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GAO-09-558R: 

United States Government Accountability Office: 
Washington, DC 20548: 

June 30, 2009: 

The Honorable John D. Rockefeller IV: 
Chairman: 
Subcommittee on Health Care: 
Committee on Finance: 
United States Senate: 

Subject: Medicaid and CHIP: Opportunities Exist to Improve U.S. Insular 
Area Demographic Data That Could Be Used to Help Determine Federal 
Funding: 

Dear Mr. Chairman: 

The five largest insular areas of the United States--American Samoa, 
the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Puerto 
Rico, and the U.S. Virgin Islands--receive federal funding through 
Medicaid and the State Children's Health Insurance Program (CHIP), 
joint federal-state programs that finance health care for certain low- 
income individuals. These programs are administered and funded 
differently in the insular areas when compared to the states.[Footnote 
1] For example, while states must extend Medicaid eligibility to 
certain individuals whose incomes are at or below a percentage of the 
federal poverty level (FPL),[Footnote 2] the insular areas are not 
required to cover this population. In addition, under both Medicaid and 
CHIP, the federal government matches state or local government 
spending. However, federal law establishes the federal matching rate 
for expenditures by the insular areas at the lowest rate available to 
states, while matching rates for the states are determined each year 
based on a formula that takes into account variations in per capita 
income in each state.[Footnote 3] Furthermore, federal Medicaid 
spending in the insular areas is subject to an annual limit that does 
not apply to the states.[Footnote 4] Finally, while CHIP funding is 
subject to annual limits for both states and insular areas, the formula 
for determining each state's CHIP allotment differs from the formula 
used for allotments for the insular areas. Taken together, these 
differences in funding formulas have contributed to per capita federal 
Medicaid and CHIP spending that has been lower in the insular areas 
than in the states.[Footnote 5] 

Some insular area governors and other insular area officials contend 
that federal Medicaid and CHIP spending in the insular areas is not 
sufficient to meet the needs of the areas and have recommended that the 
Medicaid spending limits be removed and the federal matching rates for 
Medicaid and CHIP be increased.[Footnote 6] However, you and others 
have raised concerns that limitations in Medicaid and CHIP program data 
and in available demographic data for the insular areas make it 
difficult to accurately assess the needs of the areas. For example, 
states are required to report all of their Medicaid and CHIP spending 
to the Centers for Medicare & Medicaid Services (CMS)--the agency that 
oversees these programs. In contrast, insular areas must report only 
spending up to their annual limits. Furthermore, while the Bureau of 
the Census (Census) collects household demographic data from the states 
annually, it generally only collects household demographic data for the 
insular areas once every 10 years as part of the decennial census. 

The Children's Health Insurance Program Reauthorization Act of 2009 
(CHIPRA), which was enacted in February 2009,[Footnote 7] modified the 
formula for determining federal CHIP allotments for states and insular 
areas for fiscal years 2009 through 2013. Under CHIPRA, increases in 
federal CHIP allotments to the insular areas and the states are to be 
based, in part, on any annual percentage increase in the population of 
children as determined using the most recent estimates published by 
Census.[Footnote 8] Prior to CHIPRA, for each fiscal year, CHIP 
allotments for the insular areas were to be distributed based on set 
percentages, and for the states were to be determined based, in part, 
on population data derived from the Current Population Survey (CPS), a 
monthly survey administered by the Department of Commerce (DOC) and 
designed to capture national demographic trends. Because the CPS was 
not designed to capture state-level demographic data, some researchers 
were concerned about the use of CPS data to determine CHIP funding for 
each state. CHIPRA directs the Secretary of DOC to assess whether 
available data from its annual American Community Survey (ACS)--an 
annual household survey designed to capture community-level 
demographic, housing, and socioeconomic data--would provide more 
reliable estimates than CPS for the purpose of determining increases in 
federal CHIP allotments. 

In light of these issues, you asked us to examine the Medicaid and CHIP 
programs in the insular areas and to provide information on the 
availability of program-related data for the areas. Specifically, we 
examined (1) Medicaid and CHIP income eligibility criteria used by the 
insular areas, (2) CMS's approach to collecting Medicaid and CHIP 
enrollment and spending data from the insular areas and its assessment 
of the reported spending data, and (3) the extent to which CPS or ACS 
data are available for the insular areas. 

To examine Medicaid and CHIP income eligibility criteria, we reviewed 
relevant federal laws and regulations, reviewed insular areas' approved 
State Medicaid Plans, and interviewed officials from CMS regional 
offices and from each of the insular area Medicaid offices. To examine 
CMS's approach to collecting Medicaid and CHIP enrollment data from the 
insular areas, we interviewed officials from CMS regional offices and 
from each insular area and obtained recent enrollment data from the 
insular areas. To examine CMS's approach to collecting Medicaid and 
CHIP spending data from the insular areas, we interviewed officials 
from CMS regional offices and each insular area and obtained from CMS 
electronic copies of summarized Medicaid spending reports from 1991 
through 2008--the most recent data available at the time of our review. 
To examine CMS's assessment of the insular area spending data, we 
interviewed CMS regional officials, reviewed CMS guidance on its review 
of spending data, and reviewed the single audit reports available for 
the insular areas for fiscal years 2004 through 2007--the most recent 
available at the time or our review.[Footnote 9] We did not 
independently verify the reliability of the enrollment and spending 
data reported to CMS by the insular areas because our analysis focused 
on CMS's approach to collecting and reviewing these data, not the data 
themselves. To examine the extent to which CPS or ACS data are 
available for the insular areas, we interviewed officials from the U.S. 
Department of Interior, which has general federal administrative 
authority over most insular areas, and from Census. We also reviewed 
related congressional testimony by a Census official. 

We conducted our work from October 2008 through June 2009 in accordance 
with generally accepted government auditing standards. Those standards 
require that we plan and perform the audit to obtain sufficient, 
appropriate evidence to provide a reasonable basis for our findings and 
conclusions based on our audit objectives. We believe that the evidence 
obtained provides a reasonable basis for our findings and conclusions 
based on our audit objectives. 

In summary, insular areas' Medicaid and CHIP income eligibility 
criteria vary, and contribute to wide variation in the estimated 
percent of the population covered by Medicaid in each of the insular 
areas. For example, two of the areas base their income eligibility 
criteria on the FPL, while two other areas base their income 
eligibility criteria on locally established income limits. In 2008, the 
estimated percentage of the populations covered by Medicaid in the 
insular areas ranged from 6 percent in the U.S. Virgin Islands to 88 
percent in American Samoa, according to the Congressional Research 
Service (CRS). In addition, CMS provides the insular areas with 
flexibility in how they report Medicaid and CHIP enrollment data and 
requires the areas to report spending data quarterly using a standard 
form. Based on their review of reported spending data, CMS officials 
have determined that spending reports from the insular areas are 
sufficient to justify the federal matching payments made to them. For a 
number of reasons, CPS and ACS data are not available for the five 
insular areas in our review. However, Census updates certain data 
annually for Puerto Rico, including demographic, socioeconomic, and 
housing data collected through a tailored version of the ACS. According 
to Census officials, such data could be used in a CHIP allotment 
formula that used ACS data. Similar demographic, socioeconomic, and 
housing data for the other four insular areas are collected once every 
10 years through the decennial census. Census officials identified two 
options to update demographic information for the other four insular 
areas between decennial censuses--the agency could implement survey 
programs to collect demographic, socioeconomic, and housing data or it 
could update certain demographic data through its Population Estimates 
Program. However, according to agency officials, the agency would need 
additional resources or would need to take additional steps to develop 
either of these updates, depending on the method used. 

