Evidence record
Medicaid Managed Care: CMS’s Accuracy Check Process For State-Submitted MLR Data Has Limitations
- Publishing agency
- Centers for Medicare & Medicaid Services
- Publication date
- September 2026
- Source record
- Metadata record
Findings
6
Recommendations
3
Overall conclusion
CMS’s oversight of State-submitted Medicaid MLR data has limitations due to reliance on optional data elements and lack of internal communication; while CMS has taken steps such as releasing an MLR Toolkit, implementing a web-based submission portal, and making MLR data public, the 2019 testing identified potential inaccuracies and missed follow-ups, indicating a need for enhanced procedures and internal sharing to improve data accuracy for capitation rate development.
Scope
Scope: This audit evaluated CMS's oversight activities to verify State-submitted MLR data accuracy, focusing on 2019 MLR reporting year with 595 final MLR summary reports from 44 States, and follow-up practices; data sources included CMS's five accuracy checks and CMS follow-up on missing data, with data requests spanning December 2023.
Findings (6)
Each finding has a stable link.
- F-1448
CMS’s accuracy checks of the four required MLR data elements were limited because states often did not submit optional MLR data elements, preventing CMS from conducting the checks for more than half of the final MLR summary reports.
- F-1449
CMS did not follow up with states that submitted potentially inaccurate MLR data.
- F-1450
Results of CMS’s accuracy checks were not shared across CMS staff responsible for reviewing capitation rates, limiting use of findings to inform rate development.
- F-1451
For the 2019 MLR reporting year, CMS identified 57 MLR summary reports with potential inaccuracies submitted by 16 states.
- F-1452
Potential inaccuracies identified included 23 MLR numerators, 15 MLR denominators (Check 1), 18 MLR denominators (Check 2), and 1 adjusted MLR.
- F-1453
About 25% of the 595 MLR summary reports could not be matched to the Enrollment Report, so CMS could not perform the Member Months Check; among the matched reports, 25 had potentially inaccurate member months.
Recommendations (3)
- R-1295
Establish procedures that outline the steps to address potentially inaccurate Medicaid MLR data submitted by States and follow up with States, as needed.
Related finding F-1449 - R-1296
Ensure that insights from CMS’s reviews of State-submitted Medicaid MLR data are communicated to CMS staff responsible for reviewing capitation rates.
Related finding F-1450 - R-1297
Improve the efficiency and effectiveness of CMS’s oversight of the accuracy of State-submitted Medicaid MLR data.
Related finding F-1448