Supplemental Security Income: Timely Data Could Prevent Millions in
Overpayments to Nursing Home Residents (Letter Report, 06/03/97,
GAO/HEHS-97-62).

Pursuant to a congressional request, GAO reviewed overpayments to
Supplemental Security Income (SSI) recipients in nursing homes and other
medical treatment institutions, focusing on: (1) the extent of such
overpayments; (2) the success or failure of the Social Security
Administration's (SSA) actions in preventing and detecting these
overpayments; and (3) the methods by which SSA can better prevent such
overpayments.

GAO noted that: (1) SSA estimates that overpayments to individuals in
nursing homes may exceed $100 million annually; however, the exact
extent is unknown; (2) despite SSA procedures to prevent overpayments,
and recent legislation designed to further help prevent these
overpayments to SSI recipients in nursing homes, GAO determined, based
on SSA data, that it had detected overpayments totaling $24 million to
about 31,000 recipients in fiscal year 1995; (3) in two states GAO
visited, New York and Texas, GAO determined that SSA may not have been
aware of an additional 1,699 SSI recipients recently admitted to nursing
homes during a 1-month period and potentially overpaid these individuals
$515,714 in benefits during the subsequent month alone; (4) SSA efforts
to prevent these overpayments or detect them in a timely manner have had
little success; (5) in many cases, recipients or their representative
payees did not report the change in living arrangements in a timely
manner; (6) in addition, because of other work priorities, SSA field
representatives have not routinely contacted the over 23,000 U.S.
nursing homes to solicit their cooperation in notifying SSA of
admissions of SSI recipients, as SSA policies require; (7) furthermore,
GAO's analysis of SSA data shows that overpayments to SSI recipients
residing in nursing homes have increased by nearly 13 percent since the
October 1995 effective date of the legislation that was designed to
reduce overpayments; (8) SSA could more quickly detect overpayments by
electronically obtaining nursing home admissions data directly from
states to help identify recent changes in recipients' living
arrangements; (9) SSA could then use an automated interface to
automatically adjust the benefits of SSI recipients admitted to nursing
homes who are ineligible for continuation of benefits due to temporary
institutionalization and prevent the occurrence of overpayments for the
ensuing months; (10) in the states GAO visited, GAO found that the state
Medicaid agencies can make these data available to SSA; (11) SSA could
use an existing data exchange system with states to obtain the needed
data electronically; (12) in the interim period, while some states
prepare their automated systems to make the electronic exchange of data
with SSA, states could provide SSA with tapes or paper listings of this
information for SSA's use in detecting overpayments; and (13) to identi*

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-97-62
     TITLE:  Supplemental Security Income: Timely Data Could Prevent 
             Millions in Overpayments to Nursing Home Residents
      DATE:  06/03/97
   SUBJECT:  Overpayments
             Income maintenance programs
             Electronic data interchange
             Computer security
             State-administered programs
             Computer matching
             Nursing homes
             Reporting requirements
             Federal/state relations
             Right of privacy
IDENTIFIER:  Supplemental Security Income Program
             SSA Supplemental Security Record Data Base
             Medicaid Program
             Texas
             New York
             Tennessee
             Medicaid Statistical Information System
             HCFA Medicaid Management Information System
             Resident Assessment Instrument System
             SSA File Transfer Management System
             
**************************************************************************
* This file contains an ASCII representation of the text of a GAO        *
* report.  Delineations within the text indicating chapter titles,       *
* headings, and bullets are preserved.  Major divisions and subdivisions *
* of the text, such as Chapters, Sections, and Appendixes, are           *
* identified by double and single lines.  The numbers on the right end   *
* of these lines indicate the position of each of the subsections in the *
* document outline.  These numbers do NOT correspond with the page       *
* numbers of the printed product.                                        *
*                                                                        *
* No attempt has been made to display graphic images, although figure    *
* captions are reproduced. Tables are included, but may not resemble     *
* those in the printed version.                                          *
*                                                                        *
* A printed copy of this report may be obtained from the GAO Document    *
* Distribution Facility by calling (202) 512-6000, by faxing your        *
* request to (301) 258-4066, or by writing to P.O. Box 6015,             *
* Gaithersburg, MD 20884-6015. We are unable to accept electronic orders *
* for printed documents at this time.                                    *
**************************************************************************


Cover
================================================================ COVER


Report to Congressional Requesters

June 1997

SUPPLEMENTAL SECURITY INCOME -
TIMELY DATA COULD PREVENT MILLIONS
IN OVERPAYMENTS TO NURSING HOME
RESIDENTS

GAO/HEHS-97-62

Overpayments to Nursing Home Residents

(106809)


Abbreviations
=============================================================== ABBREV

  FTMS - File Transfer Management System
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  MMIS - Medicaid Management Information System
  MSIS - Medicaid Statistical Information System
  OPIR - Office of Program and Integrity Reviews
  RAIS - Resident Assessment Instrument System
  SSA - Social Security Administration
  SSI - Supplemental Security Income program
  SSR - Supplemental Security Record

Letter
=============================================================== LETTER


B-271862

June 3, 1997

The Honorable Nancy L.  Johnson
Chairman, Subcommittee on Oversight
Committee on Ways and Means
House of Representatives

The Honorable E.  Clay Shaw, Jr.
Chairman, Subcommittee on Human Resources
Committee on Ways and Means
House of Representatives

Recent growth in the Supplemental Security Income (SSI) program and
approximately $1 billion in annual overpayments to SSI recipients
have increased congressional interest in ensuring that SSI recipients
receive only those benefits to which they are entitled.  In 1996,
about 6.6 million SSI recipients received about $24 billion in
federal payments and $3 billion in state supplemental payments, and
the maximum monthly SSI federal benefit for eligible individuals was
$470.  There were about 1.8 million individuals in nursing homes and
other similar institutions having their care paid by Medicaid at a
cost of about $39 billion in 1995, and contrary to law, some of them
were continuing to receive their full SSI benefits.  This usually
occurs because the Social Security Administration (SSA), which
administers the SSI program, is unaware that the individuals are in
Medicaid facilities. 

Because of your concern that some SSI recipients in nursing homes and
other medical treatment institutions may receive overpayments, you
asked us to determine (1) the extent of such overpayments, (2) the
success or failure of SSA actions in preventing and detecting these
overpayments, and (3) the methods by which SSA can better prevent
such overpayments. 