To improve the availability of the data that could be used in a CHIP 
allotment formula, we are recommending that the Secretary of Commerce 
direct Census to update, between decennial censuses, the demographic 
data for American Samoa, CNMI, Guam, and the U.S. Virgin Islands. In 
written comments on a draft of this report, DOC agreed with our 
recommendation. 

Background: 

American Samoa, Guam, CNMI, the Commonwealth of Puerto Rico, and the 
U.S. Virgin Islands are the largest insular areas of the United States. 
While each insular area has its own government and maintains a unique 
diplomatic relationship with the United States, all areas are under the 
sovereignty of the United States.[Footnote 10] With the exception of 
Puerto Rico, the populations in the insular areas are small relative to 
the states, and with the exception of Guam, they are significantly 
poorer.[Footnote 11] Although insular area participation in Medicaid 
and CHIP is voluntary, all insular areas currently participate in both 
programs. 

Medicaid: 

Established in 1965, Medicaid operates as a joint federal-state program 
to finance health care coverage for certain categories of low-income 
individuals. To obtain federal matching funds, the states and insular 
areas must operate their Medicaid programs within broad federal 
guidelines and under federally approved plans. Two insular areas, 
however, operate their Medicaid programs under federally approved 
waivers, which exempt them from federal eligibility 
requirements.[Footnote 12] The remaining insular areas have some 
flexibility in covering their Medicaid populations.[Footnote 13] 
Program eligibility in the insular areas is generally limited to 
certain categories of individuals whose incomes do not exceed certain 
limits. 

The federal share of spending on services for the insular areas' 
Medicaid programs--the Federal Medical Assistance Percentage (FMAP)-- 
is statutorily set at 50 percent, the lowest rate available to any 
state under the program.[Footnote 14] In addition, total federal 
Medicaid spending in the insular areas is subject to an annual limit or 
cap.[Footnote 15] As a result, the federal government will match every 
Medicaid dollar spent by the insular areas up to each area's limit, and 
any insular area spending above the limit is not matched. 

Under the Balanced Budget Act of 1997, the fiscal year 1998 limits on 
federal Medicaid spending for the insular areas were increased by 
varying amounts, subject to an additional percentage increase in the 
medical care component of the Consumer Price Index (CPI) for all urban 
consumers for subsequent fiscal years.[Footnote 16] The Jobs and Growth 
Tax Relief Reconciliation Act of 2003 provided the insular areas with a 
temporary increase of 5.9 percent above each areas' annual limits for 
fiscal years 2003 and 2004,[Footnote 17] and the Deficit Reduction Act 
of 2005 increased the annual limits in fiscal years 2006 and 2007 by 
varying amounts in each of the insular areas, and maintained these 
increases for subsequent fiscal years.[Footnote 18] Figure 1 shows the 
changes in insular areas' annual federal Medicaid spending limits from 
1998 through 2008. (See enclosure I for more detail on federal Medicaid 
spending to the insular areas.) More recently, the American Recovery 
and Reinvestment Act of 2009 (Recovery Act), which was enacted on 
February 17, 2009, provides temporary increases to each insular area's 
FMAP and annual federal spending limits from the first quarter of 
fiscal year 2009 through the first quarter of fiscal year 2011. 
[Footnote 19] 

Figure 1: Insular Areas' Federal Medicaid Spending Limits, 1998 through 
2008: 

[Refer to PDF for image: multiple line graph] 

Year: 1998; 
CNMI: $1.8 million; 
Guam: $5.1 million; 
Puerto Rico: $ million; 
American Samoa: $3 million; 
U.S. Virgin Islands: $5.3 million. 

Year: 1999; 
CNMI: $1.9 million; 
Guam: $5.2 million; 
Puerto Rico: $171.5 million; 
American Samoa: $3.1 million; 
U.S. Virgin Islands: $5.4 million. 

Year: 2000; 
CNMI: $1.9 million; 
Guam: $5.4 million; 
Puerto Rico: $177.5 million; 
American Samoa: $3.2 million; 
U.S. Virgin Islands: $5.6 million. 

Year: 2001; 
CNMI: $2.0 million; 
Guam: $5.6 million; 
Puerto Rico: $184.4 million; 
American Samoa: $3.3 million; 
U.S. Virgin Islands: $5.8 million. 

Year: 2002; 
CNMI: $2.1 million; 
Guam: $5.9 million; 
Puerto Rico: $192.9 million; 
American Samoa: $3.5 million; 
U.S. Virgin Islands: $6.1 million. 

Year: 2003; 
CNMI: $2.3 million; 
Guam: $6.3 million; 
Puerto Rico: $207.3 million; 
American Samoa: $3.7 million; 
U.S. Virgin Islands: $6.5 million. 

Year: 2004; 
CNMI: $2.4 million; 
Guam: $6.7 million; 
Puerto Rico: $219.4 million; 
American Samoa: $4.0 million; 
U.S. Virgin Islands: $6.9 million. 

Year: 2005; 
CNMI: $2.4 million; 
Guam: $6.7 million; 
Puerto Rico: $219.6 million; 
American Samoa: $4.0 million; 
U.S. Virgin Islands: $6.9 million. 

Year: 2006; 
CNMI: $3.5 million; 
Guam: $9.5 million; 
Puerto Rico: $241 million; 
American Samoa: $6.1 million; 
U.S. Virgin Islands: $9.7 million. 

Year: 2007; 
CNMI: $4.6 million; 
Guam: $12.3 million; 
Puerto Rico: $250.4 million; 
American Samoa: $8.3 million; 
U.S. Virgin Islands: $12.5 million. 

Year: 2008; 
CNMI: $4.8 million; 
Guam: $12.8 million; 
Puerto Rico: $260.4 million; 
American Samoa: $8.6 million; 
U.S. Virgin Islands: $13.0 million. 

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) 
data. 

Note: Figure 1 uses a logarithmic scale. A logarithmic scale can be 
useful when displaying data with large differences in numeric values. 
Logarithmic scales do not include zero. 

