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Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

DETERMINING IF 

CHILDREN CLASSIFIED AS 

SCHIP MEDICAID 

EXPANSION MEET 

ELIGIBILITY CRITERIA 

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. 
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Δ EXECUTIVE SUMMAR 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 Children’s 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 State’s 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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EXE CUTIVE S U MMAR Y 

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 Carolina’s 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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EXE CUTIVE S U MMAR Y

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 OIG’s 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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EXE CUTIVE S U MMAR Y 

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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Δ T ABLE OF CONTENTS 

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

INTR O D U C T I O N .........................................................................................1 

FINDI NGS .....................................................................................................9 

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

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

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

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

RECOM M E NDATI O N 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 

ACKN O W LEDGMENTS ...........................................................................30 
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Δ INTRODU C TION 

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 Children’s 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 America’s 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 State’s 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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INTROD UCT ION 

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 Children’s Eligibility for Medicaid Expansion 

States’ Medicaid-expansion criteria are broadly based on factors such as 

household composition,

4 the family’s countable income, and the child’s 

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 family’s income cannot 

exceed.

7 The upper and lower income limits for Medicaid expansion 

vary by State. See Figure 1 for an example of one State’s income 

eligibility guidelines. 

Figure 1: Example of State Eligibility Guidelines 

100% FPL 

133% FPL 

150% FPL 

185% FPL 

1 year 6 years 19 years 

Medicaid-expansion 

Eligibility 

Medicaid Eligibility 

Exceeds Eligibility 

child's 

age 

To determine a family’s countable income, States first determine the 

family’s 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 child’s 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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INTROD UCT ION 

disregards are subtracted from the family’s gross income to arrive at the 

family’s 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 family’s countable income and the household composition are then 

used to determine what percentage of the FPL the family’s countable 

income represents. If the family’s countable income falls within the 

Medicaid-expansion eligibility range that the State established for the 

child’s age group, the child is determined to be income-eligible for 

Medicaid expansion. 

Redeterminations 

Federal regulations require that States redetermine an enrolled child’s 

eligibility at least every 12 months.8 In general, to redetermine a child’s 

eligibility, the State collects information on the family’s income, the 

child’s age, the household composition, and any other factors that affect 

a child’s 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 applicant’s 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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INTROD UCT ION

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 family’s 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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INTROD UCT ION 

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 State’s 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 State’s 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 State’s 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 family’s gross income prior to any income disregards; 

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INTROD UCT ION 

o family’s countable income after any income disregards (calculated 

by OIG based on the case-file documentation, as well as the 

caseworker’s calculation, when this figure was available); and 

o the FPL percentage represented by the family’s countable income 

(calculated by OIG based on case-file documentation, as well as 

the caseworker’s 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 State’s 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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INTROD UCT ION 

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 Medicaidexpansion populations that we later discovered included children who 

were actually enrolled in traditional Medicaid. Also, the Medicaidexpansion 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 President’s Council on Integrity 

and Efficiency. 

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Δ FINDINGS 

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 Medicaidexpansion 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 child’s eligibility. 

o The caseworker used an incorrect income input screen when 

entering this child’s case into the State’s 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 family’s income correctly in the 

State’s 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 family’s income cannot exceed. If a family’s 

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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F I NDING S 

One of these three errors was caused by the caseworker making an 

incorrect calculation. One error was the result of a problem in the 

State’s 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. 

For 10 percent of sampled children, States 

could not support their Medicaid-expansion 

eligibility determinations 

Federal regulation 42 CFR 

§ 435.913(a) requires States to 

include in each applicant’s case 

record facts to support the 

determination of eligibility, and 42 CFR § 435.916(a) requires that 

States redetermine each enrolled child’s 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 children’s 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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F I NDING S 

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 family’s 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 family’s 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 family’s 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 caseworker’s 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. 