To answer these questions, we interviewed officials from the Health
Care Financing Administration (HCFA), which is the U.S.  Department
of Health and Human Services (HHS) agency responsible for the
Medicaid program; SSA headquarters in Baltimore, Maryland; 4 SSA
regional offices; and 13 field offices.  We also visited with
Medicaid agencies in five states (California, Florida, New York,
Tennessee, and Texas) to collect information on their Medicaid data
systems.  In addition, we analyzed SSA data on detected overpayments
caused when SSA was not notified in a timely manner of SSI
recipients' admissions to medical institutions.  We also obtained
Medicaid nursing home admissions data for December 1996 from New York
and Texas to determine the number of SSI recipients recently admitted
to nursing homes in these states and potentially receiving
overpayments.  To demonstrate the potential of an automated
information interface between SSA and state Medicaid agencies to help
minimize overpayments, we obtained Tennessee state Medicaid data on
admissions to nursing homes and other Medicaid facilities and matched
that information against the Supplemental Security Record (SSR),
SSA's payment record for the SSI program.  This showed those
recipients who were residing in nursing homes but who were still
receiving full SSI benefits.  (See app.  I for more information on
our scope and methodology.)


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

SSA estimates that overpayments to individuals in nursing homes may
exceed $100 million annually; however, the exact extent is unknown. 
Despite SSA procedures to prevent overpayments, and recent
legislation designed to further help prevent these overpayments to
SSI recipients in nursing homes, we determined, based on SSA data,
that it had detected overpayments totaling $24 million to about
31,000 recipients in fiscal year 1995.  Furthermore, in two states we
visited, New York and Texas, we determined that SSA may not have been
aware of an additional 1,699 SSI recipients recently admitted to
nursing homes during a 1-month period and potentially overpaid these
individuals $515,714 in benefits during the subsequent month alone. 

SSA efforts to prevent these overpayments or detect them in a timely
manner have had little success.  In many cases, recipients or their
representative payees\1 did not report the change in living
arrangements in a timely manner.  In addition, because of other work
priorities, SSA field representatives have not routinely contacted
the over 23,000 U.S.  nursing homes to solicit their cooperation in
notifying SSA of admissions of SSI recipients, as SSA policies
require.  Furthermore, our analysis of SSA data shows that
overpayments to SSI recipients residing in nursing homes have
increased by nearly 13 percent since the October 1995 effective date
of the legislation that was designed to reduce overpayments.  While
the effect of this legislation is difficult to determine because SSA
does not have uniform systems for either following up on admission
notifications from nursing homes or monitoring compliance with the
law, it has likely been diminished by limited SSA actions to enforce
the reporting requirement and the lack of a statutory penalty for
nonreporting by nursing homes.  Moreover, SSA's other processes to
detect overpayments in a timely manner have not been effective. 
SSA's redetermination process does not always provide timely
identification of individuals in nursing homes because
redeterminations are typically conducted only once every 6 years. 
Also, SSA's annual computer match with HCFA does not contain Medicaid
data from all states; does not result in timely identification of
admissions; and places a substantial, manual workload on field office
personnel. 

SSA could more quickly detect overpayments by electronically
obtaining nursing home admissions data directly from states to help
identify recent changes in recipients' living arrangements.  SSA
could then use an automated interface to automatically adjust the
benefits of SSI recipients admitted to nursing homes who are
ineligible for continuation of benefits due to temporary
institutionalization and prevent the occurrence of overpayments for
the ensuing months.  In the states we visited, we found that the
state Medicaid agencies can make these data available to SSA.  SSA
could use an existing data exchange system with states to obtain the
needed data electronically.  Additionally, we found that in the
interim period, while some states prepare their automated systems to
make the electronic exchange of data with SSA, states could provide
SSA with tapes or paper listings of this information for SSA's use in
detecting overpayments.  To identify the program improvements such an
automated interface could potentially produce, we conducted a joint
effort with SSA and the Tennessee Department of Health Services. 
Through this match, SSA identified $31,000 in overpayments to
individuals who had been approved for nursing home admission during
February 1996 that SSA had not previously detected.  Furthermore, by
identifying SSI recipients in nursing homes sooner, the match
demonstrated the potential to prevent an additional 9 months or more
of overpayments that would likely have occurred before SSA detected
the nursing home admissions.  SSA and state Medicaid officials told
us that they are addressing privacy concerns that may arise from this
automated match. 


--------------------
\1 Representative payees are individuals or organizations that
receive checks on behalf of SSI recipients who are unable to manage
their own affairs.  A representative payee is responsible for
dispensing the SSI payment in a manner that is in the best interest
of the recipient. 


   BACKGROUND
------------------------------------------------------------ Letter :2

The SSI program is the country's largest cash assistance program for
the poor and one of the fastest-growing federal entitlement programs. 
SSI benefits are available under title XVI of the Social Security Act
to people who are aged, blind, or disabled and have limited income
and resources.  The total SSI benefit is based on the amount of
income and resources the recipients report and are verified to have
by SSA.  The benefit consists of a basic federal payment and, in some
cases, a state supplement. 

In cases where SSI recipients are expected to be permanent residents
throughout a full calendar month in Medicaid-certified medical
treatment institutions\2 and Medicaid pays over 50 percent of the
costs of that care, the maximum SSI federal benefit is limited to $30
per month.  The benefit reduction is applicable beginning with the
first full month of permanent residence.  If the admission is not
reported promptly to SSA, a recipient may receive more than he or she
is entitled to in the months following admission.  In some cases, at
the time of application for admission to a nursing home, a physician
preliminarily determines whether the individual is expected to stay
in the facility temporarily, and this information is provided to the
state Medicaid agency.  The agency is responsible for determining
eligibility for Medicaid coverage of nursing home care.  Individuals
may continue to receive their full monthly benefit for up to 3 months
if a physician certifies that they are expected to be
institutionalized for 90 full calendar days or less and they
demonstrate the need to pay expenses to maintain their home or living
arrangement to which they may return upon discharge from the
facility.  Recipients have until the day of discharge or the 90th day
of institutionalization, whichever is earlier, to provide the
physician certification and statement of need.  SSA does not change
the benefit amount until a determination is made of whether the
recipient's nursing home stay will be temporary. 

SSA attempts to prevent overpayments to nursing home residents by
relying on recipient self-reporting and maintaining contacts with
nursing homes to obtain admissions information.  In addition to
attempting to prevent overpayments from occurring, SSA also uses its
redetermination process, a periodic review of SSI recipients'
financial eligibility, and an annual computer match with Medicaid
data provided by 28 states to HCFA to detect and stop payments that
have occurred.  (See app.  II for more detailed information on SSA
actions to prevent and detect overpayments.)


