Department of Health and Human Services   
 
OFFICE OF INSP ECTOR GENERAL   
   
    
 
S U : T-MSIS D  
TATUS  PDATE      ATA 
N Y A O
OT  ET  VAILABLE FOR  VERSEEING 
M  
EDICAID 
Daniel R. Levinson 
Inspector General 
OEI-05-15-00050 
June 2017   
Status Update 
 
June 2017 
 
OEI-05-15-00050 
 
Why OIG Did This Review   T-MSIS Data Not Yet Available for Overseeing 
In 2016, the Federal Government  Medicaid 
Key Takeaway 
and States spent $574 billion on 
Medicaid, serving more than  What OIG Found  States and CMS reported 
74 million enrolled individuals.  States and CMS report that early  challenges to States 
Complete, accurate, and timely  implementation challenges have  successfully submitting data 
Medicaid data are vital for the  resulted in delays with T-MSIS.  These  to T-MSIS.  As a result, the 
effective administration and  delays were caused by technological  goal for when all States 
oversight of the Medicaid  problems during data testing and by  would be reporting data has 
program by States and the  competing priorities for States IT  been repeatedly postponed.  
Federal Government.  Historically,  resources.  As a result, the goal for when  States and CMS also reported 
problems with Medicaid data  T-MSIS will contain data from all State  concerns related to the 
have hindered program integrity,  Medicaid programs has been repeatedly  completeness and reliability 
research, budgeting, and policy.   postponed.  Most recently, CMS  of the reported data.    
Consequently, the Office of  indicated that it expects that all States 
 
Inspector General (OIG) has  will be reporting to T-MSIS by the end of 2017. 
designated the improvement of 
As of December 2016, 21 of 53 State programs were submitting data to 
Medicaid data as a top 
T-MSIS.  As States and CMS continue to work together to submit data 
management challenge facing the 
into T-MSIS, they continue to raise concerns about the completeness 
Department of Health and Human 
and reliability of the data; these same concerns were raised in OIGs 
Services.  The Transformed 
2013 review of the T-MSIS pilot.  Specifically, States indicate that they 
Medicaid Statistical Information 
are unable to report data for all the T-MSIS data elements.  
System (T-MSIS) is a new data 
Additionally, even with a revised data dictionary that provides 
system intended to improve the 
definitions for each data element, States and CMS report concerns 
completeness, accuracy, and 
about States varying interpretations of data elements.  If States do not 
timeliness of Medicaid data.   
have uniform interpretations of data elements, the data they submit 
This review provides a status  for these elements will not be consistent across States, making any 
update on the implementation of  analysis of national trends or patterns inherently unreliable.  
T-MSIS, building on OIGs 2013 
Conclusion 
review of the T-MSIS pilot. 
Successfully getting all States data into T-MSIS requires States and CMS 
How OIG Did This Review 
to prioritize T-MSIS implementation.  Because of CMSs history of 
We analyzed the implementation 
delaying target dates for implementation, OIG is concerned that CMS 
status of T-MSIS as of December 
and States will delay further rather than assign the resources needed to 
2016 using 40 States approved 
address the outstanding challenges.  Thus, OIG continues to support 
plans for data submission.  In 
our 2013 recommendation that CMS establish a deadline for when 
addition, we interviewed staff 
T-MSIS data will be available for program analysis and other 
from the Centers for Medicare & 
management functions.  Without a fixed deadline, some States and 
Medicaid Services (CMS) and 
CMS may not make the full implementation of T-MSIS a management 
16 States about their experiences 
priority. 
implementing T-MSIS.   
  The complete report can be found at http://oig.hhs.gov/oei/reports/oei-05-15-00050.asp   
 
 
HHS OIG Status Update  June 2017  OEI-05-15-00050 
 
T-MSIS Data Not Yet Available for Overseeing Medicaid  
BACKGROUND
 
Medicaid is a joint Federal-State health insurance program for low-income and medically needy 
individuals.  In 2016, the Federal Government and States spent $574 billion on Medicaid, 
serving more than 74 million enrolled individuals.  Complete, accurate, and timely Medicaid 
data are vital for the effective joint administration and oversight of the Medicaid program by 
States and the Federal Government.  National Medicaid data are necessary for program 
integrity, assessments of access and quality, budgeting, and policy analyses.1  Inaccurate and 
incomplete data on claims and eligibility inhibit detecting fraud and ensuring that dollars spent 
on Medicaid promote quality and value.   
The Office of Inspector General (OIG) and the Government Accountability Office (GAO) have 
identified problems with missing, inaccurate, and outdated Medicaid data, finding that data 
were not adequate for the oversight of Medicaid programs nationwide.2  Because of these 
problems, OIG has designated the improvement of Medicaid data as a top management 
challenge facing the Medicaid program and the Department of Health and Human Services.3 
The Transformed Medicaid Statistical Information System (T-MSIS) replaces the Medicaid 
Statistical Information System (MSIS) as the national Medicaid dataset.  It is a joint effort by the 
States and the Centers for Medicare & Medicaid Services (CMS) to build a Medicaid dataset that 
addresses identified problems with Medicaid data in MSIS.  This review provides a status 
update on the implementation of T-MSIS.  To perform this review, we collected and analyzed 
information from CMS and States.  Appendix A describes our methodology. 
Purpose of T-MSIS  
The purpose of T-MSIS is to improve the completeness, accuracy, and timeliness of national 
Medicaid data.  Improved national Medicaid data will allow States, the Federal Government, 
and other oversight entities to collaborate and more effectively oversee the Medicaid program.  
CMS intends for T-MSIS to provide States and the Federal Government with a national Medicaid 
                                                           