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 for Medicaid expansion in their State. Michigan’s 

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 Carolina’s 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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Δ RECOMME NDA TIONS 

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 Medicaidexpansion 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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R E C O MMENDA T I O N S 

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 OIG’s 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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ΔA G E N C Y CO MMENT S APPENDIX ~ APPENDIX ~ A A 

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 

Enrollment 

[ [ [ NR [ [ [ [ , [ [ [ [ [ , 

Redetermination 

Information 

Verified Same as 

at Enrollment 

[ NR [ NR [ [ [ [ NR [ [ [ [ [ , 

Eligibility 

Determinations 

Reviewed for 

Accuracy 

[ [ [ [ [ [ [ [ , [ [ [ [ [ [ 

Children Identified 

Through State 

Reviews as 

Incorrectly 

Enrolled 

, , NR , , NR [ , NR [ [ , , [ , 

Key 

[ Indicates State’s response was Yes 

, Indicates State’s response was No 

NR Indicates State did not respond 

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APP E N D I X ~A 

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 

Enrollment 

[ [ [ , [ [ [ [ [ NR [ [ [ NR [ 

Redetermination 

Information 

Verified Same as 

at Enrollment 

NR NR NR NR NR [ [ [ [ [ [ [ NR [ [ 

Eligibility 

Determinations 

Reviewed for 

Accuracy 

[ [ [ [ [ [ [ [ [ [ [ [ [ [ [ 

Children Identified 

Through State 

Reviews as 

Incorrectly 

Enrolled 

, , , [ , [ , NR , , [ , [ , , 

Key 

[ Indicates State’s response was Yes 

, Indicates State’s response was No 

NR Indicates State did not respond 

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Δ APPENDIX ~ B 

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. 

State 

Reported 

Expansion 

Population 

Expansion 

Sample 

Percent of 

Sample 

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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Δ APPENDIX ~ C 

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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APP E N D I X ~C 

Source: OIG worksheet used in case review. 

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Δ APPENDIX ~ D 

Children With Family Income Below States’ Eligibility Guidelines for 

Medicaid Expansion 

Age Range 

Federal Poverty 

Level Range* Income Range 

Case 1 

State Guidelines 6 - 19 100% - 133% $2,021.67 - $2,688.82 

Family 

(6 members total) 

Child is 9 

years old 69% $1,393.46 

The caseworker multiplied one parent’s daily wage by 5 days to calculate 

weekly wages, but the parent only worked 2 days per week. 

Case 2 

State Guidelines 0 - 5 133% - 200% $1,664.72 - $2,503.33 

Family 

(3 members total) 

Child is 5 

years old 16% $209.00 

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. 

Case 3 

State Guidelines 1 - 5 133% - 185% $1,664.72 - $2,315.58 

Family 

(3 members total) 

Child is 2 

years old 72% $906.00 

When the caseworker input one parent’s income in the State eligibility system, 

the caseworker incorrectly specified that it was paid weekly instead of biweekly. Therefore, the system calculated the family’s monthly income at twice 

the rate it should have been, making the child appear to be eligible under 

Medicaid-expansion criteria. 

Case 4 

State Guidelines 0 - 18 100% - 200% $2,899.16 - $5,798.33 

Family

 (7 members total) 

Child is 15 

years old 88% $2,574.28 

The caseworker used an incorrect income input screen when entering this case 

into the State’s eligibility system, resulting in the child being assigned an 

eligibilty code that indicated eligibility under Medicaid-expansion criteria. 

Case 5 

State Guidelines 6 - 18 100% - 133% $1,533.33 - $2,039.33 

Family 

(4 members total) 

Child is 15 

years old 0% $0 

State Guidelines 6 - 19 100% - 185% $1,765.00 - $3,265.25 

Case 6 Family 

(5 members total) 

Child is 9 

years old 53% $950.00 

In cases 5 and 6, the caseworkers redetermined the children’s eligibility without 

considering the changes in the families’ incomes that had occurred. When the 

changes in income were brought to the State’s attention, the children were 

discovered to be eligible for traditional Medicaid. 

