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Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

D
ETERMINING IF 

C C
HILDREN  LASSIFIED AS 

SCHIP M
EDICAID 

E M
XPANSION  EET 

E C
LIGIBILITY  RITERIA 

Daniel R. Levinson

Inspector General 

October 2005

OEI-07-03-00221
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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 all 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 in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts management and program 
evaluations (called inspections) that focus on issues of concern to HHS, Congress, and 
the public.  The findings and recommendations contained in the inspections generate 
rapid, accurate, and up-to-date information on the efficiency, vulnerability, and 
effectiveness of departmental programs.  OEI also oversees State Medicaid Fraud 
Control Units which investigate and prosecute fraud and patient abuse in the Medicaid 
program. 
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers.  The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, 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 in OIG's internal operations. OCIG imposes program exclusions and civil 
monetary penalties on health care providers and litigates those actions within HHS. 
OCIG also represents OIG in the global settlement of cases arising under the Civil False 
Claims Act, develops and monitors corporate integrity agreements, develops compliance 
program guidances, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  Report Template Version  = 01-13-05 
  E X E C U T I V E   S U M M A R Y  

OBJECTIVE 
To determine if children classified as Medicaid expansion meet State 
Medicaid-expansion eligibility criteria. 
BACKGROUND 
The Balanced Budget Act of 1997, Public Law 105-33, established the 
State Childrens Health Insurance Program (SCHIP) under Title XXI of 
the Social Security Act (the Act).  Under the Act, States can design a 
separate SCHIP, expand their existing Medicaid program, or do both.  
Benefits offered to children eligible under Medicaid-expansion criteria 
must be the same as those offered to children eligible under traditional 
Medicaid. Typically, States classify children determined eligible under 
Medicaid-expansion criteria as Medicaid expansion within their 
electronic data systems to distinguish them from traditional Medicaid 
and help ensure that these States seek the appropriate Federal match 
rate.  To encourage States to expand child health insurance eligibility, 
the Federal match rate for States SCHIP expenditures, including 
Medicaid expansion, is greater than the rate for traditional Medicaid.  
For a simple random sample of 357 cases from 29 of the 30 States that 
expanded their Medicaid program as of January 1, 2003, we reviewed 
case-file documentation according to each States Medicaid-expansion 
criteria to determine if the children met the Medicaid-expansion 
eligibility criteria. 
FINDINGS 
Approximately 7 percent of sampled children did not meet States 
eligibility criteria. 
Of the 357 sampled children classified as Medicaid expansion, 24 did 
not meet the States Medicaid-expansion eligibility criteria.  For 
21 sampled children, their families countable income was too low for 
Medicaid expansion, suggesting that States may be improperly 
receiving the enhanced Federal match rate.  For three sampled children, 
their families countable incomes exceeded eligibility requirements for 
the States in which they resided. These children were not eligible for 
Medicaid (traditional or expansion); therefore, no Federal 
reimbursement should have been claimed for them.  Those States that 
were able to identify the causes of the errors attributed them to 
caseworker mistakes and automated eligibility system failures. Given 
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the nature of a simple random sample, some States with 
Medicaid-expansion programs had few or no cases selected.  It is 
possible that these States have vulnerabilities similar to those 
identified in the States with more cases selected.  
For 10 percent of sampled children, States could not support their 
Medicaid-expansion eligibility determinations. 
States could not locate the case files to provide documentation to 
support eligibility determinations for 6 of the 357 sampled children.  For 
30 children in our sample, eligibility determinations could not be 
supported because case files lacked documentation of a timely 
redetermination, as required.   
Case files for 24 percent of sampled children contained income 
calculations that exhibited vulnerabilities. 
Documentation from 34 case files indicated that caseworkers varied 
from State guidelines in their use of multiplication methods, income 
disregards, and rounding.  For 36 case files, the caseworkers 
calculations were not documented, and we could not determine why our 
countable incomes, which were based on calculations that followed State 
guidelines, differed from those of the caseworkers.  Thirteen case files 
indicated that caseworkers did not include all documented income or did 
not use the most recent or representative income available in their 
calculations. Finally, we could not duplicate the caseworkers 
calculations in three case files, even though those calculations were 
documented.  Although the vulnerabilities identified did not result in 
incorrect eligibility determinations for these 86 children, such 
vulnerabilities could potentially lead to errors in future determinations. 
A few States had difficulty identifying their Medicaid-expansion 
populations, raising concerns about whether States claim the 
appropriate Federal match rate for some children. 
State officials from Michigan responded to our request for their 
Medicaid-expansion population by stating that they were unable to 
provide the information because unique identifiers were not assigned to 
children eligible under Medicaid-expansion criteria in their State.  
Additionally, South Carolinas Medicaid-expansion population included 
children the State correctly determined eligible for traditional Medicaid, 
but were classified as Medicaid expansion.  The inability of Michigan 
and South Carolina to accurately identify children eligible under 
Medicaid-expansion criteria could result in these States inappropriately 
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seeking the enhanced Federal match rate. Due to various reasons, 
Oklahoma, Maryland, and Ohio included in their Medicaid-expansion 
populations children who were accurately classified as traditional 
Medicaid. 
RECOMMENDATIONS 
States may improperly receive the enhanced Federal match rate when 
children whose family income is below the Medicaid-expansion 
eligibility criteria are classified as Medicaid expansion. States may 
improperly receive Federal reimbursement when children whose family 
income is above Medicaid-expansion eligibility criteria are classified as 
Medicaid expansion. Additionally, some States inability to locate cases, 
the lack of evidence of required redeterminations, and vulnerabilities 
created by caseworkers inconsistent application of State guidelines 
could lead to additional errors and cause concern. The inability of 
States to accurately identify their Medicaid-expansion populations could 
result in States improperly seeking an enhanced Federal match rate. 
We recommend that the Centers for Medicare & Medicaid Services: 
o 	 Work with States to improve caseworker performance in making 
eligibility determinations, thereby preventing errors due to 
caseworker mistakes. A possible method to pursue this goal is 
encouraging States to review and take appropriate action relating 
to their initial and ongoing caseworker training programs and 
their quality control practices. 
o 	 Work with States to ensure that automated eligibility systems 
accurately classify children determined eligible under 
Medicaid-expansion criteria. A possible method to pursue this 
goal is providing technical assistance and guidance to States in 
developing and implementing their automated eligibility systems. 
o 	 Ensure that State Medicaid programs conduct redeterminations of 
Medicaid-expansion eligibility, as required. 
o 	 Remind States of the requirement to properly maintain case-file 
documentation. 
o 	 Ensure that all States can accurately identify children determined 
eligible based on Medicaid-expansion criteria. 
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AGENCY COMMENTS 
In its comments to the report, CMS noted that screen and enroll 
requirements do not apply to Medicaid and SCHIP Medicaid-expansion 
programs. CMS stated the real issue is whether States are claiming the 
correct Federal financial participation rate. 
However, CMS concurred with our recommendations and provided steps 
it has taken or is taking in response to those recommendations.  CMS 
notes that it is committed to continuous improvement of its technical 
assistance and program integrity efforts.  Some of its actions are 
intended to address all of OIGs concerns, while other actions address 
specific findings and recommendations.  CMS will use the monthly 
Associate Regional Administrators conference call, the Eligibility 
Technical Advisory Group conference call, National Eligibility 
Conference, and the 2005 annual meeting of the American Public 
Human Services Association-Information System Management to bring 
attention to the issues addressed in this report. 
CMS also described efforts it has taken to work with two States 
(Michigan and South Carolina) that had trouble identifying their 
Medicaid-expansion populations in response to an OIG data request. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
According to screen and enroll requirements for separate SCHIP, before 
enrolling a child in separate SCHIP, the State must first determine if 
that child is eligible for Medicaid.  Only after determining that a child is 
not eligible for Medicaid will a State determine if the child is eligible for 
separate SCHIP. OIG agrees that screen and enroll requirements do 
not apply to Medicaid-expansion eligibility determinations.  However, it 
is still important to ensure that Medicaid-expansion eligibility 
determinations are made accurately, and that children determined 
eligible are classified correctly.  If a child is classified as Medicaid 
expansion, it is reasonable to assume that the State could claim the 
enhanced match for that child.  Approximately 7 percent of sampled 
children did not meet eligibility criteria, meaning that States may have 
claimed an improper Federal match for these children.  However, the 
issue of whether States actually sought and/or received the enhanced 
reimbursement rate for those children classified as Medicaid-expansion 
was outside the scope of this study.  
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CMS also commented that an OIG study with state sample sizes that 
would allow state-specific error rates would be helpful in their efforts to 
more accurately identify the causes of errors in specific States. OIG will 
take this request under advisement as a course for future work that 
could be pursued. 
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  T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY .......................................................................... i