1 Social Security Act (SSA)  1903(r)(1)(F) as added by the Balanced Budget Act of 1997, P.L. No. 105-33 
 4753(a)(1) and amended by the Patient Protection and Affordable Care Act (ACA), P.L. No. 111-148  6504 to 
include data elements the Secretary determines are necessary for program integrity, oversight, administration. 
2 OIG, MSIS Data Usefulness for Detecting Fraud, Waste, and Abuse, OEI-04-07-00240, August 2009; OIG, Medicaid 
Managed Care Encounter Data: Collection and Use, OEI-07-06-00540, May 2009; GAO, Medicaid Financial 
Management: Steps Taken to Improve Federal Oversight but Other Actions Needed to Sustain Efforts, GAO-06-705, 
June 2006; GAO, Medicaid Financial Management: Better Oversight of State Claims for Federal Reimbursement 
Needed, GAO-02-300, February 2002.  
3 OIG, Top Management and Performance Challenges Facing HHS, 2016.   
  
   
data repository that would, among other functions, support program management, financial 
management, and program integrity.4  States will have the opportunity to use T-MSIS data to 
compare Medicaid program outcomes.  Further, CMS intends for T-MSIS to replace the reports 
that it requires from States, such as reports for the Early Periodic Screening, Diagnosis, and 
Treatment Program.5 
To improve Medicaid program oversight, CMS requires States to submit new files and data 
elements for T-MSIS.  Following consultation with a wide array of stakeholders, CMS 
established over 1,000 data elements for T-MSIS.6  This expands on the approximately 400 data 
elements collected in MSIS.  T-MSIS builds on the original five MSIS files (eligibility and 
four types of claims: inpatient, long-term care, pharmacy, and other) by adding files for 
third-party liability, information from managed-care plans, and providers.   
T-MSIS Implementation Timeline 
T-MSIS Pilot.  CMS piloted T-MSIS with 12 volunteer States starting in 2011.  After the pilot 
ended in 2012, OIG conducted an early implementation review and found that although most 
of the volunteer States made some progress in implementing T-MSIS, CMS and States would 
likely face challenges to making T-MSIS function as intended.7  Early outcomes from the 
implementation of T-MSIS raised questions about whether T-MSIS data would be complete and 
accurate upon national implementation of the system.  None of the 12 volunteer States could 
make data available for all T-MSIS data elements.  Further, both CMS and the 12 States 
expressed concerns about the accuracy of the data that States could provide upon 
implementation.  Finally, OIG also found that CMS had not established a deadline for when 
national T-MSIS data would be available.   
National Implementation of T-MSIS.  In an August 2013 letter to State Medicaid directors, CMS 
indicated that it planned to begin implementing T-MSIS with States on a rolling basis.8  At that 
time, CMSs goal was for all States to be submitting T-MSIS data on a monthly basis by 
July 1, 2014.   
For a timeline of the history of Medicaid data since mandatory submission of data began in 
1997, including the implementation of T-MSIS, see Exhibit 1.   
 
                                                           
4 CMS, State Medicaid Director Letter, August 23, 2013 (SMD #13-004).  Accessed at 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf on December 21, 2016. 
5 Ibid.  
6 The stakeholders were entities internal and external to CMS.  Internal stakeholders included the following: CMSs 
Center for Program Integrity, Center for Medicare and Medicaid Innovation, Financial Management Group, CHIP, 
Division of Pharmacy, and Center for Clinical Standards and Quality.  External stakeholders included OIG.  See OIG, 
Early Outcomes Show Limited Progress for the Transformed Medicaid Statistical Information System, 
OEI-05-12-00610, September 2013. 
7 Ibid. 
8 CMS, State Medicaid Director Letter, August 23, 2013 (SMD #13-004).  Accessed at 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf on December 21, 2016. 
2 
   
Exhibit 1: Timeline of Medicaid Data 
Oct. 2015: All States 
stopped sending MSIS data 
 
Mandatory MSIS  CMS piloted  Aug. 2013: CMS 
Dec. 2015: 
submission began    MSIS Redesign and  announced goal of  CMS released 
MSIS Plus, both efforts  having all States submit 
T-MSIS 2.0  
  to improve Medicaid  T-MSIS data by July 1, 
data  2014 
  Jan. 2017: CMS 
CMS piloted  CMS revised prior  revised prior goal of 
 