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Case 7 

State Guidelines 6 - 19 100% - 185% $1,271.67 - $2,352.58 

Family 

(3 members total) 

Child is 15 

years old 81% $1,034 

The caseworker recorded $1,000 in earned income for one parent who had no 

income, and incorrectly recorded the other parent’s income as being from selfemployment. 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.) 

Case 8 

State Guidelines 1 - 6 133% - 185% $1,323.35 - $1,840.75 

Family 

(2 members total) 

Child is 3 

years old 123% $1,222.00 

The caseworker did not record the family’s income correctly in the State’s 

eligibility system, resulting in the system assigning a code to the child indicating 

eligibility under Medicaid-expansion criteria. 

Case 9 

State Guidelines 6 - 19 100% - 150% $1,533.33 - $2,300.00 

Family 

(3 members total) 

Child is 7 

years old 21% $270.00 

State Guidelines 6 - 19 100% - 150% $1,010.00 - $1,515.00 

Case 10 Family 

(2 members total) 

Child is 10 

years old 97% $980.00 

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. 

Case 11 

State Guidelines 6 - 19 100% - 150% $1,533.33 - $2,300.00 

Family 

(4 members total) 

Child is 13 

years old 89% $1,368.20 

State Guidelines 6 - 19 100% - 150% $1,533.33 - $2,300.00 

Case 12 Family 

(4 members total) 

Child is 18 

years old 0% $0 

State Guidelines 6 - 19 100% - 150% $1,533.33 - $2,300.00 

Case 13 Family 

(1 member total) 

Child is 17 

years old 7% $53.75 

State Guidelines 1 - 5 0% - 133%† $0 - $1,691.32 

Case 14 Family 

(3 members total) 

Child is 1 

year old 45% $572.00 

State Guidelines 6 - 18 0% - 100%† $0 - $748.33 

Case 15 Family 

(1 member total) 

Child is 11 

years old 56% $422.00 

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Case 16 

State Guidelines 6 - 18 100% - 200% $1,508.00 - $3,016.67 

Family 

(4 members total) 

Child is 13 

years old 93% $1,426.00 

State Guidelines 6 - 18 100% - 200% $1,795.00 - $3,590.00 

Case 17 Family 

(5 members total) 

Child is 16 

years old 86% $1,520.00 

State Guidelines 6 - 18 100% - 133% $1,533.33 - $2,039.33 

Case 18 Family 

(4 members total) 

Child is 7 

years old 72% $1,098.94 

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. 

Case 19 

State Guidelines 1 - 5 133% - 150% $2,347.45 - $2,647.50 

Family 

(5 members total) 

Child is 5 

years old 107% $1,887.00 

State Guidelines 6 - 18 100% - 150% $1,271.67 - $1,907.50 

Case 20 Family 

(3 members total) 

Child is 7 

years old 59% $761.40 

State Guidelines 6 - 17 114% - 150% $1,719.12 - $2,262.50 

Case 21 Family 

(4 members total) 

Child is 8 

years old 0% $0.00 

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 Medicaidexpansion 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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Δ APPENDIX~E 

Children With Family Income Above States’ Eligibility Guidelines for 

Medicaid Expansion 

Age Range 

Federal Poverty 

Level Range* Income Range 

Case 1 

State Criteria 6 - 18 100% - 200% $1,251.67 - $2,503.33 

Family 

(3 members total) 

Child is 6 

years old 345% $4,325.00 

The caseworker mistakenly counted the family’s income for one month over a 

two month period, making it appear that the family’s income was half of what it 

actually was. 

Case 2 

State Criteria 0 - 5 133% - 200% $1,664.72 - $2,503.33 

Family 

(3 members total) 

Child is 1 

year old 222% $2,784.00 

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. 

Case 3 

State Criteria 6 - 18 100% - 200% $995.00 - $1,990.00 

Family 

(2 members total) 

Child is 15 

years old 255% $2,545.00 

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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Δ ACKNOWLEDGMENTS 

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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