--------------------
\2 These include hospitals, nursing homes, psychiatric institutions,
and intermediate care facilities for the mentally retarded.  For the
purposes of this report, we will refer to these facilities as
"nursing homes."


   ACTUAL EXTENT OF OVERPAYMENTS
   IS UNKNOWN, BUT MAY EXCEED $100
   MILLION
------------------------------------------------------------ Letter :3

SSA's Office of Program and Integrity Reviews (OPIR), which annually
conducts detailed examinations of a sample of cases to determine the
accuracy of benefit payments, estimates that overpayments to SSI
recipients in nursing homes may exceed $100 million each year.  OPIR
identifies erroneous payments that would otherwise go undetected
because it reviews and verifies all nonmedical factors of payment
eligibility for a random sample of individuals currently receiving
benefits.  For example, OPIR reviews include visits to institutions
and recipients' residences to verify living arrangements.  These
types of in-depth examinations on a small sample of cases are in
contrast to the usual procedures used in SSA field offices.  There,
claims representatives rely primarily on recipients to self-report
changes in status because, according to SSA, it would be
cost-prohibitive for field offices to conduct the same in-depth
examinations.  As a result, many admissions to nursing homes go
undetected. 

In contrast to OPIR's estimate of potential overpayments of $100
million, we found that in fiscal year 1995 SSA detected overpayments
totaling $24 million to about 31,000 SSI recipients in nursing homes. 
Detected overpayments averaged about $800 or about 2 months of
benefits; however, SSA estimates that such overpayments can continue
for up to 9 months before they are detected.  As shown in table 1,
detected overpayments to SSI recipients in nursing homes in 1995
ranged from less than $500 to over $7,500.  Our analysis of SSA's
overpayment data showed that 1,960 recipients received in excess of
$2,500 in overpayments, including 386 who received more than $5,000. 



                          Table 1
          
           Range of SSA-Detected Overpayments to
           Nursing Home Residents in Fiscal Year
                            1995

Amount of                    Number of       Percentage of
overpayment                 recipients          recipients
------------------  ------------------  ------------------
$1-$499                         17,701                57.5
$500-$999                        6,074                19.7
$1,000-$2,499                    5,043                16.4
$2,500-$4,999                    1,574                 5.1
$5,000-$9,999                      383                 1.2
>$10,000                             3                 0.1
==========================================================
Total                           30,778               100.0
----------------------------------------------------------
Source:  SSA's Supplemental Security Record. 


      SSA IS UNAWARE OF SOME SSI
      RECIPIENTS RECENTLY ADMITTED
      TO NURSING HOMES
---------------------------------------------------------- Letter :3.1

We obtained nursing home admissions data for December 1996 from New
York and Texas, two of the states that do not provide data to HCFA
via the Medicaid Statistical Information System (MSIS) and,
therefore, are not included in the annual match with SSA.  We
determined that SSA paid $515,714 in benefits to 1,699 SSI recipients
in the month following their admission to nursing homes.  Because
these individuals were institutionalized for a full calendar month,
SSI payments to them after that time are overpayments unless the
recipients receive continuation of benefits due to temporary
institutionalization.  According to SSA records at the time of our
review, these individuals were still classified as having living
arrangements other than institutionalization, indicating SSA may not
have been aware that they were in nursing homes.  Thus, SSA would
have continued to erroneously pay them full benefits either
indefinitely or until SSA found out about the situation.  These
matches indicate both that non-MSIS states have undetected
overpayment situations and that they have information readily
available that SSA could use to minimize its SSI overpayments to
nursing home residents. 


   SSA ACHIEVED LIMITED SUCCESS IN
   PREVENTING AND DETECTING
   OVERPAYMENTS
------------------------------------------------------------ Letter :4

We found that SSA efforts to prevent and detect overpayments to
residents in nursing homes have had limited success.  SSA has not
been able to effectively prevent overpayments because some SSI
recipients (or their representative payees) are not reporting changes
in living arrangements as required, SSA field offices are not
routinely contacting facilities to identify SSI recipients residing
in the facilities, and recent legislation requiring nursing homes to
notify SSA of admissions of SSI recipients has had little effect. 
Likewise, additional efforts to detect overpayments have been
hindered by (1) redeterminations that may be too infrequent to
identify many institutionalized individuals in a timely manner and
(2) an incomplete and untimely computer match with HCFA. 


      RECIPIENTS AND
      REPRESENTATIVE PAYEES ARE
      NOT REPORTING ADMISSIONS AS
      REQUIRED
---------------------------------------------------------- Letter :4.1

SSA's first line of defense against making overpayments to nursing
home residents is reports from the SSI recipients themselves. 
However, our review of SSA records indicate that some SSI recipients
or their representative payees did not report changes in living
arrangements as required.  Of the 30,778 individuals in nursing homes
that SSA determined were overpaid in 1995, about 47 percent had
representative payees while institutionalized.  In one region we
visited, SSA found that almost 75 percent of erroneous payments to
individuals in nursing homes had been caused by recipients or their
representative payees failing to report changes in living
arrangements.  Twenty-five percent of erroneous payments had resulted
from field offices not following procedures when determining a
recipient's living arrangement. 


      SSA FIELD OFFICES NOT
      ROUTINELY OBTAINING
      ADMISSIONS DATA FROM
      FACILITIES
---------------------------------------------------------- Letter :4.2

SSA field office representatives have not routinely contacted nursing
homes to solicit their cooperation in notifying SSA of admissions, as
SSA policies require.  In October 1993, SSA established policies
requiring all field offices to work closely with the staffs of
nursing homes to facilitate the flow of information regarding the
admission to nursing homes of SSI recipients.  We found that most
field offices we contacted had not established working relationships
with the facilities, and in some cases they were not even aware of
the facilities in their area of responsibility. 

According to the field office personnel we interviewed, some nursing
homes have routinely notified SSA field offices of SSI recipient
admissions; however, field offices could not always account for the
notifications because some do not maintain a log or have standard
procedures for following up on notifications.  We found that neither
SSA headquarters staff nor field office representatives routinely
monitor facility notifications to ensure follow-up. 

Each field office manager establishes the office's work priorities,
and in the offices we visited we found that the priority placed on
following up on facility notifications varied.  We were told that
facility notifications are given much lower priority than work
responsibilities that are monitored, such as claims processing.  In
addition, both SSA field office representatives and regional office
representatives stated that some notifications would not have been
processed in a timely manner, or in some cases not at all, because
they had been misplaced or lost.  We were unable to quantify the
number of untimely or unprocessed facility notifications because no
records of notifications have been maintained. 