T-MSIS with  goal of having all  having all States 
  12 volunteer  States submit  submit T-MSIS data 
  States  T-MSIS data by  by the end of 2017 
Dec. 2015 
 
 
 
1997  2006  2009  2011  2012  2013  2014  2015  2016 & 
  2017 
 
 
 
 
 
  GAO and OIG  Sept. 2013: OIG issued report,  OIG conducts current 
  iwdietnht tifhiee dr eplriaobbilleitmy s  fminaddien gs othmaet  1p2ro vgorleusnst weeitrh S tthaete Ts-  review 
  and completeness of  MSIS pilot, but that data quality 
  MSIS data   concerns remain 
 
Source: OIG summary of CMS documents, relevant laws, and OIG and GAO reports, 2017. 
 
T-MSIS Data Submissions 
A State must complete two concurrent and iterative processes before it may begin submitting 
T-MSIS data to CMS: (1) receive approval of the data submission plan and (2) conduct data 
testing.   
First, to obtain approval of its data submission plan, a State must submit to CMS a plan that 
both identifies the T-MSIS data elements for which the State can submit data upon 
implementation and provides a justification for any data elements for which it cannot submit 
data.  Typically, a State cannot submit data for a particular T-MSIS data element because the 
State does not cover the benefit with which the data element is associated, or because the 
information for the data element is not available in the States data systems.  CMS reviews and 
approves the States data submission plan, and it uses the plan to determine whether the State 
is submitting the data elements it committed to submitting.  
Second, completing data testing involves the transmission of data (to determine whether the 
State and CMS have the technological capacity to send and receive data) and the validation of 
data (to determine if the States data meet specified data requirements).  
3 
   
Once a State receives CMSs approval to submit T-MSIS data and begins making its submissions, 
CMS requires it to catch up on any missing data submissions.  This means that States need to 
submit T-MSIS data dating back to at least October 2015.  States that were not up to date on 
their MSIS submissions will also need to catch up on any months for which they had not 
submitted data previously.    
 
RESULTS 
States reported early challenges that delayed implementation of 
T-MSIS 
States reported a number of challenges that resulted in delays getting their data into T-MSIS.  
A number of technological problems in the first 2 years of T-MSIS national implementation 
hampered the ability of States and CMS to complete data testing.  While CMS stated that these 
technological problems have largely been resolved, States and CMS lost significant time in 
understanding and dealing with these challenges.  States also reported facing competing 
priorities for their IT resources that hampered their T-MSIS progress.   
As a result, CMSs publicly stated goal for when T-MSIS would contain data from all State 
Medicaid programs has been repeatedly postponed.  CMS launched national implementation of 
T-MSIS in August 2013, with an initial goal of having all States begin submitting data by 
July 1, 2014.  Since that time, CMS has moved the date by which it expected that all States 
would be submitting T-MSIS data six additional times.  (See Appendix B for more details about 
these delays.)  Most recently, CMS indicated that it expects that all States will be reporting to 
T-MSIS by the end of 2017.  Throughout this time, CMS has not established a firm deadline for 
State submissions. 
Both the technological problems, which created an early and significant setback, and competing 
data-system priorities, which reduced State resources that could be devoted to implementing 
T-MSIS, help explain how the goal of implementing T-MSIS by 2014 was missed.  Neither should 
continue to present challenges to the States in implementing T-MSIS. 
States reported technological problems with T-MSIS that delayed data testing.  States and 
CMS reported that technological problems, primarily associated with T-MSISs initial design, 
contributed to the initial delays in the successful transmission of States data to T-MSIS.  
Specifically, States staff cited (1) T-MSISs inability to accept files with large amounts of data 
and (2) T-MSISs generation of defective error reports that CMS sent to States.   
 
