Medicaid Monitor

Policy Intelligence

Medicaid Monitor

Policy Intelligence

Updated Fri 12:06 PM MT

© 2026 Lanphier Ventures, LLC
Informational use only. Not legal or compliance advice.

Source

← All Sources

OIG Reports

19 stories

Legal·SC·1d ago

OIG Finds SC Underreported $108.6M in Medicaid COVID FMAP Collections

HHS OIG found that South Carolina failed to report approximately $108.6 million of the federal share of Medicaid and CHIP collections subject to the temporary increased FMAP authorized during the COVID-19 public health emergency. The finding stems from an audit examining whether the state properly identified and returned collections tied to the enhanced federal match rate. The report affects South Carolina's Medicaid agency, which will likely need to refund the unreported federal share to CMS and correct its reporting processes. The audit underscores broader compliance risk for states that received the temporary FMAP bump and must accurately reconcile collections against the higher match rate.

Legal·WI·1d ago

OIG Finds Wisconsin May Have Misclaimed $455M in School Medicaid Funds

The HHS Office of Inspector General reports that Wisconsin may have improperly claimed $455 million in federal Medicaid reimbursement for its school-based services program. The finding affects the state Medicaid agency and school districts that bill Medicaid for services delivered to eligible students, as OIG's audit identifies claims that did not meet federal reimbursement requirements. The report does not specify a comment deadline but signals likely recoupment action and corrective-action requirements from CMS. The audit underscores recurring compliance risk in state school-based Medicaid billing programs nationally.

Legal·GA·5d ago

OIG Reviews Georgia Medicaid Fraud Control Unit's 2024 Operations

HHS OIG conducted its periodic onsite inspection of Georgia's Medicaid Fraud Control Unit, evaluating the unit's caseload, staffing, training, and compliance with federal performance standards for 2024. Medicaid Fraud Control Units investigate and prosecute provider fraud and patient abuse or neglect in Medicaid-funded facilities, and OIG's inspections assess whether states are meeting federal operational and reporting requirements. The report covers findings and any recommendations for Georgia's unit as of the 2024 review period. State Medicaid agencies and program integrity stakeholders use these reports to benchmark fraud unit performance and identify operational gaps.

Legal·TN·8d ago

OIG Finds Tennessee Improperly Claimed Millions in Federal Medicaid Reimbursement for Targeted Case Management

The HHS Office of Inspector General determined that Tennessee claimed federal Medicaid reimbursement for targeted case management services that failed to meet federal and state requirements. The audit identified millions of dollars in improper payments during the review period. Tennessee must repay the improper federal share and strengthen its oversight of targeted case management claims to ensure compliance with Medicaid program requirements. The finding underscores OIG's ongoing scrutiny of state compliance with service-specific billing standards and federal claiming accuracy.

Federal Policy·9d ago

OIG Finds CMS Medical Loss Ratio Data Validation Process for Medicaid MCOs Has Gaps

The HHS Office of Inspector General found that CMS's process for verifying the accuracy of medical loss ratio data submitted by states for Medicaid managed care organizations has limitations that may affect oversight. The report identifies weaknesses in how CMS validates state-reported MLR data used to determine whether MCOs meet federal standards requiring at least 85% of capitation payments go toward medical care and quality improvement. OIG's findings affect CMS's ability to ensure compliance with MLR requirements and identify MCOs that may owe remittances to states. The report matters for state Medicaid agencies responsible for collecting and reporting MLR data and for managed care plans subject to MLR requirements and potential remittance obligations.

Legal·NY·10d ago

OIG Finds New York Made Unallowable Capitation Payments for Incarcerated Enrollees

The HHS Office of Inspector General determined that New York made unallowable managed care capitation payments on behalf of incarcerated Medicaid enrollees. Federal law prohibits federal Medicaid funding for services provided to incarcerated individuals, with limited exceptions for inpatient hospital care. The audit findings indicate the state made capitation payments to managed care organizations for enrollees who were incarcerated during the coverage period. OIG recommendations typically require states to refund the federal share of identified overpayments and implement corrective actions to prevent future unallowable payments.