      EFFECT OF RECENT LEGISLATION
      IN PREVENTING OVERPAYMENTS
      IS QUESTIONABLE
---------------------------------------------------------- Letter :4.3

The effect that recent legislation\3 requiring nursing homes to
report admissions to SSA has had in preventing SSI overpayments to
nursing home residents is difficult to determine; SSA does not have a
uniform system for following up on admission notifications from
nursing homes or for monitoring compliance with the law.  However,
our analysis of overpayment data and interviews with SSA headquarters
and field office officials indicate that the legislation has had
little effect in preventing overpayments.  For example, the amount of
detected overpayments to SSI recipients in nursing homes has grown by
12.3 percent since the October 1995 effective date of the
legislation, increasing from $24 million in fiscal year 1995 to $27
million in fiscal year 1996.  In instances where facilities had
reported admissions of SSI recipients, the majority of the field
offices we visited had no system for documenting the receipt or
disposition of the admissions referrals to SSA.  As a result, SSA has
no data on which to determine whether nursing homes are complying
with the law, and there is no assurance that field office claims
representatives are following up on all admissions notifications. 

The effectiveness of the law has likely been diminished by limited
SSA efforts to carry out the reporting requirement and the lack of a
penalty for nonreporting by nursing home administrators.  SSA has not
developed any regulations establishing a uniform mechanism for
nursing homes to report admissions or revised its agency policies on
coordinating with institutions since enactment of the law.  Instead,
SSA efforts primarily focus on having its 1,300 field offices
maintain contacts and solicit information from the over 23,000 U.S. 
nursing homes.  SSA has publicized the nursing home reporting
requirement and HCFA has issued notices to nursing home
administrators informing them of their reporting responsibilities. 
The legislation, however, does not have a penalty for nonreporting by
nursing home administrators, and the amount of reimbursement nursing
homes receive for treating Medicaid patients is not affected by
reporting or not reporting; therefore, SSA must rely on voluntary
compliance by nursing homes.  In 1995, SSA requested that HCFA
develop and implement procedures for monitoring compliance with the
reporting requirement.  To date, neither SSA nor HCFA has developed
such a system. 


--------------------
\3 The Social Security Domestic Employment Reform Act of 1994 (P.L. 
103-387, sec.  6, Oct.  22, 1994). 


      OFTEN REDETERMINATIONS HAVE
      NOT IDENTIFIED
      INSTITUTIONALIZED
      INDIVIDUALS IN A TIMELY
      MANNER
---------------------------------------------------------- Letter :4.4

SSA uses its redetermination process to verify that recipients remain
financially eligible for SSI payments and are receiving the correct
amounts.  However, because of resource constraints, SSA reviews the
eligibility of most recipients only once every 6 years.  SSA records
indicated that in 1995, 4,792 of the 30,778 overpaid individuals had
redeterminations while they were in nursing homes.  We found that
3,099 individuals each had one redetermination, 352 had two, and 60
had three or more.  According to SSA records, 364 of these
redeterminations involved face-to-face contact between an SSA field
office employee and the recipient or the representative payee. 
Because of the infrequency of some redeterminations, SSA cannot rely
on this process to routinely and effectively identify in a timely
manner overpayments due to nursing home residency. 


      CURRENT COMPUTER MATCH WITH
      HCFA IS INCOMPLETE, NOT
      TIMELY, AND RESULTS IN
      UNNECESSARY FIELD OFFICE
      WORK
---------------------------------------------------------- Letter :4.5

Although SSA's computer match with state Medicaid data from HCFA
results in about $4 million in program savings each year, it only
contains data from 28 states, identifies overpayments only after they
have continued for a lengthy period, and places an unnecessary work
burden on field offices.  SSA does not independently obtain Medicaid
nursing home admissions data from states not participating in MSIS. 
Consequently, admissions of SSI recipients to nursing homes in the
remaining states, unless self-reported, are likely to go undetected
for long periods. 

In addition, SSA's computer match with HCFA is not timely.  For
example, in June 1995 HCFA matched data on possible nursing home
admissions occurring between April 1, 1994, and March 31, 1995.  The
resulting match cases were sent to SSA field offices in October 1995
to be included in their annual workload.\4 Based on our review of a
sample of cases identified using the match, we found that an average
of 14 months elapsed from the time an individual was admitted to a
nursing home until SSA headquarters notified the field office to
review the person's case.  Furthermore, it took field office
representatives an additional 4 months before they reviewed the cases
and made changes, if necessary, to the benefit amount. 

The match also incorrectly identifies many individuals as having
changed their living arrangement, therefore placing an unnecessary
and unproductive work burden on field offices.  Field office
officials told us that many of the match cases they review result in
no changes in recipients' living arrangements or benefit amounts.  We
analyzed a sample of 1996 MSIS match cases sent to field offices at
the beginning of the fiscal year and found that as of the close of
the year, SSA field offices had not completed reviews of 141 (28
percent) of the 503 cases in our sample.  About 28 percent of the
completed cases were erroneously selected for review because the
individuals were temporarily institutionalized and had been granted a
continuation of full benefits.  Another 26 percent of the completed
cases identified individuals who did not require a change in benefit
amount.  SSA officials are aware of the deficiencies in the match
selection criteria that result in temporarily institutionalized
individuals or those in nursing homes for less than a full calendar
month being selected for review.  However, they have yet to change
the criteria to only identify individuals institutionalized for a
full calendar month who have not been granted a continuation of full
benefits because of temporary institutionalization. 


--------------------
\4 Field office workloads consist of processing initial claims and
completing postentitlement actions, such as redeterminations, benefit
recomputations, and address changes. 


   AUTOMATED INTERFACE COULD HELP
   PREVENT OVERPAYMENTS
------------------------------------------------------------ Letter :5

Obtaining MMIS data on nursing home admissions directly from states
and conducting an automated interface in accordance with laws and
standards governing computer matching, privacy, and security could
provide SSA with the opportunity to prevent or detect erroneous
payments more quickly, without the use of SSA field office personnel,
and could result in program savings and reduced administrative costs. 
The cost and ease of states making MMIS data directly available to
SSA electronically will vary depending upon the level of automation
in each state.  However, we have discussed this with selected state
Medicaid, HCFA, and SSA officials, who agreed that such a data
exchange would be both practical and desirable. 