4 
   
Example of challenge that delayed data testing: One State with a large 
Medicaid populationand thus large amounts of Medicaid datasent only 
smaller subsets of data to complete initial data testing.  However, final data 
testing could not be completed for the State until CMS was able to receive 
the data in their entirety, not as subsets.  
States staff reported that there were delays because the data system that CMS initially 
deployed to receive State Medicaid data could not receive State submissions with large 
amounts of data.  As a result, States and CMS had to focus resources on troubleshooting 
transmission problems related to large files and devising temporary solutions.   
States staff also reported that there were delays because of defective error reports generated 
during data testing.  States must go through numerous testing phases that determine whether 
they and CMS have the technological capacity to send and receive data.  CMS processes the 
States files through its data validation edits and produces error reports for States, requiring 
States to address any errors identified.  However, States said that the reports identified errors 
that were mostly the result of T-MSIS system errors in processing data, not problems with the 
data that States submitted.   
Ultimately, CMS responded to these technological problems by making structural changes to T-
MSIS.  In December 2015, CMS released a new version of T-MSIS: T-MSIS 2.0.  With T-MSIS 2.0, 
CMS increased its data processing capacity enough to allow it to process larger data files.  In 
addition, T-MSIS 2.0 updated the systems data dictionary by consolidating changes to data 
elements, coding requirements, and data validation rules.  CMS staff reported that they shared 
the updated data dictionary with States and informed States of what to expect through a 
national webinar in January 2016.       
Example of challenge that delayed data testing: During data testing, one 
State reported receiving notification of more than a million errors as a result 
of flaws with CMSs data processing.     
While the structural changes addressed the technological problems that States were reporting, 
these changes also caused delays.  Staff from a number of States reported that to ensure 
successful data submissions to T-MSIS 2.0, they had to revise the computer coding needed to 
identify and transmit State data so that it would map correctly to T-MSIS data elements.  These 
delays also included time for additional testing and data verification.  One State estimated that 
accommodating these changes required an additional 4 to 5 months of work.   
States reported competing initiatives that limited their capacity to focus on T-MSIS.  State 
staff reported also facing competing data-system priorities that contributed to delays in their 
progress because they required State staff and resources that were needed for T-MSIS.  At the 
5 
   
same time that the national implementation of T-MSIS began, States began implementing 
a new mandated set of diagnostic codes known as ICD-10.9  States efforts to incorporate the 
new diagnostic codes may have continued through 2015, as the final compliance date for 
implementation was in late 2015.10  In addition, in late 2013 many States began expanding their 
Medicaid programs.  This required States to modify their existing data systems to accommodate 
new Medicaid beneficiary eligibility categories and increased enrollment numbers.  Some States 
reported that their contractors tasked with working on T-MSIS implementation were busy 
managing the priority demands related to expansion.  While these competing priorities help 
explain how implementing T-MSIS was initially delayed, they should no longer present 
challenges to the States.  
 
As of December 2016, 21 States were submitting T-MSIS data 
As of December 2016, more than 2 years after the initial target established by CMS, 21 of 
53 State programs were submitting T-MSIS data after getting their respective plans for data 
submission approved and successfully completing data testing.11  The statuses of the 32 States 
that were not submitting data at that time were mixed.  Nineteen of these States had received 
CMS approval for their plans outlining the T-MSIS data elements for which they could submit 
data, but they had yet to successfully complete data testing.  The remaining 13 States did not 
have CMS-approved data submission plans nor had they successfully completed data testing.   
See Exhibit 2 for the status of each States ability to submit T-MSIS data as of December 2016.  
For a list of the States in each implementation category, see Appendix C.   
   
                                                           
9 45 CFR part 162. 
10 The Protecting Access to Medicare Act of 2014, P.L. No. 113-93 (April 1, 2014),  212. 
11 We included all Medicaid programs and Childrens Health Insurance Programs (CHIPs) that plan to independently 
submit T-MSIS data, except territories.  This included all 50 States, the District of Columbia, and 2 States CHIPs 
(Pennsylvania and Iowa).  The remaining States CHIPs plan to submit data to T-MSIS jointly with their respective 
States Medicaid programs (and are therefore included in our scope of work but not counted as separate entities).  
We refer to the 53 State programs as States in the remainder of this report.   
6 
   
Exhibit 2: Less than one-half of the States are submitting T-MSIS data, December 2016 
Source: OIG analysis of CMS status update, December 2016.  
 
States and CMS recognize that the next challenge is to ensure the 
quality of the data 
As States and CMS continue to work together to submit Medicaid data into T-MSIS, they are 
aware that another challenge awaitsensuring that T-MSIS data are complete and reliable (i.e., 
have the same meaning across States).  OIG raised concerns about the completeness and 
reliability of T-MSIS data in past work.  Specifically, a 2013 OIG report reviewing the T-MSIS 
pilot raised questions about the completeness of T-MSIS data and whether States would collect 
and submit T-MSIS data elements based on a uniform understanding of T-MSIS data element 
definitions.   
Concerns remain about the completeness of T-MSIS data.  States report being able to provide 
data for an average of 82 percent of the T-MSIS data elements (1,197 of 1,458).  Among the 
40 State plans we reviewed, States ranged from one State being able to report 60 percent of 
the data elements to another State that is able to report 96 percent of the data elements.  
States inability to report all data elements means gaps exist in the completeness of national 
data.   
Further, when we compared data elements that all 40 States will be submitting in common, 
only 26 percent of the data elements (380 of 1,458) will be submitted by all States.12 
Additionally concerning is that only one-fourth of the data elements that all 40 States indicated 
they could report in common capture data that are useful in managing the Medicaid program.  
                                                           
