Reports & Testimonies

  • GAO’s recommendations database contains report recommendations that still need to be addressed.

    GAO’s recommendations help congressional and agency leaders prepare for appropriations and oversight activities, as well as help improve government operations. Recommendations remain open until they are designated as Closed-implemented or Closed-not implemented. You can explore open recommendations by searching or browsing.

    GAO's priority recommendations are those that we believe warrant priority attention. We sent letters to the heads of key departments and agencies, urging them to continue focusing on these issues. These recommendations are labeled as such. You can find priority recommendations by searching or browsing our open recommendations below, or through our mobile app.

  • Browse Open Recommendations

    Explore priority recommendations by subject terms or browse by federal agency

    Search Open Recommendations

    Search for a specific priority recommendation by word or phrase



  • Governing on the go?

    Our Priorities for Policy Makers app makes it easier for leaders to search our recommendations on the go.

    See the November 10th Press Release


  • Have a Question about a Recommendation?

    • For questions about a specific recommendation, contact the person or office listed with the recommendation.
    • For general information about recommendations, contact GAO's Audit Policy and Quality Assurance office at (202) 512-6100 or apqa@gao.gov.
  • « Back to Results List Sort by   

    Results:

    Subject Term: "Managed health care"

    23 publications with a total of 57 open recommendations including 6 priority recommendations
    Director: Katherine Iritani
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To improve CMS's oversight of states' MLTSS programs, the Administrator of CMS should take steps to identify and obtain key information needed to oversee states' efforts to monitor beneficiary access to quality services, including, at a minimum, obtaining information specific to network adequacy, critical incidents, and appeals and grievances.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To build upon CMS's collaborative audit efforts and help enhance future collaboration, CMS should identify opportunities to address barriers that limit states' participation in collaborative audits. Such opportunities could include improving communication with states before, during, and after audits are completed; and ensuring that audits align with states' program integrity needs, including the need for oversight of services provided in managed care delivery systems.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To better support states' efforts to reduce improper payments and communicate effective program integrity practices across the states, CMS should collaborate with states to develop a systematic approach to collect promising state program integrity practices.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To better support states' efforts to reduce improper payments and communicate effective program integrity practices across the states, CMS should collaborate with states to create and implement a communication strategy for sharing promising program integrity practices with states in an efficient and timely manner.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should establish standard reporting guidance for personal care services collected through Transformed-MSIS (T-MSIS) to ensure that key data reported by states, such as procedure codes, provider identification numbers, units of service, and dates of service, are complete and consistent.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure, for all types of personal care services programs, that data on provision of personal care services and other home-and community-based services (HCBS) collected through T-MSIS claims can be specifically linked to the expenditure lines on the CMS-64 that correspond with those particular types of HCBS services.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should better ensure that personal care services data collected from states through T-MSIS and MBES comply with CMS reporting requirements.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve the collection of complete and consistent personal care services data and better ensure CMS can effectively monitor the states' provision of and spending on Medicaid personal care services, CMS should develop plans for analyzing and using personal care services data for program management and oversight.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should require all states to collect and report on progress toward achieving MLTSS program goals, such as whether the program enhances the provision of community-based care.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should establish criteria for what situations would warrant exceptions to the federal standards that the data used to set rates be no older than the three most recent and complete years.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To improve oversight of states' payment structures for MLTSS, the Administrator of CMS should provide states with guidance that includes minimum standards for encounter data validation procedures.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Brenda S. Farrell
    Phone: (202) 512-3604

    7 open recommendations
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to assess the Triad of Care model's effectiveness in light of the changes in WTU diagnoses and take the appropriate action.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to exercise oversight responsibility to track full adherence to selection processes for squad leaders and platoon sergeants, including the requirement to conduct interviews for these positions.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop a mechanism to conduct post-training assessments on squad leaders and platoon sergeants' application of training to the work environment and incorporate the results into the training program.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop plans to adjust staff levels, if needed, to accommodate a potential future surge in demand.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to establish a process that assigns oversight responsibility for tracking instances in which Commanders make exceptions to WTU entrance criteria so that the Army Surgeon General is aware of the extent Commanders' decisions are consistent with program goals.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To increase oversight of the Army's Warrior Transition Unit program, the Secretary of the Army should direct the Army Surgeon General to develop and implement an approach and associated procedures for providing senior leadership, such as the Warrior Transition Command, with complaints information concerning the WTU program and WTU soldiers.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Recommendation: To help ensure the best use of resources for managing the medical care of soldiers recovering from serious medical conditions, the Secretary of the Army should direct the Chief of the Army Reserve, in conjunction with the Army Surgeon General, to develop an analysis that compares the costs and benefits of maintaining the current system of Community Care Units with the costs and benefits of expanding the Reserve Component Managed Care program.