I N T RO DUC T IO N .........................................................................................1 

F I N D IN G S .....................................................................................................9 

Identified errors...................................................................................9 

Unsupported eligibility determinations ........................................... 10 

Eligibility determination vulnerabilities..........................................11 

Identification of States Medicaid-expansion populations ............... 13 

R E C O MMEN D A T ION S ............................................................................15 

APPENDIXES ............................................................................................17 

A: 	States Verification and Quality Assurance Practices................17 

B: 	Medicaid-Expansion Universe and Sample................................19 

C: 	Worksheets Used in Case Review ............................................... 20 

D: 	Children With Family Income Below States Eligibility  

 Criteria for Medicaid Expansion ....................................................22

E: 	Children With Family Income Above States Eligibility  

 Criteria for Medicaid Expansion .................................................25 

F: Agency Comments........................................................................26 

A C K NO WL E D G M E N T S ...........................................................................30 
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OBJECTIVE 
To determine if children classified as Medicaid expansion meet State 
Medicaid-expansion eligibility criteria. 
BACKGROUND 
The Balanced Budget Act of 1997 (BBA), Public Law 105-33, established 
the State Childrens Health Insurance Program (SCHIP) under 
Title XXI of the Social Security Act (the Act).  Congress appropriated 
nearly $40 billion over 10 years to help States expand health insurance 
to children whose families earn too much to qualify for Medicaid, yet not 
enough to afford private health insurance.  The SCHIP is designed to 
help reduce the number of uninsured low-income children by providing 
them with health care coverage. To cover uninsured children under 
Title XXI, States can design a separate SCHIP, expand their existing 
Medicaid program, or do both. Section 4911 of the BBA amended the 
Medicaid statute to create a new optional eligibility category to cover 
targeted low-income children for those States desiring to expand their 
Medicaid coverage.1 
Medicaid, which was established in 1965 by Title XIX of the Act, is the 
largest program providing health care services to Americas poorest 
people.  Within broad national guidelines set by the Federal 
Government, the Act enables States to furnish medical assistance to 
those who meet eligibility requirements.  Each State administers its 
own Medicaid program, sets its own eligibility standards, determines 
the type, amount, duration and scope of services, and sets payment 
rates. 
By law, Title XXI Medicaid expansion (hereinafter referred to as 
Medicaid expansion) is subject to all the requirements of Title XIX 
Medicaid (hereinafter referred to as traditional Medicaid), but raises the 
income-eligibility thresholds to include more children. Medicaid 
expansion is administered and operated within a States traditional 
Medicaid program and must comply with traditional Medicaid 
requirements for comparability and statewideness.  The benefits are the 
same regardless of the eligibility criteria (Medicaid expansion or 
1 Optional targeted low-income children are defined in section 2110 of the BBA. The 
eligibility category for these children is established by 42 U.S.C. 
 1396a(a)(10)(A)(ii)(XIV). 
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traditional Medicaid) under which the child enters the program.  For 
the purpose of this report, we described children as being eligible for 
Medicaid expansion to clarify for the reader that the children are 
enrolled in Medicaid based on the expanded criteria. 
This inspection addresses the 30 States that expanded their traditional 
Medicaid program as of January 1, 2003.  Thirteen of these States only 
expanded their traditional Medicaid program, and 17 States expanded 
their traditional Medicaid program and also administered a separate 
SCHIP. 
Enhanced Federal Match Rates and Congressional Interest 
To encourage States to expand child health insurance eligibility, the 
Federal match rate for States Medicaid-expansion expenditures is 
greater than the match rate for traditional Medicaid.2  The average 
match rate for Medicaid expansion is 72 percent, while the average rate 
for traditional Medicaid is 60 percent.3  This could create a financial 
incentive for States to determine children eligible under the 
Medicaid-expansion criteria. 
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act 
of 1999 mandates that the Office of Inspector General (OIG) sample 
States administering separate SCHIPs every 3 years to determine the 
number of SCHIP enrollees, if any, who are eligible for Medicaid.  In 
February 2001, OIG released the first mandated report on separate 
SCHIPs entitled Ensuring Medicaid-eligibles are not Enrolled in 
SCHIP, OEI-05-00-00241.  We identified only 9 enrollment errors in a 
sample of 500 children. In 2004, we completed a second study of 
separate SCHIPs (Determining if Children Enrolled in Separate 
SCHIPs were Eligible for Medicaid, OEI-07-03-00220).  Again, we 
found few errors, only 5 in a sample of 386. 
After completion of the 2001 study, our discussions with Congress 
indicated an interest in collecting similar information for States that 
expanded their traditional Medicaid programs. Therefore, we conducted 
this study, in addition to the mandated study addressing separate 
SCHIPs. 
2 42 CFR  433.11(a)(1). 
3 Federal Register, December 3, 2003.  Retrieved August 16, 2005, from 
http://www.aspe.hhs.gov/health/fmap05.htm. 
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Determining Childrens Eligibility for Medicaid Expansion 
States Medicaid-expansion criteria are broadly based on factors such as 
household composition,4 the familys countable income, and the childs 
age.5  The lower income limit for Medicaid expansion, as a percentage of 
the Federal Poverty Level (FPL),6 is essentially the upper income limit 
for traditional Medicaid.  Medicaid expansion also has an upper income 
limit, as a percentage of the FPL, which a familys income cannot 
exceed.7  The upper and lower income limits for Medicaid expansion 
vary by State.  See Figure 1 for an example of one States income 
eligibility guidelines. 
Figure 1:  Example of State Eligibility Guidelines 
Exceeds Eligibility 
185% FPL 
Medicaid-expansion 
150% FPL 
Eligibility 
133% FPL 
100% FPL 
Medicaid Eligibility 
child's 
age  1 year  6 years  19 years 
To determine a familys countable income, States first determine the 
familys gross income.  Each State establishes its own procedure for 
calculating gross income.  States generally take either an actual or 
averaged weekly gross income amount and multiply by 4 or 4.3, or an 
actual or averaged bi-weekly amount and multiply by 2 or 2.15 to 
calculate gross monthly income.  Then, the appropriate income 
4  Within parameters set by the Aid to Families with Dependent Children and Medicaid law 
and regulations, each State sets its own rules for deciding which members of the 
household to include in determining a childs eligibility.   
5 42 CFR  435.522. 
6  The FPL is a set of income guidelines used for determining whether a person or family is 
financially eligible for assistance or services under a particular Federal program.  The 
FPL is published yearly in the Federal Register. 
7 BBA  2110(b)(4).  
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disregards are subtracted from the familys gross income to arrive at the 
familys countable income.  At the time of our review, most States 
permitted monthly income disregards of $90 for each working parent, 
$50 for child support payments received, and a deduction of $175 to 
$200 for childcare expenses. 
The familys countable income and the household composition are then 
used to determine what percentage of the FPL the familys countable 
income represents.  If the familys countable income falls within the 
Medicaid-expansion eligibility range that the State established for the 
childs age group, the child is determined to be income-eligible for 
Medicaid expansion.   
Redeterminations 
Federal regulations require that States redetermine an enrolled childs 
eligibility at least every 12 months.8  In general, to redetermine a childs 
eligibility, the State collects information on the familys income, the 
childs age, the household composition, and any other factors that affect 
a childs eligibility for Medicaid expansion.  The State considers all this 
information to determine whether or not a child continues to meet the 
eligibility requirements for Medicaid expansion. Based on the results of 
the redetermination, the child (1) continues to be eligible under 
Medicaid-expansion criteria; (2) is determined to be eligible under 
traditional Medicaid criteria; (3) is moved to the separate SCHIP; or 
(4) is disenrolled. 
Documentation Requirements 
Federal regulations require States to include facts to support the 
eligibility determination in each applicants record.9  States determine 
the documentation that they require from families who apply and the 
processes they use to verify information.  (See Appendix A for a listing 
of the States verification and quality assurance practices.)  Some of the 
documentation commonly found in case files includes the following: 
o 	 application for medical assistance;  
o 	 copies of pay stubs or tax forms; 
o 	 proof of other income, such as Social Security or unemployment 
benefits; 
8 42 CFR  435.916(a).   

9 42 CFR  435.913(a). 