Currently, for those who do not self-report their nursing home
admission, our review of a sample of 1996 cases found that it takes
an average of 14 months from the time an individual enters a facility
until the overpayment is detected using the annual computer match
with HCFA data that are only available from 28 states, and takes an
additional 4 months for the benefit amount to be reduced by SSA.  By
electronically obtaining nursing home admissions data directly from
state Medicaid agencies SSA could prevent overpayments or detect them
much sooner--1 to 3 months after they begin--for all 50 states.  For
example, an automated interface could consist of matching SSI payment
data with monthly nursing home admissions data from state Medicaid
Management Information Systems (MMIS) obtained using existing
telecommunications lines.\5 According to SSA and HCFA officials, SSA
could obtain the data directly from states by modifying existing
state data exchange agreements\6 to make SSA the recipient agency of
state MMIS data on nursing home admissions. 

A way to efficiently use state MMIS data on nursing home admissions
would be through an automated system.  An individual identified in
the data as residing in a facility for a full calendar month and
subject to a benefit reduction could automatically be sent a notice
generated by computer explaining the detection of a potential
overpayment situation, the potential revised payment amount, criteria
for receiving the continuation of benefits if the recipient is
temporarily institutionalized, and the process for appealing the
benefit reduction.  Following a reasonable response time period to
provide due process, the computer could, in appropriate cases,
automatically adjust the SSI benefit to the correct amount for the
appropriate months' payments.  Field office claims representatives
would not have to review the case or manually input changes to the
recipient's payment file in order to correct the benefit amount. 
This would minimize the time period over which the overpayment
occurs, thereby saving program dollars, and would reduce field office
time devoted to this activity, freeing it for other purposes.  In
those cases in which individuals requested, and were determined to be
eligible for continuation of benefits due to temporary
institutionalization, SSA could manually input changes to the
recipients' files, overriding the automatic benefit reduction and
thereby continuing uninterrupted full benefit payments.  Such an
automated system would require testing on SSA's part to ensure the
reliability of state data for making automatic payment reduction
decisions and to minimize the risk of inappropriate reductions. 

Some states have already demonstrated their capability to share data
with SSA to prevent and detect overpayments.  Currently, the SSI
payment file is matched with data from the 28 states participating in
MSIS.  Furthermore, in 1994, SSA began establishing direct
connections between its field offices and states that had automated
databases that could be easily linked to SSA's computer system. 
Currently, 15 states have entered into agreements allowing SSA field
offices to directly access certain state databases containing
information SSA can use to verify recipients' reported income and
other factors of financial eligibility. 

State Medicaid and SSA field office officials we interviewed said
that SSA's routinely obtaining nursing home admission data directly
from states could provide the best opportunity to prevent or detect
overpayments to SSI recipients in nursing homes.  Three of the states
we visited do not participate in MSIS, but the Medicaid officials in
these states said that they can make nursing home admissions data
available to SSA electronically.  Tennessee has already made various
state databases available for use by SSA field offices.  New York and
Texas are negotiating with SSA to establish pilot projects granting
SSA access to certain state databases. 


--------------------
\5 These lines, known as the File Transfer Management System (FTMS),
already exists between SSA headquarters and the states.  SSA
installed FTMS so that it could transmit SSA data on its clients to
every state.  State agencies are required by the 1984 Deficit
Reduction Act to use this information to better identify those who
are not eligible for public assistance or who are receiving incorrect
benefits. 

\6 At least monthly, SSA makes available to all states SSI
eligibility and payment information to assist them in administering
SSI state supplemental payments and other federally funded programs
such as Medicaid and food stamps. 


      PILOT MATCH WITH TENNESSEE
      DEMONSTRATES FEASIBILITY AND
      EFFECTIVENESS OF DIRECTLY
      OBTAINING STATE DATA
---------------------------------------------------------- Letter :5.1

To help demonstrate the feasibility of SSA's directly obtaining state
Medicaid nursing homes' admissions data and more quickly detecting
overpayments, we coordinated a joint effort between SSA and the
Tennessee Department of Health Services to identify SSI recipients in
nursing homes.  On the basis of data we obtained from Tennessee and
provided to SSA, SSA detected $31,000 in overpayments to 40 SSI
recipients from February to July 1996.  These recipients had not
previously been identified by SSA as residing in nursing homes.  The
overpayment amounts ranged from less than $10 to almost $1,800, and
the average overpayment was $775.  In addition to detecting
overpayments, the pilot allowed SSA to prevent at least 9 months of
additional overpayments to individuals that would likely have gone
undetected and that SSA would not have been likely to collect.  The
pilot match in Tennessee, a state that accounts for about 3 percent
of all SSI recipients, demonstrates that by directly obtaining state
MMIS data, SSA could not only more quickly identify SSI recipients in
nursing homes, but also prevent future overpayments. 


      SSA CURRENTLY CONDUCTS
      AUTOMATED INTERFACES WITH
      SOME FEDERAL AGENCIES
---------------------------------------------------------- Letter :5.2

SSA already conducts routine automated computer interfaces with the
Department of Veterans Affairs, the Office of Personnel Management,
and the Railroad Retirement Board that result in automatic benefit
reductions without SSA field office involvement.  In each of these
interfaces, SSR and files from the source agencies are matched.  When
the match determines that an individual on both the SSR and the
source agency file are the same person and there has been a change in
income affecting the SSI benefit, the system automatically adjusts
the benefit and generates a notice to the recipient about the revised
payment amount.  Before any benefit reduction occurs, a recipient has
10 days after receiving notification of the benefit change to file an
appeal and continue receiving unreduced benefits, otherwise the
benefit reduction occurs automatically, without a field office
representative reviewing the case.  SSA estimates that these
interfaces result in about $41 million in program savings each year. 


      SSA AND STATES HAVE TAKEN
      ACTIONS THAT ADDRESS PRIVACY
      AND SECURITY CONCERNS RAISED
      BY ELECTRONIC DATA EXCHANGES
---------------------------------------------------------- Letter :5.3

Certain privacy and security concerns may arise when data are
exchanged electronically between agencies.  These concerns center on
ensuring that personal information that an individual provides to one
government agency is protected from being disclosed to other agencies
that do not have a legal right to it.  Granting SSA direct access to
state Medicaid data will not violate the privacy rights of
individuals who provide this information because SSA will simply
electronically obtain information to which it already has a legal
right.  SSA already obtains this information from 28 states using
HCFA's MSIS data. 