12 See Appendix D for the number of data elements that each State plans to submit. 
7 
   
These data are related to a specific beneficiary or provider (e.g., provider billing number) or the 
care of the beneficiary (e.g., diagnosis and drug codes).  The other three-fourths of the 
380 common data elements are designed to describe technical aspects of the data file itself.  
This includes the file name and the date the file was created.  While these data elements are 
essential to managing T-MSIS as a dataset, they do not contain data that are helpful in 
overseeing the Medicaid program, such as data on claims or encounters.   
Concerns remain about the reliability of T-MSIS data.  States and CMS report concerns about 
data reliability.  These concerns are similar to those raised in OIGs 2013 report on the T-MSIS 
pilot.  In that report, States and CMS raised concerns that States interpretations of given data 
elements may not be consistent across States.13  In other words, a State may submit data for 
a given data element that differ in meaning from the data another State submits for the same 
data element.  If States do not have uniform interpretations of data elements, using T-MSIS 
data for analysis of national trends or patterns would lead to unreliable results. 
Specifically, States raised concerns that, as one State put it, the data extracted for T-MSIS may 
not be uniform in all cases.  Each State Medicaid agency maintains an individualized data 
system, which means it must map its State-specific data to T-MSIS data elements.  
Consequently, for uniform data to exist, States must create crosswalks that match the data in 
their systems to the T-MSIS data dictionary.14  As one State put it, the next big challenge for 
ensuring quality Medicaid data is to determine whether the mapping processes for each State is 
resulting in data that are uniform across the States.  Some data sources may be State systems 
outside of States Medicaid agencies or Childrens Health Insurance Program (CHIP) agencies, 
making the process even more difficult. 
Example of T-MSIS reliability concerns: States may have different 
interpretations of the same data element.  For example, CMSs rules for the 
data element on Medicaid paid amount only advise that States report the 
amount paid by Medicaid on the claim.  Some States may interpret this to 
mean the combined amounts paid by the Federal Government and the State 
share, some States may interpret it as just the State share, and others may 
interpret it just as the Federal share.  Differences in interpretation and 
reporting would result in unreliable data for the paid amount.    
                                                           
13 In OIGs 2013 report, we used the term data consistency to refer to issues with data reliability.  See OIG, Early 
Outcomes Show Limited Progress for the Transformed Medicaid Statistical Information System, OEI-05-12-00610, 
September 2013.   
14 The term crosswalks refers to States processes for (1) identifying data that best meet the T-MSIS data 
dictionary definition and (2) transferring that data from their unique State data systems to T-MSIS.     
8 
   
In January 2016, CMS shared with States a revised data dictionary that provided definitions for 
each data element.  However, CMS staff acknowledged that even with this updated dictionary, 
States may vary in their interpretation of data elements.   
In January 2017, CMS announced that to determine whether T-MSIS data are reliable, it is 
convening a Technical Evaluation Panel, composed of Federal and external partners, charged 
with conducting a quality review of T-MSIS data and documenting variation across States for 
future users of T-MSIS data.15  CMS plans to share these quality reviews with users of T-MSIS 
data to ensure that they are aware of how data vary across States and limitations of the data.   
 
CONCLUSION 
A quality national Medicaid dataset is essential to States and the Federal Governments ability 
to effectively and collaboratively administer and ensure the integrity of States Medicaid 
programs and CHIPs.  States, CMS, OIG, and other stakeholders need complete and reliable 
national Medicaid data to ensure that Medicaid and CHIP funds are used appropriately and 
effectively and that beneficiaries receive safe and appropriate care.  For example, CMS plans to 
analyze T-MSIS data to identify trends or patterns, including those that may indicate potential 
fraud, waste, and abuse at a national level.16  Further, States would be able to use T-MSIS data 
to compare program outcomes to help them in making important policy decisions as well as to 
identify instances of fraud, waste, and abuse.17  All this can only be done if the data are 
complete and reliable. 
However, States and CMS reported challenges to States successfully submitting data to T-MSIS 
to create a national Medicaid dataset.  As a result, the goal for when all States would be 
reporting data to T-MSIS has been repeatedly postponed.  CMS launched the national 
implementation of T-MSIS in August 2013, with an initial goal for all States to be submitting 
data by July 2014.  Most recently, CMS indicated that it expects that all States will be reporting 
to T-MSIS by the end of 2017.  Based on the status of implementation as of December 2016, it 
is unclear whether that date can be met. 
Successfully getting all States data into T-MSIS requires States and CMS to prioritize T-MSISs 
implementation.  Because of CMSs history of delaying implementation target dates, OIG is 
concerned that CMS and States will continue to delay rather than assign the resources needed 
to address the outstanding challenges by the deadline.  Without a fixed deadline, some States 
and CMS may not make the full implementation of T-MSIS a management priority.  OIG 
                                                           
