the Medicaid Interstate
Match 
Thirty-four of the fifty-two States had policies addressing at least one of 
the steps to reduce improper payments through participation in the 
Medicaid Interstate Match. Nine of those States had policies related to all 
four steps.  Almost half of all States had policies on submitting Medicaid 
enrollment data.  More than half of all States had policies on verifying 
matches, and more than a third of all States had policies on discontinuing 
benefits and policies on recovering improper payments.  See Table 2 for 
the number of States that had policies addressing each of the four steps for 
participating in the match.   
   
 
29 In addition, CMS guidance did not set a deadline for States to amend their respective 
Medicaid State Plans.   In the absence of such a deadline, 15 States had not amended their 
plans as of November 2012.  
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   12 
   
   
Table 2. Number of States That Have Policies Regarding Steps Related to 
the Medicaid Interstate Match  
Number of States 
Step Related to  Participation in the 
With Policies 
Medicaid Interstate Match 
Regarding Step  
Submitting Medicaid enrollment data  25 
Verifying matches   27 
Discontinuing benefits  19 
Recovering improper payments   20 
Source:  OIG analysis of PARIS policies, 2013.  

Note: Categories are not mutually exclusive.  Therefore, the total number 
 
of States exceeds 52.  
 
 
 
 
   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   13 
   
   
CONCLUSION AND RECOMMENDATION 
State participation in the Medicaid Interstate Match is required unless 
PARIS is succeeded by a system that provides for data matching to 
identify beneficiaries who may be enrolled in multiple State Medicaid 
programs.  As of the date of this report, there is no such successor 
system.  The match provides States with an opportunity to reduce 
improper Medicaid payments.  However, State participation in the match 
is limited.  States do not consistently perform all four steps to reduce 
improper payments.  Furthermore, CMS guidance does not define the 
meaning of participation as it relates to the match.   
For States to receive the full benefit of their participation in the Medicaid  
Interstate Match, CMS needs to provide additional guidance to States that 
helps maximize the matchs potential to accurately identify beneficiaries  
who are enrolled in multiple States.  States did not verify the majority of  
matches from the August 2011 match because they concluded that these 
matches did not merit verification.  Guidance to States that helps improve 
the accuracy of the matches would likely increase the usefulness of the 
match.  Until a successor system exists for PARIS, we recommend that 
CMS: 
Issue Guidance to States on the Requirement for Participating 
in the Medicaid Interstate Match 
Guidance from CMS could assist States in complying with the 
requirement for participating in the Medicaid Interstate Match.  This 
guidance also could help States receive the full benefit of their 
participation.  Until PARIS is succeeded by another system, CMS should 
define the meaning of participation in the match by establishing clear 
expectations for the actions that States should take to comply with the 
requirement.  CMS should then issue guidance to States on its 
expectations for State participation in the match.  In addition to assisting 
States in achieving compliance, guidance would also help ensure that 
States develop consistent policies regarding the match. 
CMS guidance should address the following steps: 
Submitting Medicaid Enrollment Data to DMDC. Guidance for 
submitting enrollment data should clarify whether States should submit 
Medicaid enrollment data for all of their beneficiaries.  Guidance that 
requires States to do so would maximize the potential of the match to 
identify all beneficiaries who may be enrolled in multiple State Medicaid 
programs.  Guidance also should clarify what data States should submit 
for the match.  Submitting consistent, accurate, and complete enrollment 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   14 
   
   
data for the match could potentially (1) generate the most accurate 
matches and (2) reduce the amount of time needed to verify matches.     
Verifying Matches Identified by the Medicaid Interstate Match. After 
CMS issues guidance for the submission of Medicaid enrollment data, it 
should issue guidance requiring States to verify matches to determine 
beneficiaries Medicaid eligibility.  CMS could also provide guidance to 
States on how to track match-related activities and timelines for verifying 
matches.  This type of guidance could result in the prompt verification and 
discontinuation of Medicaid benefits, which could reduce the length of 
time when beneficiaries are enrolled in multiple State Medicaid programs 
and thus ultimately reduce the amount of improper payments.  
Discontinuing Benefits and Recovering Improper Payments. Although 
States vary in their systems and processes for discontinuing benefits and 
recovering improper payments, CMS could gather information from States 
regarding their best practices for these tasks.  Working with States to 
develop guidance may result in fewer improper payments and/or in more 
money being returned to Federal and State governments.  As appropriate, 
CMS could include the best-practices information in its guidance to States  
on these topics. CMS could also collaborate with ACF to provide 
additional guidance through the PARIS Web site and annual conference.  
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   15 
   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
CMS concurred with our recommendation that it issue guidance to States 
on the requirement for participating in the Medicaid Interstate Match.  
For the full text of CMSs comments, see Appendix C. 
   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   16 
   