    Agency: Department of Defense: Department of the Army
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To help provide reasonable assurance that VHA achieves its long-term goal of modernizing its claims processing system, the Secretary of Veterans Affairs should direct the Under Secretary for Health to ensure that the agency develops a sound written plan that includes the following elements: (1) a detailed schedule for when VHA intends to complete development and implementation of each major aspect of its new claims processing system; (2) the estimated costs for implementing each major aspect of the system; and (3) the performance goals, measures, and interim milestones that VHA will use to evaluate progress, hold staff accountable for achieving desired results, and report to stakeholders the agency's progress in modernizing its claims processing system.

    Agency: Department of Veterans Affairs
    Status: Open
    Priority recommendation

    Comments: As of June 2017, VHA's Office of Community Care is in the process of consolidating VA's community care programs, and as part of this process it plans to transition to a third party administrator for the purposes of claims processing. While an active procurement is underway, VHA still needs to develop a written plan to fully implement this recommendation. VHA's written plan must include details about the schedule, cost estimates, performance goals, and interim milestones associated with transitioning to a third party administrator for the purposes of processing claims for VA community care.
    Director: Kathleen King
    Phone: (202) 512-7114

    3 open recommendations
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, Office of Medicare Hearings and Appeals (OMHA), or Departmental Appeals Board (DAB) to modify the various Medicare appeals data systems to collect information on the reasons for appeal decisions at Level 3.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, OMHA and DAB were considering the cost and technical feasibility of collecting this information within their appeals data systems. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to capture the amount, or an estimate, of Medicare allowed charges at stake in appeals in Medicare Appeals System (MAS) and Medicare Operations Division Automated Case Tracking System (MODACTS).

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, this information was not captured in any CMS system, including MAS. HHS reported that if MAS is modified to capture the amount of Medicare allowed charges at stake, OMHA will consider modifying its Electronic Case Adjudication and Processing Environment (ECAPE) to include this information as well, and DAB can capture it in a new case management system currently being developed by the agency. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Recommendation: To reduce the number of Medicare appeals and to strengthen oversight of the Medicare FFS appeals process, the Secretary of Health and Human Services should direct CMS, OMHA, or DAB to modify the various Medicare appeals data systems to collect consistent data across systems, including appeal categories and appeal decisions across MAS and MODACTS.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: According to HHS as of August 2016, HHS reported taking several initial steps to standardize data across Medicare appeals systems. Specifically, HHS stated that, in November 2016, CMS will modify MAS to standardize appeal categories between Levels 1 through 3 and that OMHA will incorporate the standardized MAS appeal categories for Levels 1 and 2 into ECAPE in its next release. DAB will also work to incorporate these standardized categories into its new appeals data system. In addition, HHS reported that CMS is working to modify MAS to collect additional information related to appeal decisions. As of September 2017, HHS officials have not implemented this recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Randall B. Williamson
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To enhance oversight of access to mental health care and help ensure that servicemembers have timely access to mental health care, the Secretary of Defense should direct the Assistant Secretary of Defense for Health Affairs to establish an access standard for mental health follow-up appointments and regularly monitor data on these appointments.