[End of figure] 

CHIP: 

In 1997, Congress created CHIP, a joint federal-state program that 
provides health care coverage to uninsured, low-income children living 
in families whose incomes exceed the eligibility limits for Medicaid 
programs.[Footnote 20] States and insular areas have three options for 
implementing CHIP; they can either expand their Medicaid programs, 
establish separate child health programs, or do a combination of both. 
The federal government matches insular area CHIP spending using an 
enhanced FMAP, which for all five areas is at the lowest rate available 
for the states--65 percent.[Footnote 21] Federal CHIP spending for both 
the insular areas and the states is limited to an annual allotment set 
in statute.[Footnote 22] 

Prior to CHIPRA, insular areas were allotted 0.25 percent of the total 
annual amount appropriated for CHIP allotments, which was distributed 
among the insular areas using statutorily set percentages,[Footnote 23] 
and allotments to the states were to be determined based, in part, on 
population data derived from the CPS.[Footnote 24] (See enclosure II.) 
Under CHIPRA, increases in CHIP allotments for fiscal years 2009 
through 2013 for states and the insular areas are to be determined 
based, in part, on any annual percentage increase in the population of 
children using the most recent estimates published by Census prior to 
the beginning of each fiscal year.[Footnote 25] CHIPRA also directs the 
Secretary of DOC--the department responsible for collecting demographic 
data in the United States--to assess whether available data from the 
ACS would provide more reliable estimates than CPS for determining 
increases in these CHIP allotments.[Footnote 26] Based on this 
assessment, the Secretary of DOC must recommend to the Secretary of HHS 
whether ACS data should be used in lieu of, or in combination with, CPS 
data, a recommendation that the Secretary of HHS may implement using a 
transition period.[Footnote 27] 

Medicaid and CHIP Program Data: 

Insular areas report Medicaid and CHIP enrollment and spending data to 
CMS, and CMS uses the spending reports to determine the amount of 
federal Medicaid and CHIP matching payments.[Footnote 28] CMS's Region 
2 office, located in New York, New York, has oversight responsibility 
for Puerto Rico and the U.S. Virgin Islands and reviews reports 
submitted by these areas. CMS's Region 9 office, located in San 
Francisco, California, has oversight responsibility for American Samoa, 
CNMI, and Guam and reviews the reports submitted by these areas. All 
five insular areas operate their CHIP programs as expansions of their 
Medicaid programs, and accordingly, include CHIP enrollment and 
spending data in their Medicaid reports. Because federal Medicaid and 
CHIP spending in the insular areas is limited, the areas are required 
to report only local spending up to that limit. However, CMS officials 
told us that for several years the agency has encouraged the insular 
areas to report actual spending, including any spending above the 
annual federal limits, to provide better estimates of Medicaid and CHIP 
costs for each area. 

Insular Areas' Medicaid and CHIP Income Eligibility Criteria Vary, and 
Wide Variation in Covered Populations Is Reported: 

Each insular area relies on different income criteria to determine 
Medicaid and CHIP eligibility. Two of the areas explicitly base 
Medicaid income eligibility on the FPL: Guam extends eligibility to 
certain individuals earning up to 100 percent of the FPL, and American 
Samoa extends eligibility to individuals earning under 200 percent of 
the FPL. The other three areas use different income eligibility 
criteria for eligible individuals, such as locally established income 
limits.[Footnote 29] As a result, the Medicaid annual income 
eligibility limits for individuals vary widely among the five insular 
areas, ranging from $4,800 in Puerto Rico to about $22,000 in American 
Samoa. For the CHIP program, four of the five insular areas' income 
eligibility criteria are the same as their Medicaid income eligibility 
criteria.[Footnote 30] Puerto Rico is the only insular area that uses 
CHIP funds to extend Medicaid eligibility to children in families 
earning incomes that exceed its Medicaid program's income eligibility 
limits. See table 1 for more detailed descriptions of the Medicaid and 
CHIP income eligibility criteria used in each insular area. 

Table 1: Insular Area Medicaid and CHIP Income Eligibility Criteria in 
2009: 

Insular area: American Samoa; 
Program: Medicaid and CHIP; 
Income eligibility criteria[A]: Below 200 percent of the FPL; 
2009 annual income limits for an individual[B]: $21,660. 

Insular area: CNMI; 
Program: Medicaid and CHIP; 
Income eligibility criteria[A]: At or below 150 percent of the 
Supplemental Security Income (SSI) federal benefit amount[C]; 
2009 annual income limits for an individual[B]: $12,132. 

Insular area: Guam; Program: Medicaid and CHIP; Income eligibility 
criteria[A]: At or below 100 percent of the FPL; 2009 annual income 
limits for an individual[B]: $10,830. 

Insular area: Puerto Rico; 
Program: Medicaid; 
Income eligibility criteria[A]: At or below 100 percent of the 
commonwealth poverty level (CPL)[D]; 
2009 annual income limits for an individual[B]: $4,800[E]. 

Insular area: Puerto Rico; 
Program: CHIP; 
Income eligibility criteria[A]: Over 100 percent and up to 200 percent 
of the CPL; 
2009 annual income limits for an individual[B]: Over $4,800 and up to 
$9,600. 

Insular area: U.S. Virgin Islands; 
Program: Medicaid and CHIP; 
Income eligibility criteria[A]: At or below locally established income 
limits[D]; 
2009 annual income limits for an individual[B]: $5,500. 

Source: CMS and insular area officials and GAO analysis of insular area 
Medicaid State Plans. 

[A] In addition to income eligibility requirements, some insular areas 
consider resources when determining Medicaid eligibility. 

[B] CHIP eligibility is generally determined based on family income. 

[C] SSI is a federal income supplement program designed to help aged, 
blind, and disabled people who have little or no income and provides 
cash to meet basic needs for food, clothing, and shelter. 

[D] Puerto Rico and the U.S. Virgin Islands use a lower Medicaid income 
limit for certain groups of people. The CPL is used by Puerto Rico as a 
measure of poverty in lieu of the FPL. 

[E] Certain aged, blind, and disabled individuals who earn up to $9,600 
per year may also qualify for Medicaid in Puerto Rico. In these cases, 
up to $4,800 of the individual's income can be excluded when 
determining Medicaid eligibility. 

[End of table] 

Insular areas' rationale for determining their Medicaid and CHIP income 
eligibility criteria varied. For example, CNMI and Guam based income 
eligibility on the SSI federal benefit amount and the FPL, 
respectively, because these two areas used these criteria to determine 
eligibility for other poverty-related programs. In addition, the U.S. 
Virgin Islands, which is relatively poor when compared to the states, 
based income eligibility on a locally established income limit which is 
equivalent to about half the FPL because, according to a U.S. Virgin 
Islands Medicaid official, limits on both federal and local program 
spending have required the area to restrict the size of the covered 
population. In contrast, American Samoa, which is similarly poor, 
considers every resident with an income below twice the FPL--the 
majority of the population--eligible for Medicaid.[Footnote 31] 
According to American Samoan officials, the area must use this 
relatively high income limit in order to spend all available federal 
funds.[Footnote 32] 

The differences in the income eligibility criteria used by the insular 
areas contribute to wide variation in the estimated percent of the 
population covered by Medicaid in each of the insular areas. For 
example, according to estimates by the CRS, in 2008 the covered 
populations ranged from 6 percent in the U.S. Virgin Islands to 88 
percent in American Samoa. (See table 2.) 

