Evidence record
Medicaid Managed Care: CMS’s Accuracy Check Process For State-Submitted Medical Loss Ratio Data Has Limitations
- Audit organization
- Office of Inspector General, U.S. Department of Health and Human Services
- Publication date
- September 21, 2026
- Source record
- Original document linked
Findings
3
Recommendations
3
Overall conclusion
The OIG identified limitations in CMS's process to verify State-submitted Medicaid MLR data and recommended procedures to address inaccuracies, with CMS concurring.
Scope
Evaluation of CMS's process to verify the accuracy of State-submitted Medicaid Medical Loss Ratio data, including the limited accuracy checks, follow-up actions, and cross-staff communication, as described in the report text.
Findings (3)
Each finding has a stable link.
- F-1417
CMS performed only limited accuracy checks on the four required MLR data elements, and those checks showed that some State-submitted MLR data may be inaccurate.
- F-1418
CMS did not follow up with States that submitted potentially inaccurate MLR data.
- F-1419
Results of MLR accuracy checks were not shared across CMS staff, limiting the ability to inform capitation-rate reviews.
Recommendations (3)
- R-1274
CMS should establish procedures that outline the steps to be taken to address potentially inaccurate Medicaid MLR data submitted by States and follow up with States, as needed.
Related finding F-1418 - R-1275
CMS should ensure that insights from its reviews of State-submitted Medicaid MLR data are communicated to CMS staff responsible for reviewing plans’ capitation rates.
Related finding F-1419 - R-1276
CMS should improve the efficiency and effectiveness of its oversight of the accuracy of State-submitted Medicaid MLR data.
Related finding F-1417