As part of its procedures to determine whether to implement
electronic data exchanges with state agencies, SSA assesses the
costs, benefits, and security risks of conducting such exchanges. 
According to SSA officials, an automated computer interface between
SSA and state MMIS would be subject to the same procedures and
feasibility testing prior to nationwide implementation.  Although we
did not evaluate the effectiveness of SSA's or the states' security
procedures, SSA and state officials told us that these procedures
will be stringent enough so that SSA can obtain state data
electronically and conduct automated interfaces without compromising
confidentiality.  SSA and states have taken steps specified in
federal security standards that, we were told, would ensure the
confidentiality and security of data exchanged electronically.  These
include instituting written agreements between SSA and state agencies
regarding how the data will be used and using computer lines
dedicated solely to the transmission of data between government
agencies. 


      STATES CAN PROVIDE DATA TO
      SSA IN OTHER FORMATS WHILE
      PREPARING TO MAKE IT
      AVAILABLE ELECTRONICALLY
---------------------------------------------------------- Letter :5.4

In the interim period, while states are preparing to make the
necessary nursing home admissions data directly available to SSA
electronically, they could provide SSA with tapes or paper listings
of admissions to nursing homes.  SSA could use this information to
detect overpayments sooner than it can using data from the current
annual computer match.  In the states that we contacted during our
review, state officials told us that providing this information to
SSA routinely would require only minimal computer programming to
format the data for SSA's use.  Two states we visited, New York and
Texas, provided this information to us on computer tapes so that we
could identify previously undetected potential overpayments to
nursing home residents in those states. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

Generally, SSI benefits are supposed to be reduced for those
individuals in nursing homes for more than a full calendar month when
Medicaid is paying the cost of care.  For many years, however, SSA
has lacked an effective process to prevent SSI recipients in nursing
homes from receiving overpayments.  It has relied primarily on (1)
inadequate self-reporting by recipients, (2) inconsistent and
irregular field office contacts with nursing homes, (3) untimely
redeterminations, and (4) an incomplete computer match with Medicaid
data from HCFA that does not result in timely identification of
nursing home admissions.  Neither SSA's efforts nor the recent
legislation requiring nursing homes to report admission of SSI
recipients to SSA has been fully effective.  As a result, SSA
continues to overpay millions of dollars to thousands of recipients
in nursing homes.  Given SSA's experience that only about 15 percent
of outstanding overpayments to SSI recipients are collected, it is
important that SSA detect these overpayments as soon as possible and
prevent future overpayments. 

HCFA has the authority to require states to make available to SSA
MMIS information on nursing home admissions.  States would be paid 90
percent of the costs of developing the necessary capabilities and 75
percent of the operating costs.  Our efforts with three states have
shown that directly obtaining state MMIS data could help SSA prevent
or more quickly detect overpayments and simultaneously reduce the SSA
field office workload.  In the interim, while such arrangements are
being made, states could provide tapes or hard copies of these data
to SSA to help control its payments, with minimal effort or cost to
the states.  Preventing or detecting erroneous payments more quickly
and decreasing SSA's reliance on recipients and nursing homes to
report changes in circumstances that affect eligibility would bolster
the integrity of the SSI program by helping ensure that clients are
receiving only those benefits to which they are entitled and would
save both program and administrative costs. 


   RECOMMENDATIONS
------------------------------------------------------------ Letter :7

To prevent overpayments to SSI recipients in nursing homes or detect
them sooner, we recommend that the Secretary of Health and Human
Services direct the Administrator of HCFA to require states, as part
of MMIS systems requirements, to include information on nursing home
admissions as standard data elements in their MMIS and make these
data elements available to SSA electronically, in accordance with the
laws and standards governing computer matching, privacy, and
security. 

We also recommend that the Commissioner of SSA take the following
actions: 

  Establish agreements with the states to routinely obtain state MMIS
     data on nursing home admissions electronically, as soon as
     feasible. 

  Establish interim agreements with state Medicaid agencies, while
     states adapt their systems to make this information available to
     SSA electronically, to obtain computer tapes or paper listings
     of admissions to nursing homes and use this information to
     identify overpayment situations and begin recovery actions and
     payment reductions. 

  Determine the reliability of state MMIS data for purposes of
     supporting automatic benefit reductions for those SSI recipients
     identified as residing in nursing homes for a full month who are
     not eligible for continuation of full benefits due to temporary
     institutionalization and, if the data are reliable, implement a
     system for automatic benefit reduction. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :8

In commenting on a draft of this report, SSA agreed that improvements
can be made in obtaining and processing nursing home admissions data
on SSI recipients (see app.  III).  SSA noted that it has been
working on solutions to this problem, including obtaining MSIS data,
which are submitted voluntarily by 28 states, from HCFA. 
Acknowledging that MSIS data do not cover all admissions, SSA is
working with HCFA to determine if HCFA's new system, the Resident
Assessment Instrument System (RAIS), can be used to identify SSI
recipients in nursing homes in a more timely manner.  The primary
purpose of collecting the assessment information is to help nursing
home staff plan and evaluate the care they provide to residents.  SSA
said that should RAIS not prove feasible, it would then consider the
recommendations in our report. 

We have no objection to SSA's use of RAIS, if in fact it is the most
effective and efficient way of reducing SSI overpayments to nursing
home residents.  However, while RAIS may provide SSA with the data it
needs to more quickly identify SSI recipients in nursing homes, we
have several significant concerns in this regard.  First, not all
states participate in RAIS.  While HCFA has instructed all Medicare-
and Medicaid-certified nursing facilities to complete the assessment
on all residents upon admission, currently HCFA does not require that
the assessment results be submitted to it or any other entity. 
According to HCFA officials, HCFA will require all states to
participate in RAIS as part of the President's fiscal year 1998
budget proposal to create a separate prospective payment system for
nursing homes.  HCFA officials told us that they do not know whether
this proposal will be adopted.  However, contrary to SSA's comments
on our report, HCFA already has the authority to require all states
to make nursing home admissions data available to SSA using state
MMIS, as we suggested in this report. 

Second, we are concerned about the reliability of the RAIS data in
identifying whether Medicaid is paying for the nursing home care,
which is a key factor in determining whether a recipient's SSI
benefit amount is affected by residency in a nursing home.  According
to HCFA officials, facilities' nursing staffs would most likely be
completing the assessments and may not be familiar with the source of
payment for the residents.  If the nurses do not accurately complete
the source of payment information on the assessment forms, SSA would
be matching its file with erroneous payment data from RAIS.  The MMIS
information we recommend that SSA use is treatment authorization or
paid claims data already approved by the state Medicaid agency. 

