Status of Implementation of Medicaid Utilization Control Requirements

HRD-77-56: Published: Mar 1, 1977. Publicly Released: Mar 1, 1977.

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All states, with the exception of Delaware, have submitted acceptable certifications of compliance with section 1903(g) of the Social Security Act for the quarters beginning April 1, 1976 and July 1, 1976. This section generally provides for federal medical assistance payments for individuals receiving mental health care.

The Department of Health, Education, and Welfare (HEW) reduced funds for Delaware. Since the other states' submissions were satisfactory to the Secretary, payments for long-term care for the quarters starting April 1 and July 1, 1976, have been supported as required. HEW limited validation survey for fiscal year 1975 showed that 27 states had not performed all required medical review, and the Social and Rehabilitation Service's Administrator proposed that the Secretary reduce long-term care funds for these states by about $375 million. Continued monitoring of the implementation of 1903(g)(1) by HEW and the states is no longer necessary, but GAO should continue to monitor HEW progress in conducting validation surveys.

Recommendation for Executive Action

  1. Status: Closed

    Comments: Please call 202/512-6100 for additional information.

    Recommendation: The Secretary, HEW, should reduce long-term care funds for Delaware, Nevada, and Louisiana because of their failure to submit certifications of compliance with requirements for mental hospitals for fiscal year 1975. The Secretary should direct the Administrator of the Social and Rehabilitation Service to: (1) improve future validation surveys to include visits to institutions on a sample basis as required by law; and (2) revise the regulations to require more specific information in medical review reports, independent professional review reports, and plans of care.

    Agency Affected:


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