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o 	 dependent care expenses; 
o 	 caseworker notes; 
o 	 calculation sheets which detail how gross and countable income 
were calculated by the State; and 
o 	 the familys countable income used, and the corresponding FPL 
percentage. 
SCOPE 
This study covers those States that expanded their Medicaid program as 
of January 1, 2003. For a simple random sample of children classified 
as Medicaid-expansion as of June 1, 2003, we evaluated whether each 
child met the criteria for Medicaid expansion based on age, family 
countable income, and household composition. This study focused on 
children determined eligible for Medicaid expansion; therefore, we 
excluded eligible adults and unborn children from our review. 
Although States are allowed to claim the higher Federal match for 
children found eligible under Medicaid-expansion criteria, we did not 
evaluate the rate at which States actually sought and/or received 
reimbursement for those children. 
METHODOLOGY 
Sample Selection 
From each of the 30 States that expanded their Medicaid program, we 
requested the population of children classified as Medicaid expansion as 
of June 1, 2003. We received information from 29 States10 and 
aggregated the State populations into a single universe of 
approximately 928,000. (See Appendix B.) From this universe, we 
selected a simple random sample of 400 cases for review. Due to their 
relatively small Medicaid-expansion populations, Minnesota, New 
Hampshire, New Jersey, and North Dakota did not have any cases 
selected as part of our sample. 
10 Michigan SCHIP officials reported that they were unable to provide the information 
requested because unique identifiers were not assigned to children eligible for Medicaid 
expansion in their State. Michigan was, therefore, dropped from the universe. Michigan 
will be discussed in greater detail later in the report. 
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Sample Adjustments 
A total of 43 children were dropped from our sample because they did 
not fit our criteria.  One of these children was ineligible for traditional 
Medicaid because of his immigration status, and therefore was enrolled 
in Medicaid expansion through a State-subsidized eligibility category 
for which the State did not receive Federal funding.  A second child was 
dropped from the sample because his mother had applied for benefits for 
him before his birth, and we excluded unborn children from our 
Medicaid-expansion universe.  A third child was found ineligible for 
Medicaid expansion by the State immediately prior to our review period, 
but had not yet been removed from the Medicaid-expansion rolls on the 
date that the State produced their population data.  Ten children were 
dropped because they were enrolled in a States separate SCHIP and 
not in Medicaid expansion.  The remaining 30 children were mistakenly 
included in the Medicaid-expansion population data, and these cases 
will be discussed later in the report.  These adjustments reduced the 
total number of cases we reviewed to 357.  The findings in this report 
are based on the sample of 357 children. 
Data Collection 
For each sampled child, we requested documentation consisting of the 
medical assistance application or the most recent redetermination 
information, supporting income documentation (if required), calculation 
sheets States used to calculate income, and any notes indicating family 
circumstances or explaining how eligibility was determined.   
From each State, we collected information on the States eligibility 
criteria for Medicaid-expansion, which included, but was not limited to, 
requirements for proof of income, age requirements, and FPL limits. 
We analyzed the following elements of each case in accordance with 
each States eligibility criteria for Medicaid-expansion: 
o 	 date of application or redetermination; 
o 	 age of the child at the time of the eligibility determination; 
o 	 household composition (or number of people in the family); 
o 	 documentation used to support family income, which could include 
pay stubs, tax forms, or income information from State databases; 
o 	 familys gross income prior to any income disregards; 
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o 	 familys countable income after any income disregards (calculated 
by OIG based on the case-file documentation, as well as the 
caseworkers calculation, when this figure was available); and 
o 	 the FPL percentage represented by the familys countable income 
(calculated by OIG based on case-file documentation, as well as 
the caseworkers calculation, when this figure was available).11 
When the household composition, age, countable family income, and 
FPL were within State Medicaid-expansion criteria, we determined 
children to be income-eligible for Medicaid expansion.  When it 
appeared that these factors were not within State Medicaid-expansion 
criteria, we contacted the State to provide them an opportunity to 
support the eligibility determination.  The States in turn either: 
(1) provided additional information that we accepted as support for 
Medicaid-expansion eligibility; (2) confirmed that an error had been 
made; (3) provided information that still did not support their 
determination; or (4) were unable to provide documentation to support 
the eligibility determination.  An example of the worksheets we created 
and used in reviewing each case is found in Appendix C. 
Medicaid-Expansion Officials 
We gathered background information, such as how each program is 
administered, who determines eligibility, how States ensure correct 
eligibility determinations, and unique programmatic features within 
each State, from Medicaid-expansion directors and administrators for 
the 30 States with Medicaid-expansion programs.  We also obtained 
each States eligibility criteria and a description of its eligibility 
determination process.  
Onsite Visits 
We conducted onsite visits with eligibility staff in California, Louisiana, 
New York, and Ohio.  While onsite, we had caseworkers demonstrate 
the process of making an eligibility determination, reviewed both paper 
processes and automated eligibility systems, and observed what 
procedures were in place to ensure correct eligibility determinations. 
11 OIG FPL percentage calculations were based on the date of application.  The FPL 
guidelines for 2003 were effective on February 7, 2003.  Therefore, in reviewing 
applications dated prior to March 1, 2003, we used 2002 FPL guidelines.  For applications 
dated on or after March 1, 2003, we used 2003 FPL guidelines. 
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Limitations 
Although we drew a simple random sample, we did not project our 
findings in this report to the entire Medicaid-expansion population, 
because of problems identified with the population data.  Specifically, 
Maryland, Ohio, Oklahoma, and South Carolina provided us Medicaid-
expansion populations that we later discovered included children who 
were actually enrolled in traditional Medicaid.  Also, the Medicaid-
expansion populations provided by Kentucky and New Jersey were 
revised based on information that was received after the sample was 