Table 2: Congressional Research Service Estimates of the Medicaid 
Populations in Each Insular Area, 2008: 

Insular area: American Samoa; 
Estimated enrollment: 60,864[A]; 
Estimated percentage of the population covered: 88. 

Insular area: CNMI; 
Estimated enrollment: 11,292; 
Estimated percentage of the population covered: 13. 

Insular area: Guam; 
Estimated enrollment: 29,625; 
Estimated percentage of the population covered: 17. 

Insular area: Puerto Rico; 
Estimated enrollment: 888,370[B]; 
Estimated percentage of the population covered: 23. 

Insular area: U.S. Virgin Islands; 
Estimated enrollment: 6,668; 
Estimated percentage of the population covered: 6. 

Source: CRS. 

Note: Background Material and Data on the Programs within the 
Jurisdiction of the Committee on Ways and Means, 2008 Edition (May 5, 
2008). 

[A] American Samoan residents are not required to enroll in Medicaid or 
CHIP. Under the authority of its approved waiver, American Samoa 
annually estimates the number of residents below 200 percent of the FPL 
based on population estimates derived by American Samoa's Statistics 
Office. This number is presumed eligible for Medicaid and provides the 
basis for determining the federal share of Medicaid funding. 

[B] According to Puerto Rico officials, coverage was extended to more 
than 100,000 additional children using CHIP funds. 

[End of table] 

CMS Provides the Insular Areas Flexibility in Reporting Enrollment, Has 
a Standard Requirement for Reporting Spending, and Has Determined That 
Reported Spending Justifies Federal Matching Payments: 

CMS provides the insular areas with flexibility in how they report 
Medicaid and CHIP enrollment data, and requires the areas to report 
spending data quarterly using a standard form. CMS officials told us 
that insular area spending reports are sufficient to justify federal 
matching payments provided to them, but they have concerns that reports 
from Puerto Rico and the U.S. Virgin Islands may not reflect the full 
costs of their programs. 

CMS Provides Insular Areas Flexibility in Reporting Enrollment Data and 
Requires the Areas to Report Spending Using a Standard Form: 

CMS provides the insular areas with flexibility in how they report 
Medicaid and CHIP enrollment data because they do not use the Medicaid 
Statistical Information System (MSIS)--the system required for 
reporting Medicaid data to CMS.[Footnote 33] For example, CNMI and Guam 
have historically provided enrollment data to CMS on their quarterly 
budget reports, which include certain information on enrollees, such as 
age.[Footnote 34] Puerto Rico provides a monthly: 

enrollment report to CMS, which provides different information on 
enrollees, such as where they live and in what health plan they are 
enrolled.[Footnote 35] American Samoa and the U.S. Virgin Islands 
report enrollment data to CMS less frequently than the other insular 
areas. American Samoa, which does not enroll individuals in Medicaid or 
CHIP, provides an annual estimate of eligible individuals to CMS. The 
U.S. Virgin Islands also reports enrollment data annually. 

Unlike enrollment data, CMS requires all five insular areas to report 
Medicaid and CHIP spending data using a standard quarterly report that 
states are also required to use, and CMS uses these reported data to 
determine the amount of federal Medicaid and CHIP matching 
payments.[Footnote 36] The standard report is designed to capture both 
aggregate spending and spending by service category, such as hospital 
inpatient services or laboratory and radiological services. While CNMI, 
Guam, and the U.S. Virgin Islands report aggregate spending as well as 
spending by service category, American Samoa and Puerto Rico report 
only aggregate spending because their programs are not designed to 
track spending by service.[Footnote 37] 

According to CMS Officials, Insular Area Spending Reports Are 
Sufficient to Justify Federal Matching Payments, but May Not Reflect 
All Insular Area Program Costs: 

CMS officials told us that based on their review of the insular area 
spending reports, they have determined that the reports are sufficient 
to justify the federal matching payments made to them. CMS's review is 
focused primarily on determining whether the areas report enough 
spending to reach their annual federal Medicaid limits, and if an area 
does not, CMS works with the area to determine why and resolve any 
problems.[Footnote 38] In their review of insular area spending 
reports, CMS officials do not follow the same procedures used to review 
state reported spending.[Footnote 39] However, CMS requires the insular 
areas to attest to the reliability of their data.[Footnote 40] CMS 
officials told us that they also review the results of single audit 
reports for each area to identify problems with the areas' financial 
reporting and work with the insular areas to clear and close Medicaid- 
related findings from the single audits. CMS officials also told us 
that they do not conduct more rigorous reviews of insular area spending 
data because they do not think the reviews would result in changes in 
federal payments to the insular areas, as federal funds available to 
the insular areas are limited and the areas typically report spending 
in excess of their federal limits, according to officials.[Footnote 41] 

Although CMS officials have determined that the insular area spending 
reports are sufficient to justify the federal matching payments made to 
them, they have concerns that reports from the U.S. Virgin Islands and 
Puerto Rico may not reflect the full costs of their programs. For 
example, the U.S. Virgin Islands' preliminary spending reports for 2007 
and 2008 indicate it spent several million dollars below the federal 
limit. CMS officials told us that they believe these spending reports 
may not reflect all of the insular area's payments for services 
eligible for Medicaid reimbursement, such as certain services that are 
provided to Medicaid beneficiaries by a U.S. Virgin Islands government 
department outside of Medicaid.[Footnote 42] Similarly, CMS officials 
also noted that, despite rising costs, the area has not updated its 
Medicaid payment rate to hospitals in over a decade. As a result, the 
U.S. Virgin Islands' government currently uses non-Medicaid funds to 
pay hospitals the difference between the Medicaid rate and the actual 
cost they incur for providing services to Medicaid-eligible 
individuals.[Footnote 43] However, according to a CMS official, the 
Virgin Island's Medicaid program cannot include these payments in its 
spending reports because they exceed the area's Medicaid hospital 
payment rate. Similarly, CMS officials told us that they also question 
the completeness of the 2009 quarterly spending reports received from 
Puerto Rico. While these reports show that the area spent enough to 
receive all federal funds up to the area's Medicaid limit, the reported 
spending is significantly lower than quarterly reports from previous 
years. CMS officials told us that, based on their examination of 
Medicaid enrollment data and the managed care costs for the area, they 
question whether these recent reports capture the cost of all payments 
for Puerto Rico Medicaid enrollees. 