15 CMS, State Medicaid/CHIP Data Sharing Fact Sheet, January 17, 2017.  Accessed at 
https://www.medicaid.gov/medicaid/data-and-systems/downloads/collection-systems/tmsis-fact-sheet.pdf on 
January 27, 2017. 
16 CMS, State Medicaid Director Letter, August 23, 2013, (SMD #13-004).  Accessed at 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf on December 21, 2016. 
17 CMS, State Medicaid/CHIP Data Sharing Fact Sheet, January 17, 2017.  Accessed at 
https://www.medicaid.gov/medicaid/data-and-systems/downloads/collection-systems/tmsis-fact-sheet.pdf on 
January 27, 2017. 
9 
   
continues to support our 2013 recommendation that CMS establish a deadline for when T-MSIS 
data will be available for program analysis and other management functions.  
Getting all of the States to submit data to T-MSIS is not the only challenge.  Concerns about the 
completeness and reliability of the data remain.  Data must be complete and reliable to be of 
use to States, CMS, and other stakeholders.   
In 2013, OIG reported that early outcomes from the implementation of T-MSIS raised questions 
about the completeness and accuracy of T-MSIS data.  We found that none of the 12 volunteer 
States could make data for all T-MSIS data elements available and that CMS and States 
expressed concerns about the accuracy of the data they could provide upon implementation.  
Consequently, we recommended that CMS improve the completeness and accuracy of the data.  
In response, CMS established standards for the completeness, accuracy, and timeliness of 
T-MSIS data; created a set of data validation rules to govern the submission of T-MSIS data; and 
created a data oversight strategy and model for providing stakeholders with transparency on 
findings and data quality issues.  Therefore, OIG considered the recommendation to be 
implemented.  Yet disappointingly, despite these efforts, there are still concerns about the 
completeness and reliability of the data.   
Given the enormous potential that a national Medicaid database holds for States, CMS, and 
other oversight entities to manage the program and stop fraud, waste and abuse, OIG remains 
committed to monitoring States and CMSs implementation of T-MSIS until complete, accurate, 
and timely national Medicaid data are available.   
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE  
CMS provided formal comments on our draft report in June 2017.  CMS reported that since 
December 2016, more States have successfully started submitting data to T-MSIS.  CMS 
reported that 40 States and Pennsylvania CHIP are submitting T-MSIS data.  CMS indicated that 
these States represent 92 percent of the Medicaid and CHIP population.   
While CMS and States have made progress on the number of States submitting data to T-MSIS, 
CMS agreed with OIG on the need for reliable Medicaid and CHIP data.  In its comments, CMS 
emphasized its ongoing work to improve data quality.  CMS indicated that it has two major 
goals for T-MSIS data quality:  1) transparency for users, and 2) a continuous, ongoing 
improvement process with States to strengthen the quality of the data over time.  To achieve 
these two goals, CMS indicated that it is undertaking a variety of actions, including information 
for users on data quality, one-on-one technical assistance to States to ensure their data will be 
usable, and a post-production data quality review with a subset of States to develop an 
effective working process for improving data quality.   
CMS also highlighted the convening of a Technical Evaluation Panel to obtain initial feedback on 
data quality and usability.  CMS reported that the panel assessed a subset of T-MSIS data to 
identify anomalies in the data and potential challenges with using the data for analysis.  CMS 
10 
   
plans to use the panels findings to inform efforts to improve data quality across States and for 
specific States.   
OIG welcomes CMSs ongoing efforts and looks forward to when all States are reporting data 
that are complete, reliable, and timely.  OIG also looks forward to using this data to promote 
improved efficiency and effectiveness in the Medicaid program as well as protect the program 
and its patients from harm and potential fraud.  
For the full text of CMSs response, see Appendix E.    
 
 
11 
   
Appendix A: Methodology
 
This review determined the status of T-MSIS implementation as of December 2016.   
Scope 
This inspection was national in scope, including all 50 States and the District of Columbia.  As of 
December 2016, two StatesIowa and Pennsylvaniawere planning to submit their monthly 
Medicaid and CHIP data to CMS as two separate data submissions.18  For these States, we 
reviewed the States ability to submit Medicaid and CHIP data separately.  The remaining States 
are planning to submit Medicaid and CHIP data as one data submission.  Overall, we reviewed 
the implementation status of 53 State data submissions.  
Data Sources and Collection 
Data Request to CMS.  We requested documents and data from CMS, including: 
  CMS status updates: Updates from CMS about States progress on data submission 
plans, data testing, and data submission.  We received status updates between 
September 2015 and December 2016.     
  T-MSIS data dictionary: Document containing the names, definitions, and format for the 
1,458 data elements in T-MSIS.  We received the T-MSIS data dictionary version 2.0 
(dated November 2015) in February 2016.    
  States approved data submission plans: Plans, approved by CMS, consisting of the 
T-MSIS data elements for which States planned to submit data when they began 
submitting T-MSIS data.19  We received 40 approved plans between September 2015 
and December 2016.   
  States justifications for T-MSIS data elements for which they cannot submit data: As 
part of States approved data submission plans, they must submit a list of the elements 
for which they cannot always submit data and their justifications for not doing so.  
Some, but not all, States provided detailed justifications and plans of action and goals 
for when they can submit data for such data elements.  We received these documents in 
October 2015.   
Structured Interviews with CMS.  We conducted structured interviews with CMS staff 
responsible for T-MSIS implementation and staff who will use the data.  Specifically, we 
interviewed CMS staff from the Data and Systems Group, Office of Enterprise Information, 
Office of Communications, Office of Technological Solutions, Center for Program Integrity, 
Center for Medicare and Medicaid Innovation, Office of the Actuary, and Office of Enterprise 
Data and Analytics.  We asked questions about the progress and status of the national 
implementation of T-MSIS, including any challenges or reasons for delay.  As part of these 
                                                           