Legal·CT·11d ago

OIG Finds Connecticut DDS Failed to Monitor HCBS Waiver Compliance for Home Support Services

The HHS Office of Inspector General found that Connecticut's Department of Developmental Services did not ensure providers of individualized home support services fully complied with federal waiver requirements and state health and safety standards. The audit identified gaps in state oversight, including inadequate monitoring of service delivery, health and safety protocols, and provider compliance with waiver terms. OIG recommended that Connecticut strengthen oversight mechanisms to ensure providers meet federal Home and Community-Based Services waiver requirements. The findings highlight enforcement gaps that could affect beneficiary health and safety and federal waiver compliance.

Legal·NC·16d ago

OIG Finds North Carolina Medicaid Fraud Control Unit Compliant in 2025 Inspection

The HHS Office of Inspector General conducted an onsite inspection of North Carolina's Medicaid Fraud Control Unit in 2025 and found the unit in compliance with federal certification standards. The inspection reviewed the unit's investigative capacity, case management procedures, staffing levels, and coordination with state Medicaid agencies and law enforcement partners. MFCU certification is required for states to receive federal matching funds for fraud control activities. The findings confirm North Carolina maintains adequate resources and protocols to investigate and prosecute Medicaid provider fraud and beneficiary abuse.

Legal·AL·19d ago

OIG Inspects Alabama Medicaid Fraud Control Unit Operations in 2025

The HHS Office of Inspector General conducted an inspection of Alabama's Medicaid Fraud Control Unit in 2025. These periodic inspections assess MFCU compliance with federal certification standards, including case management, staffing, prosecution capabilities, and coordination with state Medicaid agencies. The inspection reviewed the unit's investigative procedures, conviction rates, and financial recoveries. Results inform OIG's ongoing oversight of state fraud control operations and federal funding decisions for MFCUs.

Legal·CA·25d ago

California Failed to Report and Return $6.8 Million in Medicaid Fraud Unit Overpayments

The HHS Office of Inspector General found that California did not report and return $6.8 million in Medicaid overpayments identified through its Medicaid Fraud Control Unit cases from 2019 to 2022. California reported only $27.4 million of $34.2 million in identified overpayments to CMS and returned just $24 million. The state failed to track overpayments adequately and did not follow federal requirements for reporting and returning recovered funds within 60 days. OIG recommends California strengthen controls, return the unreported amounts, and provide technical assistance to counties on federal overpayment requirements.

Legal·SC·25d ago

OIG Finds South Carolina Failed to Monitor MCO Mental Health Parity Compliance on Prior Authorization

An HHS Office of Inspector General audit found that South Carolina's Medicaid agency did not ensure that three managed care organizations complied with federal mental health and substance use disorder parity requirements for prior authorization processes during the audit period. The state lacked adequate oversight mechanisms to verify that MCOs applied comparable prior authorization criteria and processes for behavioral health services as for medical/surgical benefits. OIG recommended that South Carolina strengthen monitoring protocols and ensure MCOs document parity compliance. The findings highlight enforcement gaps in the Mental Health Parity and Addiction Equity Act as applied to Medicaid managed care.

Federal Policy·30d ago

OIG Finds CMS Oversight Gaps in State Use of Contract Surveyors for Nursing Home Surveys

The HHS Office of Inspector General found that CMS lacks adequate oversight of states' use of contract surveyors to conduct nursing home health and safety surveys. The report identifies weaknesses in how CMS monitors whether contract surveyors meet federal training and qualification requirements, and whether states appropriately use contractors when state survey agency staff are unavailable. OIG recommends CMS strengthen guidance to states on contract surveyor use, improve tracking of contractor qualifications, and enhance monitoring of state compliance with federal surveyor standards. For Medicaid-certified nursing homes, survey deficiencies directly affect provider compliance, certification status, and payment.

Legal·ND·30d ago

OIG Inspection Finds North Dakota Medicaid Fraud Control Unit in Compliance

The HHS Office of Inspector General completed its periodic inspection of the North Dakota Medicaid Fraud Control Unit in 2025, examining the unit's compliance with federal certification standards for investigating and prosecuting Medicaid provider fraud and patient abuse cases. The inspection covered staffing, case management, prosecution coordination, and reporting requirements. North Dakota's unit was found to meet federal requirements for continued federal financial participation at the 75 percent match rate. OIG conducts these inspections every three years for all state fraud control units as required by federal law.