A third issue concerning RAIS is timeliness.  RAIS is still being
piloted and, according to HCFA officials, may not be fully
operational in all states at least until summer 1998, which would
allow the current level of related SSI overpayments to continue for
over a year.  SSA stated in its comments on this report that MMIS
data would be available only quarterly.  However, MMIS data can be
provided monthly or even more frequently if sent from the states
directly to SSA.  Consequently, we continue to believe that
electronically obtaining nursing home admission data directly from
states provides SSA with the best opportunity to detect nursing home
admissions more quickly than its current efforts and also to prevent
additional overpayments. 

In the interim, while SSA determines whether RAIS is the best
solution for identifying SSI recipients in nursing homes, we believe
that obtaining MMIS data directly from states each month through
computer tapes or paper listings is preferable to the delays
experienced under SSA's current procedures.  The states we contacted
said that they could format the data for SSA's use and provide data
to SSA on a monthly basis.  Furthermore, two states we visited
demonstrated that nursing home admissions data could be made
available by providing us with computer tapes that allowed us to
identify previously undetected potential overpayments. 

Finally, SSA said that it is highly questionable that a system for
automatic benefit reduction can be implemented because of the
in-depth information required to determine whether a recipient is
eligible for continued benefits due to temporary
institutionalization.  As we stated in the report, the benefit
reduction would occur only after automated notices were sent to
recipients asking if they resided in the nursing home for more than a
full calendar month and the appropriate due process procedures were
followed.  For those recipients requesting a continuation of
benefits, the automated reduction would be suspended, and SSA would
then follow its current procedures for determining eligibility for
continued benefits.  Only the benefits of those recipients remaining
in nursing homes and not requesting a continuation of benefits would
automatically be reduced without field office review. 

In commenting on a draft of this report, HHS noted HCFA's willingness
to provide the MSIS data it now receives from the states to SSA on a
quarterly rather than annual basis.  (See app.  IV.) This suggestion
fails to recognize the underlying reason for our specific
recommendation.  Having HCFA involved in the pass-through of
information between the states and SSA causes both an unnecessary
expense for HCFA and a timeliness delay for SSA.  The SSI program
needs access to nursing home admissions data as quickly as possible
after the actual admissions to minimize the overpayments it makes. 
Consequently, we continue to believe that the most effective data
transfer is directly between the states and SSA on as frequent a
basis as possible. 

HHS also commented about the need to offset the costs associated with
our recommendation for each state and for HCFA against the benefits
to be derived by the SSI program.  We agree.  As stated in this
report, we were told by both officials of the states we visited and
knowledgeable officials in HCFA that only minimal computer
programming would be required to format the data for SSA's use.  It
should also be noted that the federal government would pay 90 percent
of the developmental costs and 75 percent of the operating costs for
operating such a data exchange system, thereby further reducing the
burden of this change on the states.  The minimal costs associated
with developing and operating such a system, including those incurred
by SSA, should be compared with the tens of millions of dollars in
reduced overpayments to the SSI program that our work indicates would
accrue.  Moreover, if our recommendations are adopted, HCFA will no
longer be asked to provide MSIS data to SSA, thereby saving HCFA the
costs it currently incurs. 

Finally, HHS suggested that we also investigate using the RAIS
database as another alternative to our recommendation.  As stated in
our response to SSA's comments on this report, it is unknown when all
states will participate in contributing data on nursing home
admissions to RAIS, and the reliability of this system for
identifying whether Medicaid is paying for the nursing home care is
questionable.  This information is paramount to determining whether
an SSI overpayment has been made. 

SSA and HHS also made other technical comments, which we incorporated
throughout the report as appropriate. 


---------------------------------------------------------- Letter :8.1

We are sending copies of this report to relevant congressional
committees; the Director, Office of Management and Budget; the
Commissioner, SSA; the Secretary of Health and Human Services; and
other interested parties.  Copies will also be made available to
others on request.  If you or your staff have any questions
concerning this report, please call me on (202) 512-7215.  Other GAO
contacts and staff acknowledgments are listed in appendix V. 

Jane L.  Ross
Director, Income Security Issues


OBJECTIVES, SCOPE, AND METHODOLOGY
=========================================================== Appendix I

To determine the extent of overpayments to individuals because they
resided in nursing homes, we reviewed the Supplemental Security
Record, the Social Security Administration's payment record for the
Supplemental Security Income program.  We obtained fiscal year 1995
and 1996 data and identified those individuals SSA determined had
been paid erroneously because of institutionalization in nursing
homes.  We analyzed the payment record and developed aggregate
information on overpaid recipients. 

To determine the success or failure of SSA's actions in preventing
and detecting overpayments, we interviewed SSA headquarters officials
in Baltimore, Maryland; 4 regional offices; and 13 field offices.  In
addition to these discussions, we analyzed the SSR to determine the
effectiveness of SSA's match with the Health Care Financing
Administration.  Of the 5,907 fiscal year 1996 Medicaid Statistical
Information System match cases sent to the field offices for review,
we identified the 503 cases that appeared in SSA's 10-percent sample
data files.  These files are random samples of all cases in a given
month on the SSR.  SSA field offices had completed reviews of 362 of
the 503 cases as of the end of the fiscal year.  We obtained and
analyzed payment history data for the completed cases to determine
the outcome of SSA's matching effort. 

Finally, to determine methods by which SSA can better prevent
overpayments, we interviewed state Medicaid officials in five states
to obtain information about Medicaid data systems to determine the
feasibility of conducting an automated interface with SSA.  We
selected Tennessee because of its advancements in providing
electronic access to the state's information systems.  We selected
the other four states (California, Florida, New York, and Texas)
because they have the four largest SSI populations, accounting for
almost 40 percent of the total SSI population.  We obtained Medicaid
nursing home admissions data for December 1996 from New York and
Texas and matched it against the SSI payment file to identify SSI
recipients admitted in that month to nursing homes in these states
and the resulting potential overpayments.  Moreover, we coordinated a
pilot between SSA and the Tennessee Department of Health Services to
further document the feasibility of SSA's directly obtaining state
Medicaid data.  Tennessee officials provided data on all individuals
in Tennessee approved for admission to nursing homes in February 1996
and paid claims data from February through July 1996.  We used these
data to determine the length of nursing home stays.  We provided this
information to SSA and had SSA systems analysts develop a computer
program to compare Tennessee's admissions and paid claims data with
SSR data to identify SSI recipients who had received overpayments
because they resided in nursing homes. 