selected. 
Standards 
This inspection was conducted in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on Integrity 
and Efficiency. 
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  F I N D I N G S  
Out of 357 randomly sampled
Approximately 7 percent of sampled children did 
children, 24 children (7 percent) did 
not meet States eligibility criteria 
not meet the eligibility criteria for 
Medicaid expansion in their States. For 21 of these children, their 
families countable income was too low for Medicaid expansion. States 
indicated that errors for eight children were caused by caseworkers 
making incorrect calculations or data entry errors, or failing to collect 
updated income information.  For three children, States reported that 
the children had been determined eligible under their Medicaid-
expansion criteria, but they were not able to provide documentation to 
support those determinations in response to our request for 
clarification.  Errors for two children resulted when the automated 
eligibility system a State used applied incorrect codes to the cases.  For 
the final eight children, States did not provide any explanation of how 
the errors occurred.   
The following three examples illustrate some of the types of errors we 
identified. Appendix D provides a summary of all 21 errors. 
o 	 The caseworker incorrectly included a stepfather and his income 
in the eligibility determination. According to State program 
guidelines, the stepfather should not have been included in the 
family for the purpose of determining the childs eligibility. 
o 	 The caseworker used an incorrect income input screen when 
entering this childs case into the States automated eligibility 
system, resulting in the child being assigned a code that indicated 
eligibility based on Medicaid-expansion criteria. 
o 	 The caseworker did not record the familys income correctly in the 
States automated eligibility system, resulting in the system 
assigning a code to the child indicating eligibility based on 
Medicaid-expansion criteria. 
Three sampled children were ineligible for Medicaid expansion because the 
families incomes exceeded eligibility limits. 
Medicaid-expansion eligibility has an upper income limit, expressed as a 
percentage of FPL, which a familys income cannot exceed.  If a familys 
countable income is in excess of the maximum income limit for Medicaid 
expansion in their State, the child is ineligible for Medicaid expansion.  
We identified three children whose families countable incomes exceeded 
the maximum income limits for their States.  These children were not 
eligible for Medicaid (traditional or expansion); therefore, the States 
should not seek any Federal reimbursement for them. 
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One of these three errors was caused by the caseworker making an 
incorrect calculation.  One error was the result of a problem in the 
States automated eligibility system, which caused an incorrect code to 
be assigned.  And for one case, the State did not acknowledge the reason 
for the error, nor did it provide documentation to support the eligibility 
determination.  Appendix E contains descriptions of these cases. 
Two sampled children met the criteria for their States separate SCHIP 
programs. 
We identified two children who were ineligible for Medicaid expansion, 
but did meet the criteria for their States Title XXI separate SCHIP 
programs. Therefore, the enhanced Federal match rate for these two 
children is appropriate, although they were enrolled in the incorrect 
programs. 
Federal regulation 42 CFR 
For 10 percent of sampled children, States 
 435.913(a) requires States to 
could not support their Medicaid-expansion 
include in each applicants case 
eligibility determinations 
record facts to support the 
determination of eligibility, and 42 CFR  435.916(a) requires that 
States redetermine each enrolled childs eligibility at least every 
12 months. However, for 36 children in our sample, States either could 
not locate the case file to provide us documentation or case files lacked 
documentation of a timely redetermination. 
States could not locate almost 2 percent of case files for sampled children. 
Despite repeated requests for the information, States could not locate 
six of the case files for children in our sample.  Due to the lack of case 
files or any other information to support eligibility, we were unable to 
make any determination regarding these childrens eligibility. 
States could not provide evidence for approximately 8 percent of sampled 
children to establish whether required redeterminations had been performed 
timely. 
For 30 children, States could not provide evidence that annual eligibility 
redeterminations had been performed timely.  Although Federal 
Medicaid regulations require redeterminations every 12 months,12 the 
last determinations for these cases occurred between 13 months and 
58 months prior to our review in June 2003.  Due to the lack of recent 
12 42 CFR  435.916(a). 
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determinations, we were unable to determine whether these children 
were eligible for Medicaid expansion. 
We identified income calculations for 
Case files for 24 percent of sampled children 
86 children that exhibited vulnerabilities.  
contained income calculations that exhibited 
The identified vulnerabilities did not result 
vulnerabilities  in the children being ineligible for Medicaid 
expansion, and therefore we agreed with 
the States that these children should be classified as Medicaid 
expansion. However, if not addressed, these vulnerabilities suggest the 
potential that some children, especially those whose families countable 
income is close to the upper or lower income limits, could be incorrectly 
determined eligible under Medicaid-expansion criteria. 
For 34 children, the caseworkers did not follow State guidelines in 
applying multiplication methods, income disregards, rounding, and 
family income to income calculations.  For example, the caseworker for 
one child multiplied the familys average weekly income by 2.16 rather 
than 4.333, as State guidelines required, resulting in an omission of 
$569.74 in countable income.  In another example, the caseworker 
allowed two earned income disregards of $120 each, although the family 
should have only received one.  This resulted in the familys countable 
income being $120 less than it should have been.  For 15 children, 
caseworkers rounded income amounts in ways inconsistent with State 
guidelines, resulting in the omission or inclusion of up to $4 in 
countable income. Although this amount may not seem significant, in 
instances where family income is near the income limits for Medicaid 
expansion, even small errors can result in a child being incorrectly 
determined eligible under Medicaid-expansion criteria.  Lastly, one 
caseworker calculated the familys countable income using net income 
figures, rather than gross income, resulting in the omission of $59.79 in 
countable income. 
For another 36 children, the caseworkers calculations were not 
documented.  Therefore, we could not determine why our calculations of 
countable income, which were based on State guidelines, differed from 