CPS and ACS Data Are Not Available for the Insular Areas, but Data 
Similar to ACS Data Could Be Collected: 

CPS and ACS data are not currently available for the five insular areas 
in our review. According to Census officials, CPS data are not 
collected from the insular areas because the CPS sampling method was 
designed to develop only national estimates. These officials further 
noted that it would not be feasible to collect CPS data from four of 
the five insular areas due to their small populations and that Puerto 
Rico was the only insular area with a large enough population from 
which it could draw a reliable CPS sample. 

ACS data--demographic, socioeconomic, and housing data collected 
annually--are not available for all of the insular areas.[Footnote 44] 
However, we found that Census currently collects similar data from 
Puerto Rico and could also do so in the other four insular areas. 
Census has conducted the Puerto Rico Community Survey (PRCS)--a 
tailored version of the ACS--annually since 2005, and according to 
agency officials, will include PRCS data when it evaluates the ACS data 
for use in a CHIP allotment formula. Currently, Census collects data 
similar to ACS data for the other four insular areas once every 10 
years through the decennial census. Census officials told us that it 
would be possible to collect the same type of data more frequently-- 
that is, between decennial censuses--from the other four areas through 
surveys. However, to do so, agency officials told us they would first 
need to develop survey programs through which they would establish a 
sampling frame for each area.[Footnote 45] Officials said the initial 
sampling frames could be developed during the 2010 Census and, if 
updated, could be used as a basis for future data collection in each of 
these areas. Census officials explained that the data from the insular 
areas that are similar to ACS data could be used in a CHIP allotment 
formula that uses, or is based on, ACS data. However, the officials 
also told us the agency would need additional resources to implement 
these types of survey programs for the other four areas. According to 
Census officials, it is also possible to estimate certain demographic 
data--not including socioeconomic and housing data--for the insular 
areas between decennial censuses through the agency's Population 
Estimates Program.[Footnote 46] While Population Estimates Program data 
are available for the states, the District of Columbia, and Puerto 
Rico, they are not available for the four other insular areas in our 
review. According to Census officials, the agency would have to take 
additional steps to begin producing such estimates for these four 
areas. 

Conclusions: 

To determine whether federal Medicaid and CHIP spending has been 
sufficient to meet the needs of the insular areas and whether the way 
this spending is determined--particularly the practice of capping 
federal spending--should be changed, policymakers can review program 
data as well as data on the insular areas' populations. Insular areas 
report program data--including spending data--to CMS, and officials 
there are working with the areas to improve the data and to ensure they 
provide a more complete reflection of program costs. In addition, 
Census has the opportunity to improve the availability of demographic 
data from the insular areas that could be used in a CHIP allotment 
formula. Census has identified two methods for collecting these data-- 
developing survey programs to update demographic, socioeconomic, and 
housing data that are similar to ACS data, or updating only demographic 
data through the agency's Population Estimates Program. Regardless of 
the method, updated demographic data could be used to help determine 
future increases in federal CHIP allotments. Such data could also have 
broader value for federal programs in the insular areas, as 
policymakers could use these data to help assess the ongoing funding 
needs of Medicaid, CHIP, and other federal programs in the insular 
areas. 

Recommendation for Executive Action: 

To improve the availability of the data that could be used in a CHIP 
allotment formula, we are recommending that the Secretary of Commerce 
direct Census to update, between decennial censuses, the demographic 
data for American Samoa, CNMI, Guam, and the U.S. Virgin Islands. 

Agency Comments and Our Evaluation: 

We received written comments on a draft of this report from DOC and 
CMS, and the comments are reprinted in enclosures III and IV, 
respectively. In commenting on the draft report, DOC concurred with our 
recommendation, noting that regular updates of the demographic data for 
the insular areas would be beneficial. DOC also noted that as part of 
the 2010 Census, Census plans to collect detailed socioeconomic and 
demographic data from all five insular areas, and is prepared to 
develop methodologies for updating these data should funding become 
available. Commenting on behalf of HHS, CMS also stated its concurrence 
with our recommendation and noted that CHIPRA authorized additional 
funding for DOC to improve data collection. We amended our report to 
describe this additional funding. 

As arranged with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
after its issue date. At that time, we will send copies to the 
Secretary of Commerce, the Secretary of Health and Human Services, the 
Secretary of Interior, insular area governments, and interested parties 
upon request. The report will also be available at no charge on GAO's 
Web site at [hyperlink, http://www.gao.gov]. If you or your staff have 
any questions regarding this report, please call me at (202) 512-7114. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. Susan Anthony, 
Assistant Director; Rebecca Abela; Gerardine Brennan; Krister Friday; 
and Hemi Tewarson were major contributors to this report. 

Sincerely yours, 

Signed by: 

Linda T. Kohn: 
Director, Health Care: 

[End of section] 

Enclosure I: 

Insular Areas Federal Medicaid Funding Caps (Amount in dollars) 1998- 
2008: 

Year: 1998; 
American Samoa: $3,010,000; 
CNMI: $1,810,000; 
Guam: $5,090,000; 
Puerto Rico: $167,000,000; 
U.S. Virgin Islands: $5,260,000. 

Year: 1999; 
American Samoa: $3,090,000; 
CNMI: $1,860,000; 
Guam: $5,230,000; 
Puerto Rico: $171,500,000; 
U.S. Virgin Islands: $5,400,000. 

Year: 2000; 
American Samoa: $3,200,000; 
CNMI: $1,930,000; 
Guam: $5,410,000; 
Puerto Rico: $177,500,000; 
U.S. Virgin Islands: $5,590,000. 

Year: 2001; 
American Samoa: $3,320,000; 
CNMI: $2,010,000; 
Guam: $5,620,000; 
Puerto Rico: $184,400,000; 
U.S. Virgin Islands: v5,810,000. 

Year: 2002; 
American Samoa: $3,470,000; 
CNMI: $2,100,000; 
Guam: $5,880,000; 
Puerto Rico: $192,900,000; 
U.S. Virgin Islands: $6,080,000. 

Year: 2003[A]; 
American Samoa: $3,727,000; 
CNMI: $2,255,000; 
Guam: $6,321,000; 
Puerto Rico: $207,341,000; 
U.S. Virgin Islands: $6,537,000. 

Year: 2004[A]; 
American Samoa: $3,947,000; 
CNMI: $2,381,000; 
Guam: $6,683,000; 
Puerto Rico: $219,397,000; 
U.S. Virgin Islands: $6,913,000. 

Year: 2005; 
American Samoa: $3,950,000; 
CNMI: $2,380,000; 
Guam: $6,690,000; 
Puerto Rico: $219,600,000; 
U.S. Virgin Islands: $6,920,000. 

Year: 2006[B]; 
American Samoa: $6,120,000; 
CNMI: $3,480,000; 
Guam: $9,480,000; 
Puerto Rico: $241,000,000; 
U.S. Virgin Islands: $9,720,000. 