18 States can design their CHIP program in one of three ways: (1) via Medicaid expansion, (2) as a separate CHIP, or 
(3) as a combination of the two approaches.  A States design for its CHIP program can influence whether it submits 
its Medicaid and CHIP data separately or together.  Accessed at https://www.medicaid.gov/chip/state-program-
information/chip-state-program-information.html on March 27, 2017. 
19 Over time, States may be able to begin submitting T-MSIS data elements that they are unable to submit initially. 
12 
   
interviews, we asked them about any concerns they had about T-MSIS data, including their 
ability to receive and use it.  We conducted these interviews from December 2015 to 
February 2016.    
Structured Interviews with Selected States.  We selected 16 States to interview from 3 different 
groups representing different phases of T-MSIS implementation.  To do this, we first divided 
States into three groups according to their respective statuses for T-MSIS implementation as of 
October 2015: (1) States that were submitting T-MSIS data, (2) States that had approved data 
submission plans, and (3) States without approved data submission plans.  At the time we 
selected States, only two States were in group one and we selected both of them.  We selected 
eight States from group two and six States from group three.  We selected Arizona, Arkansas, 
California, Georgia, Florida, Illinois, Massachusetts, Michigan, New Jersey, New York, North 
Carolina, Ohio, Pennsylvania, Texas, Virginia, and Washington.20  We did not select these groups 
to compare progress and challenges by group.  Instead, we selected these groups to ensure 
representation from different phases of T-MSIS implementation.   
We considered a number of additional factors when selecting States, including Medicaid 
population, Medicaid expenditures, care delivery model (managed care or fee-for-service), and 
Medicaid expansion status.  Our approach to selecting States did not allow us to project the 
results. 
In general, the interviews focused on the steps that States took to implement T-MSIS and the 
challenges they faced.  For the first two groups, we asked States how they overcame challenges 
they faced.  For the third group, we asked what they needed to solve any challenges.  In 
addition, we asked States about their perspectives on any future challenges or concerns about 
T-MSIS as a whole.  We conducted these interviews in November and December 2015.  We 
conducted additional followup with some States in February 2016. 
Data Analysis 
Determining Completeness of T-MSIS Data.  For each State, we determined the number of 
T-MSIS data elements for which the State planned to submit data.  We compared the data 
elements listed in each States data submission plan to the list of all T-MSIS data elements.  We 
also determined the number of data elements for which all 40 States planned to submit data.    
Determining CMS and State Challenges with T-MSIS Implementation.  We reviewed CMSs and 
States interview responses to determine the challenges that CMS and States faced with T-MSIS 
implementation.  We identified similar implementation challenges cited by both CMS and 
States.  We also identified challenges that CMS and States raised as concerns for the future.   
Limitations 
The CMS-approved data submission plans that we analyzed represent an agreement with CMS 
as to the data States will submit and were based on the best available information about the 
T-MSIS data that States will eventually submit.  However, because T-MSIS data were not 
available for our review, we could not determine whether the national T-MSIS dataset will 
                                                           
20 The 16 States represented 68 percent of fiscal year 2014 Medicaid expenditures and 70 percent of Medicaid 
enrollment as of July 2015. 
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contain all of the data States indicated would be submitted to T-MSIS in their approved data 
submission plans.  
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.   
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Appendix B: Delays in T-MSIS Implementation Goals
 
1.  All States will submit T-MSIS data by January 1, 2014. 
  Presented by CMS staff in August 2012 at the Medicaid Enterprise Systems 
Conference 
2.  All States will submit T-MSIS data by July 1, 2014. 
  August 2013 letter to State Medicaid Directors21 
3.  All States will submit T-MSIS data in 2015. 
  Department of Health & Human Services Agency Financial Report: Fiscal Year 2014, 
issued in November 201422 
4.  All remaining States will submit data in the T-MSIS file format in fiscal year 2016. 
  Department of Health & Human Services Agency Financial Report: Fiscal Year 2015, 
issued in November 201523 
5.  Most, if not all States and territories, will transition from MSIS to T-MSIS throughout 2016.  
T-MSIS data will be made public to States and stakeholders via different data products 
toward the end of 2016. 
  CMS website, accessed in July 201624 
6.  All States will submit T-MSIS data by late summer 2017. 
  CMS communication in response to official OIG questions, December 22, 2016 
7.  Most, if not all States and territories, will transition from MSIS to T-MSIS throughout 2017.  
T-MSIS data will be made public to States and stakeholders via different data products in 
2017. 
  CMS website, accessed in January 201725 
   