the caseworkers calculations.  
For 13 children, caseworkers did not include all documented income or 
did not use the most recent or representative income information 
available in their calculations.  As a result, the countable incomes we 
calculated differed from the amounts the State reported.   
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For the remaining three children, we could not duplicate the 
caseworkers calculations, although those calculations were 
documented.  For example, the caseworkers notes for one child 
indicated child support received over 2 months was averaged to arrive 
at $651.47.  However, when we made the income calculation, the 
average child support amounts received equaled $936.57 a month, 
resulting in a difference of $285.10.   
Table 1 below summarizes the differences between caseworkers 
calculations and our calculations, which are based on State guidelines 
and available documentation.  The differences between the 2 countable 
incomes, as calculated by caseworkers and OIG for these 86 children, 
ranged from $0.01 to $989.00. 
Table 1:  Differences Between Income 
Calculated by State and Income 
Calculated by OIG 
No. of Cases  Amount of Difference 
23  $.01 - $10.00 
14  $10.01 - $50.00 
11  $50.01 - $100.00 
31  $100.01 - $500.00 
7  $500.01 - $989.00 
Source:  2004 OIG analysis of case-file information. 
The potential for error resulting from identified vulnerabilities is greater for 
children whose families incomes are near the income limits for Medicaid 
expansion. 
Several of the errors we identified in this report were the result of 
caseworker mistakes, with incorrect countable income calculations 
leading to children being incorrectly determined eligible under 
Medicaid-expansion criteria rather than under traditional Medicaid 
criteria.  For the 86 children discussed above, the caseworker mistakes 
were not of sufficient magnitude to make the eligibility determinations 
incorrect, although some could have been if the families countable 
incomes had been closer to the income limit.   
For 11 percent of the families of sampled children,13 countable income 
was within 5 percent of the lower income limit for Medicaid expansion 
(i.e., within 5 percent of the income limit for traditional Medicaid). 
13 For this calculation, we excluded 30 case files that did not contain recent determinations 
and 6 missing case files, bringing the total denominator to 321. 
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Thus, relatively minor income calculation mistakes for families such as 
these could result in children being incorrectly determined eligible 
under Medicaid-expansion criteria. 
State officials from Michigan 
A few States had difficulty identifying their 
responded to our request for their 
Medicaid-expansion populations, raising concerns 
Medicaid-expansion population by 
about whether States claim the appropriate Federal  stating that they were unable to 
match rate for some children  provide the information because 
unique identifiers were not assigned 
to children eligible for Medicaid expansion in their State. Michigans 
Medicaid expansion covers children ages 16 through 18 who have family 
income between 100 and 150 percent of the FPL. Michigan reported 
using a formula to estimate the number of children eligible under 
Medicaid-expansion criteria by identifying children between the ages of 
16 and 18 whose families countable incomes fall between 100 and 
150 percent of the FPL.  Michigan officials explained that they assume 
there is an even distribution of children who meet these parameters and 
indicated that there was no way they would be able to extract this 
population for us.   
South Carolinas Medicaid-expansion population included children the 
State correctly determined eligible for traditional Medicaid but were 
classified as Medicaid expansion.  South Carolina program officials 
reported that the mistake resulted from changes they had made in their 
automated eligibility system.  These changes resulted in some children 
being recorded in their database incorrectly.14 The inability of Michigan 
and South Carolina to accurately distinguish children eligible for 
Medicaid expansion from other children could result in these States 
inappropriately seeking an enhanced Federal match rate. 
Oklahoma, Maryland, and Ohio did not accurately provide their 
Medicaid-expansion populations to us, resulting in the selection of 
30 children who were enrolled in traditional Medicaid in our sample. 
We discovered these children through our review process and excluded 
them from our sample. Unlike 21 of the errors identified in this study 
in which the children were classified as Medicaid expansion but met 
income-eligibility guidelines for traditional Medicaid, these 30 children 
were accurately enrolled in traditional Medicaid; however, the States 
14 Sampled children from South Carolina whose eligibility was determined incorrectly by 
the State were included in the first finding of this report as errors. 
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erred in including them in the Medicaid-expansion populations they 
provided.  
When we questioned the States regarding how the children enrolled in 
traditional Medicaid were included in the Medicaid-expansion 
populations, State program officials provided various explanations. 
Oklahoma indicated that, although they understood the request for the 
population, they made a mistake in preparing the data that resulted in 
children enrolled in traditional Medicaid being included.  Maryland 
misinterpreted our request for the population, and thus included 
children from all of their medical assistance programs. Ohio did not 
respond to our repeated requests for an explanation of how this 
occurred. 
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States may improperly receive the enhanced Federal match rate when 
children whose family income is below the Medicaid-expansion 
eligibility criteria are classified as Medicaid expansion.  States may 
improperly receive Federal reimbursement when children whose family 
income is above Medicaid-expansion eligibility criteria are classified as 
Medicaid expansion. Additionally, some States inability to locate cases, 
the lack of evidence of required redeterminations, and vulnerabilities 
created by caseworkers inconsistent application of State guidelines 
could lead to additional errors and cause concern.  The inability of 
States to accurately identify their Medicaid-expansion populations could 
result in States improperly seeking an enhanced Federal match rate. 
We recommend that the Centers for Medicare & Medicaid Services: 
o 	 Work with States to improve caseworker performance in making 
eligibility determinations, thereby preventing errors due to 
caseworker mistakes.  A possible method to pursue this goal is 
encouraging States to review and take appropriate action relating 
to their initial and ongoing caseworker training programs and 
their quality control practices. 
o 	 Work with States to ensure that automated eligibility systems 
accurately classify children determined eligible under Medicaid-
expansion criteria. A possible method to pursue this goal is 