Year: 2007[B]; 
American Samoa: $8,290,000; 
CNMI: $4,580,000; 
Guam: $12,270,000; 
Puerto Rico: $250,400,000; 
U.S. Virgin Islands: $12,520,000. 

Year: 2008; 
American Samoa: $8,620,000; 
CNMI: $4,760,000; 
Guam: $12,760,000; 
Puerto Rico: $260,400,000; 
U.S. Virgin Islands: $13,020,000. 

Source: CMS. 

[A] The federal amount includes funds made available through the Jobs 
and Growth Tax Relief Reconciliation Act of 2003. 

[B] The federal amount includes funds made available through the 
Deficit Reduction Act of 2005. 

[End of table] 

[End of section] 

Enclosure II: 

Insular Areas CHIP Allotments (Amount in dollars) 1998-2008: 

Year: 1998; 
American Samoa: 128,850; 
CNMI: $118,113; 
Guam: $375,812; 
Puerto Rico: $9,835,550; 
U.S. Virgin Islands: $279,175. 

Year: 1999; 
American Samoa: $512,250; 
CNMI: $469,562; 
Guam: $1,494,063; 
Puerto Rico: $39,101,750; 
U.S. Virgin Islands: $1,109,875. 

Year: 2000; 
American Samoa: $538,650; 
CNMI: $493,762; 
Guam: $1,571,063; 
Puerto Rico: $41,116,950; 
U.S. Virgin Islands: $1,167,075. 

Year: 2001; 
American Samoa: $538,650; 
CNMI: $493,763; 
Guam: $1,571,062; 
Puerto Rico: $41,116,950; 
U.S. Virgin Islands: $1,167,075. 

Year: 2002; 
American Samoa: $396,900; 
CNMI: $363,825; 
Guam: $1,157,625; 
Puerto Rico: $30,296,700; 
U.S. Virgin Islands: $859,950. 

Year: 2003; 
American Samoa: $396,900; 
CNMI: $363,825; 
Guam: $1,157,625; 
Puerto Rico: $30,296,700; 
U.S. Virgin Islands: $859,950. 

Year: 2004; 
American Samoa: $396,900; 
CNMI: $363,825; 
Guam: $1,157,625; 
Puerto Rico: $30,296,700; 
U.S. Virgin Islands: $859,950. 

Year: 2005; 
American Samoa: $510,300; 
CNMI: $467,775; 
Guam: $1,488,375; 
Puerto Rico: $38,952,900; 
U.S. Virgin Islands: $1,105,650. 

Year: 2006; 
American Samoa: $510,300; 
CNMI: $467,775; 
Guam: $1,488,375; 
Puerto Rico: $38,952,900; 
U.S. Virgin Islands: $1,105,650. 

Year: 2007; 
American Samoa: $630,000; 
CNMI: $577,500; 
Guam: $1,837,500; 
Puerto Rico: $48,090,000; 
U.S. Virgin Islands: $1,365,000. 

Year: 2008; 
American Samoa: $630,000; 
CNMI: $577,500; 
Guam: $1,837,500; 
Puerto Rico: $48,090,000; 
U.S. Virgin Islands: $1,365,000. 

Source: CMS. 

Note: The allotments do not include reallocated CHIP funds. 

[End of table] 

[End of section] 

Enclosure III: 

Comments from the Department of Commerce: 

United States Department Of Commerce: 
The Secretary of Commerce: 
Washington, D.C. 20230: 

June 15, 2009: 

Ms. Linda R. Kohn: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Kohn: 

Thank you for the opportunity to respond to the Government 
Accountability Office's (GAO) draft report entitled Federal Medicaid 
and SCHIP Funding in the U.S. Insular Areas (GAO-09-558R). Currently, 
the Census Bureau provides updated demographic data for the five 
Insular Areas through its International Data Base, and provides 
annually updated socioeconomic data for Puerto Rico through the Puerto 
Rican Community Survey (PRCS). Recently, the Census Bureau conducted a 
Compact of Free Association migrant survey in two of the Insular Areas-
Guam and the Commonwealth of the Northern Mariana Islands-that provided 
limited socioeconomic and demographic data for residents of these 
islands. As part of the Census 2010 effort, the Census Bureau plans to 
collect detailed socioeconomic and demographic data from residents of 
the five Insular Areas in April 2010. 

The Census Bureau concurs with the GAO recommendation that regularly 
updating demographic data for all five Insular Areas would be 
beneficial. For example, the Census Bureau could conduct specialized 
surveys like the PRCS in the remaining four Insular Areas, building 
from results of Census 2010. Should funding become available for such 
opportunities, the Census Bureau is prepared to develop methodologies 
for collecting these updated socioeconomic and demographic data in the 
Insular Areas. 

Sincerely, 

Signed by: 

Gary Locke: 

[End of section] 

Enclosure IV: 

Comments from the Centers for Medicare & Medicaid Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

June 2, 2009: 

Linda Kohn: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Ms. Kohn: 

Enclosed are comments on the U.S. Government Accountability Office's 
(GAO) report entitled: Medicaid and SCHIP: Opportunities Exist to 
Improve U.S. Insular Area Demographic Data That Could Be Used to Help 
Determine Federal Funding (GAO-09-558R). 

The Department appreciates the opportunity to review this report before 
its publication. 

Sincerely, 

Signed by: 

Barbara Pisaro Clark: 
Acting Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

Department Of Health & Human Services: 
Centers for Medicare and Medicaid Services: 
Administrator: 
Washington, DC 20201: 

Date: June 1, 2009: 

T0: Barbara Pisaro Clark: 
Acting Assistant Secretary for Legislation: 
Office of the Secretary: 

From: [Signed by] Charlene Frizzera: 
Acting Administrator: 

Subject: Government Accountability Office (GAO) Draft Report: "Medicaid 
and SCRIP: Opportunities Exist to Improve U.S. Insular Area Demographic 
Data That Could Be Used to Help Determine Federal Funding" (GAO-09-
558R): 

The Centers for Medicare & Medicaid Services (CMS) appreciates the 
opportunity to review and comment on the subject draft report. As 
indicated in the report, Census officials identified two options to 
update demographic information for the four insular areas between 
decennial censuses: (1) the agency could implement survey programs to 
collect demographic, socioeconomic, and housing data or (2) it could 
update certain demographic data through its Populations Estimates 
Program. CMS offers the following comment. 

GAO Recommendation: 

To improve the availability of the data that could be used in a SCHIP 
allotment formula, we are recommending that the Secretary of Commerce 
direct Census to update, between decennial censuses, the demographic 
data for American Samoa, CNMI, Guam, and the Virgin Islands. 