Legal·OR·30d ago

OIG Finds Health Share of Oregon Failed Federal Requirements in Prior Authorization Denials

The HHS Office of Inspector General found that Health Share of Oregon, a Medicaid coordinated care organization, did not always comply with federal and state requirements when denying prior authorization requests. The audit identified deficiencies in the CCO's denial processes, including inadequate documentation and failure to meet regulatory standards for timely and appropriate prior authorization determinations. Health Share of Oregon serves Medicaid beneficiaries in the Portland metro area under Oregon's 1115 waiver. The findings carry implications for federal compliance oversight of Medicaid managed care organizations' utilization management practices.

Legal·KS·30d ago

OIG Finds Kansas Failed to Enforce Mental Health Parity Rules for MCO Prior Authorization

The HHS Office of Inspector General determined that Kansas did not ensure its Medicaid managed care organizations complied with federal mental health and substance use disorder parity requirements related to prior authorization. The audit found Kansas MCOs applied more restrictive prior authorization requirements for behavioral health services than for medical/surgical services, violating parity rules. OIG recommended Kansas implement oversight mechanisms to ensure MCO compliance with parity requirements and recover inappropriate payments if applicable. This represents federal enforcement action against a state's failure to monitor MCO compliance with long-standing but frequently unenforced parity rules.

Legal·NY·30d ago

OIG Finds New York Failed to Enforce Mental Health Parity in Medicaid MCO Prior Authorization

The HHS Office of Inspector General determined that New York did not ensure selected Medicaid managed care organizations complied with mental health and substance use disorder parity requirements for prior authorization processes. The findings indicate state oversight gaps in enforcing the Mental Health Parity and Addiction Equity Act (MHPAEA) as it applies to Medicaid managed care. OIG identified instances where MCOs imposed more restrictive prior authorization requirements on behavioral health services compared to medical/surgical benefits. The report will likely prompt corrective action plans from New York and increased scrutiny of parity compliance in other states' Medicaid managed care programs.

Legal·AZ·30d ago

OIG Finds Arizona Failed to Monitor MCO Mental Health Parity Compliance on Prior Authorization

The HHS Office of Inspector General found that Arizona did not ensure its selected Medicaid managed care organizations complied with federal mental health and substance use disorder parity requirements related to prior authorization processes. The review identified gaps in state oversight of whether MCOs applied comparable authorization standards for behavioral health and medical/surgical benefits, as required under the Mental Health Parity and Addiction Equity Act. The report recommends Arizona strengthen monitoring and enforcement mechanisms to verify MCO compliance with parity requirements. This review follows increased federal scrutiny of parity compliance across states and managed care plans.

Federal Policy·94d ago

OIG Finds Part D Plans Cover Most Drugs Used by Dual Eligibles in 2026

The HHS Office of Inspector General reviewed Part D plan formularies for 2026 and found that plans generally include drugs commonly prescribed to dual-eligible beneficiaries. The analysis examined formulary coverage patterns for medications frequently used by individuals enrolled in both Medicare and Medicaid. The report provides insight into whether dual eligibles have adequate access to needed medications through Part D coverage. This matters for Medicaid managed care organizations that coordinate benefits for dually eligible members and must ensure continuity of pharmacy coverage across programs.

Federal Policy·123d ago

OIG Reports Fourth Quarter 2025 Drug Pricing Comparison Shows ASP-AMP Spreads

The HHS Office of Inspector General released its quarterly comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP) for drugs in the fourth quarter of 2025. This routine report identifies drugs where ASP exceeds AMP by specified thresholds, which triggers potential Medicaid reimbursement adjustments under federal law. The data covers Medicare Part B drugs and provides transparency into pharmaceutical pricing differentials that affect both Medicare and Medicaid programs. CMS uses these comparisons to determine when Medicaid best price penalties may apply.

Get the daily briefing.