providing technical assistance and guidance to States in 
developing and implementing their automated eligibility systems. 
o 	 Ensure that State Medicaid programs conduct redeterminations of 
Medicaid-expansion eligibility, as required. 
o 	 Remind States of the requirement to properly maintain case-file 
documentation. 
o 	 Ensure that all States can accurately identify children determined 
eligible based on Medicaid-expansion criteria. 
AGENCY COMMENTS 
In its comments to the report, CMS noted that screen and enroll 
requirements do not apply to Medicaid and SCHIP Medicaid-expansion 
programs. CMS stated the real issue is whether States are claiming the 
correct Federal financial participation rate. 
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However, CMS concurred with our recommendations and provided steps 
it has taken or is taking in response to those recommendations.  CMS 
notes that it is committed to continuous improvement of its technical 
assistance and program integrity efforts.  Some of its actions are 
intended to address all of OIGs concerns, while other actions address 
specific findings and recommendations.  CMS will use the monthly 
Associate Regional Administrators conference call, the Eligibility 
Technical Advisory Group conference call, National Eligibility 
Conference, and the 2005 annual meeting of the American Public 
Human Services Association-Information System Management to bring 
attention to the issues addressed in this report. 
CMS also described efforts it has taken to work with two States 
(Michigan and South Carolina) that had trouble identifying their 
Medicaid-expansion populations in response to an OIG data request. 
OFFICE OF INSPECTOR GENERAL RESPONSE 
According to screen and enroll requirements for separate SCHIP, before 
enrolling a child in separate SCHIP, the State must first determine if 
that child is eligible for Medicaid.  Only after determining that a child is 
not eligible for Medicaid will a State determine if the child is eligible for 
separate SCHIP. OIG agrees that screen and enroll requirements do 
not apply to Medicaid-expansion eligibility determinations.  However, it 
is still important to ensure that Medicaid-expansion eligibility 
determinations are made accurately, and that children determined 
eligible are classified correctly.  If a child is classified as Medicaid 
expansion, it is reasonable to assume that the State could claim the 
enhanced match for that child.  Approximately 7 percent of sampled 
children did not meet eligibility criteria, meaning that States may have 
claimed an improper Federal match for these children.  However, the 
issue of whether States actually sought and/or received the enhanced 
reimbursement rate for those children classified as Medicaid-expansion 
was outside the scope of this study.  
CMS also commented that an OIG study with State sample sizes that 
would allow State-specific error rates would be helpful in their efforts to 
more accurately identify the causes of errors in specific States. OIG will 
take this request under advisement as a course for future work that 
could be pursued. 
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AAA GGG EEE NNN CCC YYY     CCC OOO MMM MMM EEE NNN TTT SSS
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States Verification and Quality Assurance Practices 
The following chart illustrates the self-reported information obtained 
from structured interviews with States when asked about their 
verification and quality assurance practices prior to our case-file review. 
We did not identify any relationship between the verification and 
quality assurance practices shown in the table and incorrect eligibility 
determinations. 
State ID  AK  CA  DC  FL  HI  IA  ID  IL  IN  KY  LA  MA  MD  ME  MI 
Proof of Income 
[  [  [  ,  ,  [  ,  [  [  [  ,  [  ,  [  , 
Required 
Self-Declaration 
,  [  ,  [  [  ,  [  ,  [  ,  ,  [  [  ,  [ 
Allowed 
Proof of Other 
Eligibility Criteria  ,  [  [  ,  ,  [  [  ,  ,  ,  [  [  ,  ,  [ 
Required 
Routine 
Verification of 
Information  [  [  [  ,  [  [  [  [  [  [  [  [  [  [  , 
Provided by 
Applicants 
Written Policies 
for Verification of  [  [  [  NR  [  [  [  [  ,  [  [  [  [  [  , 
Enrollment 
Redetermination 
Information 
[  NR  [  NR  [  [  [  [  NR  [  [  [  [  [  , 
Verified Same as 
at Enrollment 
Eligibility 
Determinations 
[  [  [  [  [  [  [  [  ,  [  [  [  [  [  [ 
Reviewed for 
Accuracy 
Children Identified 
Through State 
Reviews as  ,  ,  NR  ,  ,  NR  [  ,  NR  [  [  ,  ,  [  , 
Incorrectly 
Enrolled 
Key 
[  Indicates States response was Yes 
,  Indicates States response was No 
NR Indicates State did not respond 
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State ID  MN  MO  ND  NE  NH  NJ  NM  NY  OH  OK  RI  SC  SD  VA  WI 
Proof of Income 
[  [  [  [  [  [  [  [  [  ,  [  [  [  [  , 
Required 
Self-Declaration 
,  ,  ,  ,  ,  ,  [  ,  [  [  ,  ,  ,  ,  [ 
Allowed 
Proof of Other 
Eligibility Criteria  [  [  [  ,  [  [  [  [  [  ,  [  ,  ,  ,  [ 
Required 
Routine 
Verification of 
Information  [  [  ,  [  [  [  [  [  [  ,  [  [  [  ,  [ 
Provided by 
Applicants 
Written Policies 
for Verification of  [  [  [  ,  [  [  [  [  [  NR  [  [  [  NR  [ 
Enrollment 
Redetermination 
Information 
NR  NR  NR  NR  NR  [  [  [  [  [  [  [  NR  [  [ 
Verified Same as 
at Enrollment 
Eligibility 
Determinations 
[  [  [  [  [  [  [  [  [  [  [  [  [  [  [ 
Reviewed for 
Accuracy 
Children Identified 
Through State 
Reviews as  ,  ,  ,  [  ,  [  ,  NR  ,  ,  [  ,  [  ,  , 
Incorrectly 
Enrolled 
Key 
[  Indicates States response was Yes 
,  Indicates States response was No 
NR Indicates State did not respond 
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Medicaid-Expansion Universe and Sample 
We requested States to provide us information on all children eligible 
under Medicaid-expansion criteria as of June 1, 2003.  The following 
table shows the number of children provided by each State and the 
number of children selected in our sample.  It is important to note that 
the data published here reflect the Medicaid-expansion populations as 
the States provided them.  At least four States (Maryland, Ohio, 
Oklahoma, and South Carolina) had difficulty identifying their 
Medicaid-expansion populations.  Also, there were children selected in 
the sample from three additional States (California, New York, and 
Nebraska) who were later determined to not fit our criteria. 
Reported 
Expansion  Percent of 
State  Expansion 
Sample  Sample 
Population 
AK  12,217  5  1.40 
CA  50,965  21  5.88 
DC  3,265  4  1.12 
FL  1,422  2  0.56 
HI  9,447  1  0.28 
IA  9,345  4  1.12 
ID  10,656  6  1.68 
IL  48,528  21  5.88 
IN  46,103  25  7.00 
KY*  30,010  2  0.56 
LA  86,593  34  9.52 
MA  40,229  18  5.04 
MD  103,095  26  7.28 
ME  7,818  7  1.96 
MN  15  0  0.00 
MO  82,841  36  10.08 
ND  1,121  0  0.00 
NE  22,101  13  3.64 
NH  162  0  0.00 
NJ*  4,738  0  0.00 
NM  10,377  6  1.68 
NY  66,882  29  8.12 
OH  113,824  32  8.96 
OK  49,415  22  6.16 
RI  8,864  7  1.96 
SC  45,008  16  4.48 
SD  7,359  2  0.56 
VA  20,758  8  2.24 
WI  35,427  10  2.80 
Total  928,585  357  100.00* 
*Actual percentage total is 99.96 due to rounding. 