    Agency: Department of Defense
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    3 open recommendations
    including 2 priority recommendations
    Recommendation: To improve the effectiveness of states' and plans' Medicaid managed care (MMC) plan provider screening efforts, the Acting Administrator of CMS should consider which additional databases that states and MMC plans use to screen providers could be helpful in improving the effectiveness of these efforts and determine whether any of these databases should be added to the list of databases identified by CMS for screening purposes.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS concurred with this recommendation. CMS analyzed 22 databases that were reported to GAO as being used by Medicaid managed care plans to screen providers. It determined that several were already in use by CMS and mentioned in its guidance, several required more study by CMS, and others were not reliable. In April 2017, we reviewed CMS's analysis. For 8 of the databases, CMS noted that more information is needed, including the availability of the data and whether CMS would need an identifier to link providers to the data. CMS has requested additional information for these databases and has not yet concluded whether the databases should be added to the list of databases it has identified for screening purposes. To close the recommendation, CMS will need to determine whether the remaining databases it has studied should be added to the CMS list of databases to be used for provider screening and take the appropriate action.
    Recommendation: To improve the effectiveness of states' and plans' MMC plan provider screening efforts, the Acting Administrator of CMS should collaborate with SSA to facilitate sharing CMS's Death Master File subscription with state Medicaid programs.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: HHS concurred with this recommendation. CMS has signed an Interagency Agreement that provides for the states' ability to access the SSA Death Master File. CMS said that it will provide Death Master File information to specific individuals within each state in the near future. To close the recommendation, CMS will need to begin to provide the states with access to Death Master File data and provide us with documentation that it has done so.
    Recommendation: To improve the effectiveness of states' and plans' MMC plan provider screening efforts, the Acting Administrator of CMS should coordinate with other federal agencies, as necessary, to explore the use of an identifier that is relevant for the screening of MMC plan providers and common across databases used to screen MMC plan providers.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with the recommendation. We will update the status of this recommendation when we receive additional information.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    12 open recommendations
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to establish FHCC-specific selection criteria for the FHCC facility director and deputy director positions that include responsibilities and leadership competencies for effective collaboration.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to establish FHCC-specific selection criteria for the FHCC facility director and deputy director positions that include responsibilities and leadership competencies for effective collaboration.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to ensure that the evaluation of the leadership performance at the FHCC is carried out jointly between VA and DOD.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to ensure that the evaluation of the leadership performance at the FHCC is carried out jointly between VA and DOD.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide additional guidance on the patient priority system to all staff responsible for approving consults and ensure that the monthly capability and capacity reports include information on all categories of FHCC patients defined by the patient priority system.

    Agency: Department of Defense
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Recommendation: The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide additional guidance on the patient priority system to all staff responsible for approving consults and ensure that the monthly capability and capacity reports include information on all categories of FHCC patients defined by the patient priority system.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: We will update the status of this recommendation when we determine what steps the agency has taken to implement it.
    Director: Katherine Iritani
    Phone: (202) 512-7114

    2 open recommendations
    including 2 priority recommendations
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that requires a link between the distribution of supplemental payments and the provision of Medicaid-covered services.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarks. To the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Recommendation: To promote consistency in the distribution of supplemental payments among states and with CMS policy, the Administrator of CMS should issue written guidance clarifying its policy that payments should not be made contingent on the availability of local funding.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open
    Priority recommendation

    Comments: CMS plans to publish a proposed rule for public comment in the summer of 2017 to improve the oversight of supplemental payments, including a proposal to require that supplemental payments be distributed proportional to the volume or cost of services delivered or be tied to meeting performance benchmarksTo the extent the agency issues a final rule that results in states distributing supplemental payments in a manner that aligns their distribution with individual facilities' Medicaid workloads, CMS's ability to ensure that state Medicaid payments are not excessive and are used for Medicaid purposes will improve.
    Director: Carolyn L. Yocom
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To ensure states have appropriate and current guidance to assist them in designing and administering Medicaid NEMT, the Secretary of HHS should direct CMS to assess current Medicaid NEMT guidance and update that guidance as needed.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To be able to identify and address problems that may occur and thus help ensure a smooth transition, the Secretary of Defense should require the Defense Health Agency ensure that planning documents for the expansion include specific requirements to continuously monitor affected beneficiaries, including whether (1) covered medications are available and filled in a timely and accurate manner through mail order and across MTF pharmacies; and (2) beneficiaries are satisfied with the transition to mail order and MTF pharmacies.