                                                           
21 CMS, State Medicaid Director Letter, August 23, 2013 (SMD #13-004).  Accessed at 
http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-004.pdf on December 21, 2016. 
22 Department of Health and Human Services, HHS Agency Financial Report: FY 2014, November 2014.  Accessed at 
http://www.hhs.gov/sites/default/files/afr/fy2014-agency-financial-report-final.pdf on September 13, 2016. 
23 Department of Health and Human Services, Fiscal Year 2015: Agency Financial Report, November 2015.  
Accessed at https://www.hhs.gov/sites/default/files/afr/fy-2015-hhs-agency-financial-report.pdf on September 
13, 2016. 
24 CMS, Medicaid and CHIP Data Collection Systems.  Accessed at https://www.medicaid.gov/medicaid/data-and-
systems/collection-systems/index.html on December 21, 2016.   
25 CMS, Medicaid and CHIP Data Collection Systems.  Accessed at https://www.medicaid.gov/medicaid/data-and-
systems/collection-systems/index.html on January 10, 2017.   
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Appendix C: Status of States Ability To Submit T-MSIS Data as of 
December 2016 
States that had begun submitting data, i.e., they had approved data submission plans and 
finished data testing: 
1.  Alabama 
2.  Arkansas 
3.  Colorado 
4.  Connecticut 
5.  Delaware 
6.  District of Columbia  
7.  Florida 
8.  Georgia 
9.  Illinois 
10. Nevada 
11. New Hampshire 
12. North Carolina 
13. Ohio  
14. Oklahoma 
15. Pennsylvania 
16. Pennsylvania CHIP 
17. Rhode Island 
18. South Carolina 
19. Tennessee 
20. Virginia 
21. Washington 
 
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States that were not submitting data and had approved data submission plans but had not 
completed data testing: 
1.  Alaska 
2.  Arizona 
3.  Indiana 
4.  Iowa 
5.  Kentucky 
6.  Louisiana 
7.  Maine 
8.  Massachusetts 
9.  Michigan 
10. Mississippi 
11. Missouri 
12. Montana 
13. Nebraska 
14. New Mexico 
15. Oregon 
16. Texas 
17. Vermont 
18. West Virginia 
19. Wisconsin 
 
States that were not submitting data, did not have approved data submission plans, and had 
not completed data testing: 
1.  California 
2.  Hawaii 
3.  Idaho 
4.  Iowa CHIP 
5.  Kansas 
6.  Maryland 
7.  Minnesota 
8.  New Jersey 
9.  New York 
10. North Dakota 
11. South Dakota 
12. Utah 
13. Wyoming 
 
 
 
   
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Appendix D: Number of T-MSIS Data Elements That Each of the 
40 States Planned To Submit 
Number of T-MSIS data 
State 
elements 
New Hampshire                 1,403  
Michigan  1,398 
West Virginia                 1,374  
North Carolina                 1,365  
Tennessee                 1,338  
Mississippi                 1,301  
Alaska  1,292 
Oklahoma                 1,274  
Iowa                 1,268  
New Mexico  1,264 
Arkansas                 1,263  
Connecticut                 1,262  
Massachusetts  1,256 
Oregon  1,256 
Delaware                 1,246  
Pennsylvania                 1,246  
Kentucky                 1,243  
Georgia                 1,241  
Ohio                 1,226  
Virginia                 1,220  
Nevada                 1,219  
Arizona                 1,218  
Florida                 1,217  
Louisiana  1,211 
Wisconsin  1,201 
Alabama                 1,195  
District of Columbia   1,190 
Illinois                 1,176  
Indiana                 1,161  
Maine                 1,159  
Continued    
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Number of T-MSIS data 
State 
elements 
Colorado                 1,148  
Missouri                 1,120  
Rhode Island                 1,119  
Pennsylvania CHIP                 1,055  
Washington                 1,044  
South Carolina                 1,031  
Nebraska                 1,004  
Montana                                   892  
Vermont  883 
Texas                                   882  
Source: OIG analysis of 40 States T-MSIS data submission plans, 2016.   
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APPENDIX E:  Agency Comments  
 
 
20 
   
21 
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Thomas F. Komaniecki, Regional Inspector 
General for Evaluation and Inspections in the Chicago regional office; Laura Torres Kordish, 
Deputy Regional Inspector General; and Kelly Waldhoff, Deputy Regional Inspector General.  
Nicole Hrycyk served as the team leader for this study, and Jonathan Jones served as the lead 
analyst.  Other Office of Evaluation and Inspections staff from the Chicago regional office who 
conducted the study include Nicholas Walker-Craig and Melissa Whitney.  Central office staff 
who provided support include Clarence Arnold, Kevin Manley, and Christine Moritz.  
22