Based on information received after the sample was 

selected, the population for Kentucky was revised to 30,872 

and the population for New Jersey was revised to 33,336. 

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Worksheets Used in Case Review 
The following pages show examples of the case review and calculation 
sheets we used in reviewing the sampled cases.  The example is not 
meant to represent any specific State or case, but rather to illustrate the 
process used in assessing proper eligibility determinations. 
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Source:  OIG worksheet used in case review. 
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Children With Family Income Below States Eligibility Guidelines for 
Medicaid Expansion 
Federal Poverty 
Age Range  Income Range 
Level Range* 
State Guidelines  6 - 19  100% - 133%  $2,021.67 - $2,688.82 
Case 1  Family  Child is 9 
69%  $1,393.46 
(6 members total)  years old 
The caseworker multiplied one parents daily wage by 5 days to calculate 
weekly wages, but the parent only worked 2 days per week. 
State Guidelines  0 - 5  133% - 200%  $1,664.72 - $2,503.33 
Case 2  Family  Child is 5 
16%  $209.00 
(3 members total)  years old 
The caseworker incorrectly included a stepfather and his income in the eligibility 
determination.  According to State program guidelines, the stepfather should 
not have been included in the family for the purpose of determining the child's 
eligibility. 
State Guidelines  1 - 5  133% - 185%  $1,664.72 - $2,315.58 
Case 3  Family  Child is 2 
72%  $906.00 
(3 members total)  years old 
When the caseworker input one parents income in the State eligibility system, 
the caseworker incorrectly specified that it was paid weekly instead of bi-
weekly.  Therefore, the system calculated the familys monthly income at twice 
the rate it should have been, making the child appear to be eligible under 
Medicaid-expansion criteria. 
State Guidelines  0 - 18  100% - 200%  $2,899.16 - $5,798.33 
Case 4  Family Child is 15 
88%  $2,574.28 
 (7 members total)  years old 
The caseworker used an incorrect income input screen when entering this case 
into the States eligibility system, resulting in the child being assigned an 
eligibilty code that indicated eligibility under Medicaid-expansion criteria. 
State Guidelines  6 - 18  100% - 133%  $1,533.33 - $2,039.33 
Case 5  Family  Child is 15 
0%  $0 
(4 members total)  years old 
State Guidelines  6 - 19  100% - 185%  $1,765.00 - $3,265.25 
Case 6  Family  Child is 9 
53%  $950.00 
(5 members total)  years old 
In cases 5 and 6, the caseworkers redetermined the childrens eligibility without 
considering the changes in the families incomes that had occurred.  When the 
changes in income were brought to the States attention, the children were 
discovered to be eligible for traditional Medicaid. 
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State Guidelines  6 - 19  100% - 185%  $1,271.67 - $2,352.58 
Case 7  Family  Child is 15 
81%  $1,034 
(3 members total)  years old 
The caseworker recorded $1,000 in earned income for one parent who had no 
income, and incorrectly recorded the other parents income as being from self-
employment.  The caseworker also incorrectly deducted two $120 earned 
income disregards.  (State program guidelines state that the $120 disregard is 
not deducted from self-employment income.) 
State Guidelines  1 - 6  133% - 185%  $1,323.35 - $1,840.75 
Case 8  Family  Child is 3 
123%  $1,222.00 
(2 members total)  years old 
The caseworker did not record the familys income correctly in the States 
eligibility system, resulting in the system assigning a code to the child indicating 
eligibility under Medicaid-expansion criteria. 
State Guidelines  6 - 19  100% - 150%  $1,533.33 - $2,300.00 
Case 9  Family  Child is 7 
21%  $270.00 
(3 members total)  years old 
State Guidelines  6 - 19  100% - 150%  $1,010.00 - $1,515.00 
Case 10  Family  Child is 10 
97%  $980.00 
(2 members total)  years old 
In cases 9 and 10, the State explained that a problem occurred when they 
attempted to implement a new eligibility system.  Some of the codes indicating 
eligibilty for different programs were transferred incorrectly from the old system 
to the new one, resulting in children being classified incorrectly. 
State Guidelines  6 - 19  100% - 150%  $1,533.33 - $2,300.00 
Case 11  Family  Child is 13 
89%  $1,368.20 
(4 members total)  years old 
State Guidelines  6 - 19  100% - 150%  $1,533.33 - $2,300.00 
Case 12  Family  Child is 18 
0%  $0 
(4 members total)  years old 
State Guidelines  6 - 19  100% - 150%  $1,533.33 - $2,300.00 
Case 13  Family  Child is 17 