    Agency: Department of Defense
    Status: Open

    Comments: As of April 2016, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the availability, timeliness, and accuracy of prescriptions filled by beneficiaries affected by the expansion of the TRICARE pharmacy pilot. Similarly, DOD has not provided information that it plans to separately track through mail order and military treatment facilities the satisfaction of beneficiaries affected by the expansion of the TRICARE pharmacy pilot.
    Director: James Cosgrove
    Phone: (202) 512-7114

    4 open recommendations
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should augment MA network adequacy criteria to address provider availability.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that CMS will review how to augment the MA network adequacy criteria to address provider availability in future years. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should verify provider information submitted by MAOs to ensure validity of the Health Services Delivery data.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation, and noted in a January 2016 update that the agency is working to standardize existing protocols to ensure the validity of the Health Services Delivery data submitted by MAOs with regards to exceptions requests and partial county justifications. However, unless CMS verifies provider information submitted by MAOs, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should expand network adequacy reviews by requiring that all MAOs periodically submit their networks for assessment against current Medicare requirements.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that CMS has expanded its reviews to include both existing and new service areas for network adequacy when MAOs apply for a service area expansion, However, unless CMS periodically requires evidence of compliance of all existing MAO networks, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2016, agency officials have not implemented this recommendation.
    Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should set minimum requirements for MAO letters notifying enrollees of provider terminations and require MAOs to submit sample letters to CMS for review.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: HHS concurred with this recommendation. In a January 2016 update, the agency noted that the Medicare Marketing Guidelines contain best practice suggestions of what should be included in the written termination notice; however, we note in our report those practices are not required, nor are the letters regularly reviewed. The agency also noted that it was considering rulemaking to require that MAOs submit sample written notices of termination to HHS for review and approval. As of September 2016, agency officials have not implemented this recommendation.
    Director: Kathleen M. King
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: CMS should conduct a formal analysis, using its experience and data it has collected since the implementation of the first MAC contracts, to determine whether alternative contracting approaches could be used--even if only for selected MAC contract responsibilities--to help promote improved contractor performance.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
    Director: Melvin, Valerie C
    Phone: (202) 512-6304

    1 open recommendations
    Recommendation: To ensure that the federal government's and states' investments in information systems result in outcomes that are effective in supporting efforts to save funds through the prevention and detection of improper payments in the Medicaid program, the Secretary of Health and Human Services should direct the Administrator of CMS to require states to measure quantifiable benefits, such as cost reductions or avoidance, achieved as a result of operating information systems to help prevent and detect improper payments. Such measurement of benefits should reflect a consistent and repeatable approach and should be reported when requesting approval for matching federal funds to support ongoing operation and maintenance of systems that were implemented to support Medicaid program integrity purposes.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In comments on our report, agency officials agreed with this recommendation and provided information on CMS's plans to use a template to track cost savings resulting from state Medicaid offices' use of information systems for program integrity purposes. In April 2017, CMS officials said that they were no longer planning to use the template to gather information from the states, because of the varied approaches that states take to implement systems support for program integrity purposes. The officials stated that they are developing an alternative approach for capturing this information from the states, which will be provided to us when completed. We will continue to monitor CMS's progress toward addressing the recommendation.
    Director: Debra A. Draper
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: To eliminate unnecessary program duplication and to achieve increased efficiencies and potential savings within the integrated MHS, Congress should terminate the Secretary of Defense's authority to contract with the USFHP designated providers in a manner consistent with a reasonable transition of affected USFHP enrollees into TRICARE's regional managed care program or other health care programs, as appropriate.

    Agency: Congress
    Status: Open

    Comments: As of April 2017, no actions have been taken.
    Director: Stephen M. Lord
    Phone: (202) 512-6722

    1 open recommendations
    Recommendation: To assist states that rely on or are planning to contract with an MCO to administer Medicaid prescription benefits, and to help provide effective oversight of psychotropic medications prescribed to children in foster care, the Secretary of Health and Human Services should issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: In a July 2016 written response, Health and Human Services (HHS) stated that the Centers for Medicare & Medicaid Services (CMS) in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued an informational bulletin in August 2012 and in July 2013, that addressed this recommendation. However, in the report, we acknowledged that CMS issued this bulletin along with other guidance. Further, as we stated in our report, the HHS guidance did not address third-party MCOs administering medications. We continue to believe that additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment is needed to help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.
    Director: Draper, Debra A
    Phone: (202) 512-7114

    2 open recommendations
    Recommendation: To provide decision makers with more complete information on the continued appropriateness of the current pharmacy services contract structure, and to ensure the best value and services to the government and beneficiaries, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to conduct an evaluation of the potential costs and benefits of alternative contract structures for the TRICARE pharmacy services contract.