CMS Response: 

The CMS agrees with the GAO recommendation. Section 602 of the 
Children's Health Insurance Program Reauthorization Act of 2009 
authorizes $20 million for Commerce to improve the Current Population 
Survey and American Community Survey data collection in order to 
produce more reliable estimates. 

We appreciate the effort that went into this report and look forward to 
working with the GAO on this and other issues. 

[End of section] 

Footnotes: 

[1] For purposes of Medicaid and CHIP, federal law generally defines 
states to include the 50 states, the District of Columbia, American 
Samoa, CNMI, Guam, Puerto Rico, and the U.S. Virgin Islands. 42 U.S.C. 
§ 1301(a)(1). In this report, however, the term states refers to the 50 
states and the District of Columbia, and the term insular areas only 
refers to American Samoa, CNMI, Guam, Puerto Rico, and the U.S. Virgin 
Islands. 

[2] FPL refers to the federal poverty guidelines which are used to 
establish eligibility for certain federal assistance programs. The 
Department of Health and Human Services (HHS) publishes these 
guidelines on an annual basis, updating the guidelines to reflect 
changes in the cost of living and variations according to family size. 

[3] 42 U.S.C. §§ 1396d(b), 1397ee(a), (b). 

[4] 42 U.S.C. § 1308(g). Under the American Recovery and Reinvestment 
Act of 2009 (Recovery Act), both states and insular areas may qualify 
for a temporary increase in the federal share of spending on Medicaid 
services--the Federal Medical Assistance Percentage (FMAP). Each 
insular area may choose between (1) an FMAP increase of 6.2 percentage 
points and a 15 percent increase in its annual federal Medicaid 
spending limit, or (2) a 30 percent increase in its annual federal 
Medicaid spending limit. Pub. L. No. 111-5, div. B, tit. V, § 5001(b), 
(d), 123 Stat. 115, 497-498 (2009). 

[5] GAO, U.S. Insular Areas: Multiple Factors Affect Federal Health 
Care Funding, [hyperlink, http://www.gao.gov/products/GAO-06-75] 
(Washington, D.C.: Oct. 14, 2005). 

[6] Department of the Interior, Office of Insular Affairs, Future of 
Health Care in the Insular Areas Leaders Summit: Report on Health Care 
in the Insular Areas (Washington, D.C.: Jan. 12, 2008). 

[7] Pub. L. No. 111-3, §§ 102, 602, 123 Stat. 8, 11-15, 98-99 (2009) 
(codified, as amended, at 42 U.S.C. §§ 1397dd, 1397ii(b)). 

[8] The estimates for fiscal year 2009 were derived from Population 
Estimates Program data--annual data that update the demographic data 
collected through the decennial census. Allotments for the insular 
areas were based on national estimates instead of insular areas' 
estimates. 

[9] In accordance with the Single Audit Act of 1984, as amended, 31 
U.S.C. §§ 7501-7505, and the Office of Management and Budget (OMB) 
Circular A-133, Audits of States, Local Governments and Non-Profit 
Organizations (June 27, 2003), nonfederal entities, including states 
and insular areas, that expend $500,000 or more a year in federal 
awards must have a single or program-specific audit conducted for that 
year subject to applicable requirements. 

[10] The Department of Interior has general federal administrative 
authority over all insular areas except Puerto Rico. All departments, 
agencies, and officials of the executive branch treat Puerto Rico 
administratively "as if it were a state" subject to few exceptions. Any 
matters concerning the fundamentals of the U.S.-Puerto Rican 
relationship are referred to the Office of the President. See 
Memorandum of the President, Nov. 30, 1992, 57 Fed. Reg. 57,093 (1992). 
Insular area residents are not subject to the same level of income 
taxes as residents of the states. For example, they pay no federal 
income tax on income from sources within the insular area. 

[11] For example, the median household income in Puerto Rico in 1999 
was $14,412 compared to $41,994 in the United States. 

[12] The Secretary of HHS may waive or modify requirements with respect 
to Medicaid programs in American Samoa and CNMI, except for the annual 
limits on federal Medicaid spending, the statutorily set Federal 
Medical Assistance Percentage (FMAP), and the requirement that federal 
payments only be made for Medicaid services. 42 U.S.C. § 1396a(j). 

[13] States are required to cover defined categories of individuals 
under their Medicaid program, including children, pregnant women, 
adults in families with children, the elderly, and individuals with 
disabilities. Guam, Puerto Rico, and the U.S. Virgin Islands, however, 
are not required to cover all the same categories of individuals. 

[14] In contrast, for states, the FMAP generally is determined 
according to a formula based on each state's per capita income in 
relation to the national average per capita income and may range from 
50 percent to 83 percent. See 42 U.S.C. 1396d(b). As a result, poorer 
states receive higher federal matching rates than wealthier states. In 
2009, the FMAP ranged from 50 percent in wealthier states, such as New 
York and Connecticut, to about 76 percent in Mississippi. The federal 
share for Medicaid administrative costs, however, is established under 
federal law at the same percent for states and the insular areas, with 
the percent defined by the type of administrative cost. See 42 U.S.C. § 
1396b(a)(2)-(7). 

[15] 42 U.S.C. § 1308(f), (g). In contrast, federal Medicaid spending 
in the states generally is open ended, provided the states contribute 
their share of program expenditures. 

[16] Pub. L. No. 105-33, § 4726, 111 Stat. 251, 519 (1997) (codified, 
as amended, at 42 U.S.C. § 1308(g)). 

[17] Pub. L. No.108-27, § 401, 117 Stat. 752, 764 (2003). This 
temporary increase only applied to the last 2 calendar quarters of 
fiscal year 2003 and the first 3 calendar quarters of fiscal year 2004. 

[18] Pub. L. No. 109-171 § 6055, 120 Stat. 4, 96 (2006) (codified, as 
amended, at 42 U.S.C. § 1308(g)). 

[19] Under the Recovery Act, each insular area may choose between (1) 
an FMAP increase of 6.2 percentage points and a 15 percent increase in 
its annual federal spending limit, or (2) a 30 percent increase in its 
annual federal spending limit. Pub. L. No. 111-5, div. B, tit. V, § 
5001(b), (d), 123 Stat. 115, 497-498 (2009). 

[20] See the Balanced Budget Act of 1997, Pub. L. No. 105-33, § 4901, 
111 Stat. 251, 552-571 (codified, as amended at 42 U.S.C. §§ 1397aa et 
seq.). 

[21] States and insular areas qualify for an enhanced FMAP equal to 
their Medicaid FMAP plus 30 percent of the difference between the 
state's FMAP and 100 percent. Thus, because insular areas receive a 50 
percent FMAP--the minimum FMAP for states--the areas' enhanced FMAP for 
CHIP may only be increased to 65 percent. See 42 U.S.C. § 1397ee(a), 
(b). 

[22] 42 U.S.C. § 1397dd. 

