State Medicaid Fraud Control Units

To eliminate fraud and patient abuse in the State Medicaid Programs.



Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.

Website Address

http://www.oig.hhs.gov




Selected Recipients for this Program


RecipientAmount Start DateEnd Date
State Police, Illinois State Of $ 6,069,504   2018-10-012019-09-30
Attorney General, Office Of The $ 4,894,485   2018-10-012019-09-30
Attorney General, Pennsylvania $ 6,441,963   2018-10-012019-09-30
Attorney General Of Ohio $ 7,913,871   2018-10-012019-09-30
Legal Affairs, Florida Department Of $ 14,689,443   2018-10-012019-09-30
Justice, Louisiana Department Of $ 4,804,653   2018-10-012019-09-30
Attorney General, Texas $ 14,705,757   2018-10-012019-09-30
Law, Virginia Department Of $ 7,968,864   2018-10-012019-09-30
Justice, California Department Of $ 30,855,213   2018-10-012019-09-30
Attorney General, New York State $ 33,027,645   2018-10-012019-09-30



Program Accomplishments

Not Applicable.

Uses and Use Restrictions

The statute authorizes 90 percent matching funds for the first 12 quarters, and 75 percent matching funds thereafter for investigation and prosecution of fraud and patient abuse in the State Medicaid Programs.

A unit must be separate and distinct from the single State Medicaid agency.

A unit must also employ sufficient professional, administrative and support staff to carry out its duties and responsibilities in an effective and efficient manner.

Eligibility Requirements

Applicant Eligibility

An established State Medicaid Fraud Control Unit must be a single identifiable entity of the State government which the Secretary certifies (and the Office of Inspector General annually re-certifies) as complying with the requirements of 1903(q) of the Social Security Act (42 CFR 1007) regarding location, function and procedure.

Applicants must also comply with section 1902 (a)(61) of the Act as amended by the Omnibus Budget Reconciliation Act of 1993.

Tribes (American Indian/Alaskan Native/Native American) are not eligible to apply.

Beneficiary Eligibility

Grantees are State entities.

Credentials/Documentation

Units must submit applications containing proposed organization, administration, agreements, detailed budgets and procedures for certification of eligibility (see 42 CFR 1007). Costs will be determined in accordance with 2 CFR 200 and 45 CFR 75. Governors in States applying for Federal assistance must approve the application pursuant to 42 CFR 1007.15(a). 2 CFR 200, Subpart E - Cost Principles applies to this program.

Aplication and Award Process

Preapplication Coordination

Preapplication coordination is not applicable.

Environmental impact information is not required for this program.

This program is excluded from coverage under E.O.

12372.

Application Procedures

2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards applies to this program. The standard application forms (SF 424, SF 424A, and SF 424B) must be used for the application. The Inspector General's staff is available to assist with technical development of programs, plans, and budget amendments and revisions.

Award Procedures

States are awarded funds based on a detailed description of estimated expenditures needed to support the program. Award funds are distributed quarterly on a fiscal year basis as follows: October 1, January 1, April 1, and July 1.

Deadlines

Contact the headquarters or regional office, as appropriate, for application deadlines.

Authorization

Social Security Act (The Act), as amended, Title XIX, Section 1902(a)(61).

Range of Approval/Disapproval Time

The time required to process an application may take up to 90 days.

Appeals

From 60 to 90 days. If the application is not approved, the State may submit an amended application at any time.

Renewals

The application for the annual re-certification must be submitted 60 days prior to the end of each certification period.

Assistance Considerations

Formula and Matching Requirements

Statutory Formula: Matching Requirements: States are awarded, through the issuance of a grant award, for 90 percent of their costs for the first 12 quarters, and 75 percent thereafter, computed against a quarterly maximum allowable of the higher of $125,000, or one-fourth of 1 percent of the sums expended by the Federal, State, or local government in carrying out the State plan under Title XIX of the Social Security Act. This program does not have MOE requirements.

Length and Time Phasing of Assistance

Grant periods are 1 year in length and funds are awarded quarterly based on an approved annual budget and limitations on entitlement. Method of awarding/releasing assistance: quarterly.

Post Assistance Requirements

Reports

Annual Reports are required and must be submitted 60 days prior to the expiration of the MFCU's certification period.

Federal Financial Reports (SF-425) to report cash transactions are required on a quarterly basis to PMS.

An Annual Report to report the MFCUs statistics is required.

Expenditure reports on the SF-425 are required to be submitted to OIG and are due 30 days following each quarter and a final expenditure report is required and is due 90 days after the grant period end date.

Performance monitoring is required through the submission of annual reports by the MFCUs to HHS/OIG and through site visits to the MFCUs that are conducted by the HHS/OIG.

Audits

In accordance with the provisions of 2 CFR 200, Subpart F - Audit Requirements, non-Federal entities that expend financial assistance of $750,000 or more in Federal awards will have a single or a program-specific audit conducted for that year. Non-Federal entities that expend less than $750,000 a year in Federal awards are exempt from Federal audit requirements for that year, except as noted in 2 CFR 200.503. OIG performs periodic onsite reviews of the State program, as appropriate, as well as an annual re-certification review of each SMFCU.

Records

All records are to be retained for 3 years, in accordance with 45 CFR 75.361.

Financial Information

Account Identification

75-0512-0-1-551.

Obigations

(Formula Grants) FY 16 $243,715,000; FY 17 est $255,000,000; and FY 18 est $270,000,000

Range and Average of Financial Assistance

FY 2016: Range $339,272 to $39,986,336; Average $4,670,272.

Regulations, Guidelines, and Literature

42 CFR 1007, 45 CFR 75, and Performance Standards originally issued September 1994 and revised in June 2012.

Information Contacts

Regional or Local Office

None.

Headquarters Office

Richard B. Stern 330 Independence Ave., S.W., Cohen Building, Washington, District of Columbia 20201 Email: richard.stern@oig.hhs.gov Phone: (202) 619-0480

Criteria for Selecting Proposals

Not Applicable.




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Edited by: Michael Saunders

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