    Agency: Department of Defense
    Status: Open

    Comments: The current TRICARE pharmacy services contract began in May 2015, with 1 base year and 7 option years. DOD officials stated that they intend to conduct an evaluation of the potential costs and benefits of alternative contract structures as they undergo the next acquisition cycle. GAO will continue to follow up on these recommendations as DOD begins its acquisition planning efforts for the next cycle.
    Recommendation: To provide decision makers with more complete information on the continued appropriateness of the current pharmacy services contract structure, and to ensure the best value and services to the government and beneficiaries, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to incorporate such an evaluation into acquisition planning.

    Agency: Department of Defense
    Status: Open

    Comments: DOD officials stated that they intend to include such an evaluation in their acquisition planning for the next acquisition cycle. GAO will continue to follow up on these recommendations as DOD begins its acquisition planning efforts for the next cycle.
    Director: King, Kathleen M
    Phone: (202) 512-7114

    1 open recommendations
    Recommendation: Should the Congress decide to cap payments for physician and other nonhospital services made through IHS's CHS program, the Secretary of Health and Human Services should direct the Director of IHS to monitor CHS program patient access to physician and other nonhospital care in order to assess how any new payment rates may benefit or impede the availability of care.

    Agency: Department of Health and Human Services
    Status: Open

    Comments: HHS agreed with GAO's recommendation and indicated that monitoring patient access to care in light of any payment changes is essential to providing high-quality health care to American Indians and Alaska Natives. Since there have not been any changes to the payment rates, IHS has not yet implemented this recommendation.
    Director: Iritani, Katherine M
    Phone: (206)287-4820

    2 open recommendations
    Recommendation: In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should establish a plan, with goals and time frames, to review the accuracy and completeness of information reported on the CMS 416 and CHIP annual reports and ensure that identified problems are corrected.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In September 2016, CMS said that it was taking new steps to review data on children's access and quality of care by reviewing required reports that evaluate states' Medicaid managed care plans; however, these reports do not represent a consistent set of measures used by all states that CMS can use for oversight purposes. Accurate, complete, and reliable data for both Medicaid and CHIP are necessary for CMS's oversight of children's access to services. GAO considers this recommendation open.
    Recommendation: In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: In September 2016, CMS said that it had changed the instructions for completing the CMS 416 to provide more detailed guidance for states on capturing required information on the total number of children who were referred for treatment services. However, CMS is not planning to require states to submit information on whether children received the treatment services for which they were referred. We maintain that having ability to monitor receipt of treatment services, receipt of services in managed care separate from fee-for-service, and having data from all states is important to CMS oversight. GAO considers this recommendation open.
    Director: Iritani, Katherine M
    Phone: (202)512-3000

    1 open recommendations
    Recommendation: To improve the oversight of states' Medicaid supplemental payments, the Administrator of CMS should develop a strategy to identify all of the supplemental payment programs established in states' Medicaid plans and to review those programs that have not been subject to review under CMS's August 2003 initiative.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: As of July 2016, HHS officials reported that they have not implemented this recommendation. GAO considers it to be open. We will update the status of this recommendation when we receive additional information.
    Director: Iritani, Katherine M
    Phone: (202)512-7059

    1 open recommendations
    including 1 priority recommendation
    Recommendation: To meet its fiduciary responsibility of ensuring that section 1115 waivers are budget neutral, the Secretary of Health and Human services should better ensure that valid methods are used to demonstrate budget neutrality, by developing and implementing consistent criteria for consideration of section 1115 demonstration waiver proposals.

    Agency: Department of Health and Human Services
    Status: Open
    Priority recommendation

    Comments: HHS has generally disagreed with this recommendation. However, we have reiterated the need for increased attention to the fiscal responsibility in the approval of the section 1115 Medicaid demonstrations in subsequent 2008 and 2013 reports (GAO-08-87 and GAO-13-384). Although HHS has not issued a written budget neutrality policy as of October 2016, it has taken steps to change some aspects of methods states can use to determine budget neutrality and demonstration spending limits. The new methods are intended to result in more appropriate demonstration spending limits. For example, according to CMS officials, starting in May 2016, the agency began reducing the amount of accumulated savings that states can carryover when demonstrations are renewed, which was previously unlimited. We are continuing to monitor the effect of the recent changes. The recent changes did not address all of the questionable methods we have identifed in our reports.