[23] Of the total amount available for CHIP allotments for insular 
areas each fiscal year: Puerto Rico received 91.6 percent; Guam, 3.5 
percent; the U.S. Virgin Islands, 2.6 percent; American Samoa, 1.2 
percent; and CNMI, 1.1 percent. 42 U.S.C. § 1397dd(c). 

[24] A state's CHIP allotment was to be determined, in part, based on 
the average number of low-income children (including those without 
health insurance) in the state as reported and defined in the three 
most recent March supplements to the CPS published by Census before the 
beginning of the calendar year in which the fiscal year begins. 42 
U.S.C. § 1397dd(b). 

[25] Pub. L. No. 111-3, § 102, 123 Stat. 8, 11-15 (2009) (codified, as 
amended, at 42 U.S.C. § 1397dd). The estimates for fiscal year 2009 
were derived from Population Estimates Program data--national estimates 
were used for the insular areas and state-level estimates were used for 
the states. 

[26] Through CHIPRA, Congress appropriated additional funds for this 
assessment as well as for other purposes, including the improvement of 
the data collected by DOC through the CPS for all states. The ACS, an 
annual survey that replaces the decennial census's long form, was not 
available when CHIP was initially authorized. Researchers have 
suggested that the ACS could provide better state-level population data 
than the CPS in part because its sample is larger than the CPS sample. 
Census--an agency within DOC--is responsible for collecting CPS and ACS 
data. 

[27] Pub. L. No. 111-3, § 602, 123 Stat. 8, 98-99 (2009) (codified, as 
amended, at 42 U.S.C. § 1397ii(b)). According to a CMS official, CMS 
will work with Census to determine the appropriate data to use in 
determining increases in CHIP allotments for the states and insular 
areas for fiscal years 2010 through 2013. 

[28] Medicaid spending is reported on the form known as the CMS 64. At 
the beginning of each program year, CMS makes the amounts of the 
insular areas' federal Medicaid spending limits available to the 
insular areas, and each area draws down its funds throughout the year 
based on the spending reported on the CMS 64. 

[29] Insular areas define the income eligibility criteria in their 
Medicaid plans, which are approved by CMS. 

[30] According to CMS officials, these insular areas may not use CHIP 
funds for eligible populations in any given year until they have 
exhausted all available federal Medicaid funds. 

[31] American Samoan residents are not required to enroll in Medicaid 
or CHIP. Under the authority of its approved waiver, American Samoa 
annually estimates the number of residents below 200 percent of the FPL 
based on population estimates derived by American Samoa's Statistics 
Office. This number is presumed eligible for Medicaid and provides the 
basis for determining the federal share of Medicaid funding. 

[32] Prior to 2006, American Samoa's income eligibility was limited to 
100 percent of the FPL--about 65 percent of the population--but was 
increased to 200 percent of the FPL in 2006 when the area received an 
increase in its Medicaid cap. An official from the U.S. Virgin Islands 
told us that in response to these increased federal funds, the area is 
also considering increasing the program's income eligibility limits. 

[33] The Balanced Budget Act of 1997 required states and insular areas 
to participate in the MSIS beginning in 1999 to report Medicaid claims 
data, including enrollee encounter data, and provided states and 
insular areas with increased federal Medicaid funding to develop MSIS 
systems. Pub. L. No. 105-33, § 4753, 111 Stat. 251, 525 (1997) 
(codified, as amended, at 42 U.S.C. § 1396b(r)). Although insular areas 
could have accessed these federal Medicaid funds to develop MSIS 
systems, none did so because those funds would have counted against 
their annual Medicaid caps, according to CMS officials. Officials also 
stated that because the insular areas do not have this technical 
capability, CMS does not require the areas to report enrollment data 
through the MSIS. CHIPRA, Pub. L. No. 111-3 § 109, 123 Stat. 8, 25 
(2009) (codified, as amended, at 42 U.S.C. § 1308(g)), has since 
allowed the insular areas to access federal Medicaid funding to develop 
MSIS systems outside of the areas' annual Medicaid caps. If the insular 
areas develop MSIS systems, enrollment data could become standardized. 

[34] Medicaid budget reports are submitted quarterly on the form known 
as CMS 37. 

[35] Puerto Rico's Medicaid program operates as a managed care system 
that includes several health plans. Medicaid funds are used to pay the 
health plans for their Medicaid enrollees. 

[36] States and insular areas report, on a quarterly basis, spending on 
a standard report known as the CMS 64. States and insular areas that 
operate CHIP as an expansion of their Medicaid programs must report 
CHIP spending on the CMS Form 64. Expenditures related to stand-alone 
CHIP programs are reported quarterly on the CMS 21. 

[37] Specifically, because American Samoa does not enroll individuals 
in Medicaid or CHIP, it cannot link spending to eligible individuals. 
Instead, it reports Medicaid spending in terms of a percentage of the 
area's total hospital expenditures. Similarly, because Puerto Rico 
operates Medicaid and CHIP through a managed care program, it only 
reports spending in terms of the total payments made for all Medicaid 
and CHIP enrollees. 

[38] According to CMS officials, CMS 64 spending reports and associated 
payments may be adjusted up to 2 years after the end of the program 
year. 

[39] CMS does not require officials that review insular area spending 
reports to follow the standard procedures outlined in its Financial 
Review Guide for the Quarterly Statement of Expenditures (Form CMS-64 
Report)--the guide that CMS uses to ensure uniform and comprehensive 
reviews of state-reported Medicaid spending data. 

[40] Specifically, the insular areas are required to attest to the 
accuracy of the Medicaid and CHIP data they report to CMS. By attesting 
to the data, insular areas confirm that they can readily provide 
documentation, such as provider payment invoices, to support the 
spending they report. 

[41] Furthermore, officials noted that total federal spending in the 
insular areas accounts for a very small part of total federal spending 
on Medicaid and CHIP. They noted that due to the logistics of 
performing rigorous reviews, CMS determined there is limited value in 
conducting more thorough reviews of insular area data. 

[42] A U.S. Virgin Islands' Medicaid official told us that the area is 
working with CMS to capture spending on these services in their 
spending reports. 

[43] A U.S. Virgin Islands' Medicaid official told us that the area has 
hired a contractor to examine updating its Medicaid payment rates. 

[44] The ACS is an annual survey that produces detailed demographic, 
socioeconomic, and housing data and will replace the decennial census 
long form survey beginning with the 2010 Census. 

[45] A sampling frame is a list of all members of a population used as 
a basis from which to draw a sample. According to Census officials, the 
method used to develop sampling frames in the insular areas differs 
from the method used in the states. 

[46] Population Estimates Program data provide annual updates to the 
demographic data collected through the decennial census short form, 
specifically data on age, sex, race, and Hispanic origin. Population 
Estimates Program data were used in the fiscal year 2009 CHIP allotment 
formula. 2009 CHIP allotments for the insular areas were based on 
national estimates instead of insular area estimates. 

[End of section] 

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