   
APPENDIX A 
Confidence Intervals  
95-Percent 
Point 
Estimate Description  Sample Size   Confidence 
Estimate  
Interval  
Matches that States did not verify  primarily  
because of barriers with the Medicaid enrollment  300 matches  68%   62.3%73.0%  
data 
Matches that were not verified because the 
Medicaid eligibility dates on the match file 
indicated that the beneficiary  was no longer  203 matches that  
56%  49.2%63.0%  
enrolled or would soon no longer be enrolled in  were not verified 
the Medicaid program for at least one of the 
States for which there was a match    
Matches that were not verified because the 
203 matches that  
match was associated with missing or inaccurate  18%  12.0%23.0%  
were not verified 
Medicaid eligibility dates or inaccurate SSNs  
Matches that States verified   300 matches  32%   27.0%37.7%  
Matches that did not result in a discontinuation 
of benefits because they  were verified by only   97 matches that 
49%  38.3%59.0%  
one of the States in which the beneficiary  was  were verified  
enrolled 
Matches that resulted in a discontinuation of  97 matches that 
41%  31.3%51.2%  
benefits  were verified  
 Source:  OIG analysis of match data, 2013.   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   17 
   
   
APPENDIX B 
Number of Projected Matches for the August 2011 Medicaid 
Interstate Match 
Projected   Number of  
Number of   Matches from  
Estimate Description  
Matches  the Sample 
(n=159,964)   (n=300)  
Matches that States did not verify    108,776  203 
Matches that were not verified because the 
Medicaid eligibility dates on the match file indicated 
that the beneficiary  was no longer enrolled or would 
60,915  203 
soon no longer be enrolled in the Medicaid program  
for at least one of the States for which there was a 
match 
Matches that were not verified because the match 
was associated with incomplete or inaccurate  18,492  203 
 
Medicaid eligibility dates or inaccurate SSNs  
Matches States verified   51,189  97 
Matches that did not result in a discontinuation of 
benefits because they  were verified by only one of  25,082  47 
the States in which the beneficiary was enrolled 
Matches that resulted in a discontinuation of 
20,987  40 
benefits 
  Source:  OIG analysis of match data, 2013.   
   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   18 
  APPENDIXC 
Agency Comments 
c~.~~ 
DEPARTMENT OF HEALTH & HUMAN SERVICE_s________c_e_nt-er_s_to_r_M_ed-ic_a_r_&_M_e_d_ic_ai_d_s_eTV_i_c_ 
s~ 	
Administrator 
Washington. DC 20201 
DATE:  JUN 11 2014 
TO: 	 Daniel R. Levinson 

Inspector General 

FROM: 	 Ma'ld.Jyn Tavenner 

Administretdr 

SUBJECT: 	 Office of the Inspector General (OIG) Draft Report: "Public Assistance Reporting 
Information System: State Participation in the Medicaid Interstate Match is 
Limited" (OEI-09-11-00780) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the above-referenced OIG draft report. OIG's report focuses on states' participation 
in the Medicaid Interstate Match. This is a tool used to reduce improper Medicaid payments, 
made as a result of one type of eligibility error. by identifYing beneficiaries who are enrolled in 
multiple state Medicaid programs. The findings and recommendations focus primarily on states' 
use of the tool, rather than on actual eligibility errors resulting from states' failure to use it. 
The report did find that, in its sample from August 2011, states did make improper payments for 
beneficiaries for whom interstate matches (i.e., evidence that the beneficiary was enrolled in 
more than one state) ultimately resulted in a discontinuation of benefits.  However, states only 
provided the amount of improper payments for 18 percent ofthese matches, which totaled 
$6.200 in improper Medicaid payments. 
The report does not seem to have enough information to adequately determine the real scope of 
eligibility errors resulting from inadequate use of the Medicaid Interstate Match; but, based on its 
findings, OIG did conclude that states' participation is limited and that states need more 
guidance from CMS about such participation. 
OIG Recommendation 
The OIG recommends that CMS issue guidance to states on the requirement for participating in 
the Medicaid Interstate Match. 
CMS Response 
The CMS concurs with OIG's recommendation that CMS issue further guidance to states to 
clarify the requirement for participating in the Medicaid Interstate Match. 
PARIS: State Participation in the Medicaid Interstate Match Is Limited (OEI-09-11-00780)  19   
   
Agency Comments (continued) 
 
 
   
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   20 
   
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
China Tantameng served as the team leader for this study, and  
Veronica Gonzalez served as the lead  analyst.  Other Office of Evaluation 
and Inspections staff from the San Francisco regional office who 
conducted the study include Christina Lester and Tiffany Stanley. Central 
office staff who provided support include Clarence Arnold, Kevin Manley, 
and Christine Moritz. 
 
 
PARIS: State Participation in the Medicaid Interstate Match Is Limited  (OEI-09-11-00780)   21 
   
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.