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Open Recommendations (119 total)

Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect Lessons Learned after COVID-19

GAO-24-106883
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should document and implement the oversight practices the agency learned during unwinding were needed for preventing and detecting state compliance issues with redetermination requirements. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Hospice: CMS Needs to Fully Implement Statutory Provisions and Prioritize Certain Overdue Surveys

GAO-24-106442
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2 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS Administrator should instruct SAs and AOs to prioritize the completion of standard surveys for hospices that are overdue for a survey based on potential risk factors, which could include the amount of time overdue or evidence of past quality issues. (Recommendation 4)
Open
CMS disagreed with this recommendation. However, in June 2024, the agency shared that it had recently received supplemental funding to assist with the overdue hospice standard surveys and was exploring ways to use contracted surveyors to assist the SAs with the backlog by prioritizing the states with hospices that are most at risk for not complying with health and safety standards. As of July 2024, CMS had not yet instructed SAs and AOs to prioritize the completion of their overdue hospice surveys based on potential risk factors, and we consider this recommendation open. We will continue to monitor agency action in this area.
Centers for Medicare & Medicaid Services The CMS Administrator should fully implement efforts to measure and reduce inconsistency in survey results among all surveyors, including SAs and AOs. (Recommendation 3)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Hospice: CMS Needs to Fully Implement Statutory Provisions and Prioritize Certain Overdue Surveys

GAO-24-106442
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS Administrator should make hospice survey results publicly available on Care Compare such that the information is prominent, easily accessible, and readily understandable. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid: Managed Care Plans’ Prior Authorization Decisions for Children Need Additional Oversight

GAO-24-106532
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should communicate in writing expectations for how states are to monitor the appropriateness of managed care plans' prior authorization decisions and take steps to confirm whether states are meeting those expectations. Such communication should include expectations related to monitoring prior authorization decisions of EPSDT services for children. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid: Managed Care Plans’ Prior Authorization Decisions for Children Need Additional Oversight

GAO-24-106532
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should clearly define whether managed care plans can require prior authorization for EPSDT services when the state does not have such requirements. This should include defining the term "non-quantitative treatment limits" as it relates to managed care plans providing medically necessary services to children in a manner no more restrictive than that used in the state Medicaid program. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Managed Care: Additional Federal Action Needed to Fully Leverage New Appeals and Grievances Data

GAO-24-106627
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should require states to report on the outcomes of Medicaid managed care appeals (e.g., the extent to which they were decided in favor of enrollees) and number of denials. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Managed Care: Additional Federal Action Needed to Fully Leverage New Appeals and Grievances Data

GAO-24-106627
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should implement its planned actions for analyzing the Medicaid managed care appeals and grievances data, using it for oversight, and making it publicly available. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should make publicly available all approval documents related to new and renewed state directed payments, including application attachments, state evaluation plans, and evaluation results. (Recommendation 4)
Open
HHS agreed with this recommendation. In August 2024, CMS officials told us that the agency is planning to post all approved state directed payment documents on its website but has had to delay those efforts given other priorities. Officials indicated that the agency is also working on changes to the state directed payment application that will allow the agency to capture more information in an accessible format and reduce the need for attachments that are complex to convert to an accessible format. As of August 2024, GAO continues to monitor CMS progress toward implementing this recommendation and will reconsider closure when CMS releases the updated application template.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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1 Open Recommendations
1 Priority
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services
Priority Rec.
The Administrator of CMS should enhance the agency's fiscal guardrails for approving state directed payments by establishing a definition of, and standards for, assessing whether directed payments result in payment rates that are reasonable and appropriate, and communicating those to states; determining whether additional limits are needed; and requiring states to submit data on actual spending amounts at renewal. (Recommendation 1)
Open – Partially Addressed
HHS neither agreed nor disagreed with this recommendation but highlighted that provisions in a May 2023 CMS proposed rule should address the recommendation. In May 2024, CMS finalized the rule, which included activities that enhance the agency's fiscal guardrails for state directed payments. For example, the final rule limits the total payment rate for certain state directed payments to the average commercial rate for certain services, such as inpatient hospital services. CMS stated it would use the average commercial rate as an informal benchmark for state directed payments for other types of services and would continue monitoring state directed payments for these other types of services to assess the need for any additional limits in the future. The final rule also requires states to submit data to CMS on the total dollars expended by each managed care organization for state directed payments paid to providers. CMS officials also indicated that the rule requires states to report actual spending under state directed payments and noted that they will be revising review procedures to reflect the need to consider any available spending data when approving a renewal of a state directed payment. Officials also noted that they plan to issue technical guidance to states that will include additional information on the standards for assessing whether proposed state directed payments are reasonable and appropriate. The provisions CMS included in the agency's final rule partially address GAO's recommendation. As of August 2024, GAO continues to monitor CMS progress toward implementing this recommendation and will reassess the recommendation for closure when the standard operating procedures are updated and the technical guidance issued.
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