7%  $53.75 
(1 member total)  years old 
State Guidelines  1 - 5  0% - 133%  $0 - $1,691.32 
Case 14  Family  Child is 1 
45%  $572.00 
(3 members total)  year old 
State Guidelines  6 - 18  0% - 100%  $0 - $748.33 
Case 15  Family  Child is 11 
56%  $422.00 
(1 member total)  years old 
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State Guidelines  6 - 18  100% - 200%  $1,508.00 - $3,016.67 
Case 16  Family  Child is 13 
93%  $1,426.00 
(4 members total)  years old 
State Guidelines  6 - 18  100% - 200%  $1,795.00 - $3,590.00 
Case 17  Family  Child is 16 
86%  $1,520.00 
(5 members total)  years old 
State Guidelines  6 - 18  100% - 133%  $1,533.33 - $2,039.33 
Case 18  Family  Child is 7 
72%  $1,098.94 
(4 members total)  years old 
For cases 11 through 18, although the States confirmed that the children were 
eligible for traditional Medicaid, they did not provide explanations of how the 
errors occurred. 
State Guidelines  1 - 5  133% - 150%  $2,347.45 - $2,647.50 
Case 19  Family  Child is 5 
107%  $1,887.00 
(5 members total)  years old 
State Guidelines  6 - 18  100% - 150%  $1,271.67 - $1,907.50 
Case 20  Family  Child is 7 
59%  $761.40 
(3 members total)  years old 
State Guidelines  6 - 17  114% - 150%  $1,719.12 - $2,262.50 
Case 21  Family  Child is 8 
0%  $0.00 
(4 members total)  years old 
Despite our requests for clarification on cases 19 through 21, the States were 
unable to provide proof of income.  According to OIG analysis of documented 
information in these cases, the children were not eligible under Medicaid-
expansion criteria. 
Source:  OIG analysis of case-file documentation for sampled SCHIP cases. 
*The FPL changes each fiscal year and is adjusted for family size.  Thus, 100% FPL in 2002 is different from 
100% FPL in 2003, and 100% FPL for a family of three is different from 100% FPL for a family of four. 
The income range for both Medicaid and Medicaid expansion in this State are the same for each age group; 
children are identified as Medicaid expansion if they do not meet asset requirements for Medicaid.  These two 
children were classified as Medicaid expansion erroneously, because they did meet Medicaid asset 
requirements. 
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Children With Family Income Above States Eligibility Guidelines for 
Medicaid Expansion 
Federal Poverty 
Age Range  Income Range 
Level Range* 
State Criteria  6 - 18  100% - 200%  $1,251.67 - $2,503.33 
Case 1  Family  Child is 6 
345%  $4,325.00 
(3 members total)  years old 
The caseworker mistakenly counted the familys income for one month over a 
two month period, making it appear that the familys income was half of what it 
actually was. 
State Criteria  0 - 5  133% - 200%  $1,664.72 - $2,503.33 
Case 2  Family  Child is 1 
222%  $2,784.00 
(3 members total)  year old 
The county Medicaid office responsible for this case explained that its eligibility 
system malfunctioned, assigning a code to this case that indicated eligibility 
under Medicaid-expansion criteria incorrectly. The malfunction was not 
discovered until the fall of 2003. 
State Criteria  6 - 18  100% - 200%  $995.00 - $1,990.00 
Case 3  Family  Child is 15 
255%  $2,545.00 
(2 members total)  years old 
The documentation the State provided showed that the family had too much 
income to qualify for Medicaid expansion.  No further information was received 
for this case from the State. 
Source:  OIG analysis of case-file documentation for sampled Medicaid-expansion cases. 
*The FPL changes each fiscal year and is adjusted for family size.  Thus, 100% FPL in 2002 is different from 
100% FPL in 2003, and 100% FPL for a family of three is different from 100% FPL for a family of four. 
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  A C K N O W L E D G M E N T S  

This report was prepared under the direction of Brian T. Pattison, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office, and Gina C. Maree, Assistant Regional 
Inspector General.  Other principal Office of Evaluation and Inspections 
staff who contributed include: 
Mike Craig, Project Leader 
Dennis Tharp, Program Analyst 
Elander Phillips, Program Analyst 
Michala Walker, Program Analyst 
Brian Whitley, Program Analyst 
Linda Hall, Program Specialist 
Elise Stein, Director, Public Health and Human Services 
Barbara Tedesco, Mathematical Statistician
  In Memoriam 
Mike Craig (1973  2004) served as Project Leader for this inspection.  
His leadership provided encouragement and served as a source of 
direction for his team.  His untimely death occurred just prior to the 
completion of this inspection. 
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