Since SSR and the state Medicaid information systems are subject to
periodic quality assurance reviews, we did not independently examine
the computer system controls for them.  Except for this limitation,
we conducted our review between April 1996 and April 1997 in
accordance with generally accepted government auditing standards. 


SSA ACTIONS TO PREVENT AND DETECT
OVERPAYMENTS
========================================================== Appendix II

SSA RELIES ON REPORTING BY
RECIPIENTS AND NURSING HOMES TO
PREVENT OVERPAYMENTS

SSA requires that recipients report entrance into nursing homes as
quickly as possible.  However, because many recipients do not report
this information, SSA also establishes working relationships with
nursing homes to obtain admission and discharge information on the
SSI population.  Furthermore, legislation was enacted, effective in
October 1995, to require that nursing homes provide this information
to SSA. 

At the time of application for benefits, claims representatives in
SSA field offices inform SSI recipients that they are required to
report information that may affect their eligibility or payment
amounts.  If the recipient has a representative payee, the payee is
responsible for reporting such information to SSA.  Significant
events to be reported include a change in income, resources, marital
status, or living arrangements, such as admission to or discharge
from a nursing home.  Failure to report such changes can result in
monetary penalties of up to $100 per event. 

Although SSI recipients are the primary source for reporting changes
in their living arrangements, SSA recognizes that recipients entering
nursing homes may not always report their admissions on a timely
basis, if at all.  Therefore, SSA attempts to obtain admission and
discharge information directly from nursing homes.  In October 1993,
SSA instructed its field offices to work closely with nursing homes
to facilitate the flow of information regarding the admission of SSI
recipients.  Field offices are to maintain ongoing contact with all
appropriate institutions in their service areas, use regular visits
as a means to encourage cooperation, and establish procedures for
institutions to make timely reports on events that affect SSI
recipients' eligibility and benefit amount.  Also, the Social
Security Act, as recently amended, states that the Commissioner of
SSA must require each administrator of a nursing home to report
within 2 weeks any admission occurring on or after October 1, 1995,
of any eligible individual or eligible spouse receiving SSI benefits. 
The legislation was designed to prevent overpayments to SSI
recipients who failed to report their admission to nursing homes.  To
comply with the legislation, SSA and HCFA notified nursing home
administrators of the reporting requirement.  The law, however, did
not contain a penalty for nonreporting by nursing home
administrators. 

SSA ACTIONS TO DETECT OVERPAYMENTS
ONCE THEY HAVE BEEN MADE

In addition to relying on recipient self-reporting and contacts with
nursing homes to prevent overpayments, SSA uses its redetermination
process and an annual computer match to detect such payments once
they have occurred.  A redetermination is a review of financial
eligibility factors to ensure that recipients are still eligible for
SSI payments and are receiving the correct amount.  A redetermination
addresses financial eligibility factors such as income, resources,
and living arrangements and can be conducted by mail, telephone, or
face-to-face interview.  Given its limited resources, SSA conducts
redeterminations on over two-thirds of the SSI population receiving
benefits approximately once every 6 years but may conduct them more
frequently if it determines that changes in eligibility or erroneous
payments are likely.  Recipients with a history of recent earnings
are likely to be redetermined more often than recipients, such as
institutionalized individuals, who generally do not experience
fluctuations in their income or resources.  The redetermination
procedure includes a question for recipients about whether the
recipient spent a full calendar month in a hospital, nursing home,
other institution, or any place other than the recipient's normal
residence.  With this question, SSA hopes to identify situations
where overpayments to recipients may have occurred. 

SSA has conducted an annual computer match with HCFA since 1992 to
identify SSI recipients in nursing homes.  Currently, SSA sends a
file to HCFA containing identifying information on all SSI recipients
residing in the 28 states that provide data to HCFA via the Medicaid
Statistical Information System (MSIS).  The MSIS file contains
Medicaid usage data submitted by states on a voluntary basis.  HCFA
matches the MSIS nursing home admissions data with the SSA file to
identify SSI recipients who resided in nursing homes during the
period covered by the match and sends a file to SSA with this
information.  After reviewing the match results, SSA deletes cases in
which individuals (1) have self-reported their admission to SSA, (2)
are not in current pay status, or (3) are deceased.  SSA then
distributes information on potential overpayment situations to the
appropriate field offices during October of each year.  According to
SSA procedures, field office representatives are to contact the
recipients or nursing homes during the balance of the fiscal year to
determine if overpayments have been made.  SSA does not begin
overpayment recovery efforts until recipients are discharged from
facilities and are eligible to receive their full SSI benefit. 

Although SSA uses the MSIS data from 28 states to help detect
overpayments, Medicaid data from all states exist and could be used
by SSA more frequently than once a year.  Generally, nursing homes
report admissions of individuals and file claims for reimbursement
with state Medicaid agencies in a timely manner to ensure rapid
payments from Medicaid to them.  States use automated systems, known
as Medicaid Management Information Systems (MMIS), to process claims
and to capture and report data needed by HCFA and the states to
manage the Medicaid program.  The Secretary of Health and Human
Services has broad authority to require states to report data that
HCFA needs to administer the Medicaid program.  State MMIS must meet
performance standards as well as system and compatibility
requirements established by HCFA.  HCFA requires each state's MMIS to
include 122 standard data elements and pays 90 percent of the
development costs and 75 percent of the operating costs of these
systems. 




(See figure in printed edition.)Appendix III
COMMENTS FROM THE SOCIAL SECURITY
ADMINISTRATION
========================================================== Appendix II



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)




(See figure in printed edition.)Appendix IV
COMMENTS FROM THE DEPARTMENT OF
HEALTH AND HUMAN SERVICES
========================================================== Appendix II



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


GAO CONTACTS AND ACKNOWLEDGMENTS
=========================================================== Appendix V

GAO CONTACTS

Roland H.  Miller III, Assistant Director, (202) 512-7246
George A.  Scott, Evaluator-in-Charge, (202) 512-5932

ACKNOWLEDGMENTS

In addition to those named above, the following individuals also made
important contributions to this report:  Mary Ellen Fleischman,
Evaluator; James C.  Lawson, Evaluator; Graham D.  Rawsthorn,
Evaluator; John G.  Smale, Jr., Senior Social Science Analyst; and
James P.  Wright, Assistant Director (Study Design and Analysis). 


*** End of document. ***