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Highlights

Under the CARE Act, funds are made available to assist over 530,000 individuals affected by HIV/AIDS. Grantees directly provide services to individuals (clients) or arrange with service providers to do so. The Department of Health and Human Services's (HHS), Health Resources and Services Administration (HRSA), which administers CARE Act programs, is required to cancel balances of grants that are unobligated after one year and redistribute amounts to grantees in need. HRSA began to collect client-level data in 2009. Under the CARE Act, states and territories receive grants for AIDS Drug Assistance Programs (ADAP), which provide HIV/AIDS drugs. GAO was asked to examine elements of the CARE Act. In this report, we review: (1) HRSA's implementation of the unobligated balance provisions, (2) HRSA's actions to collect client-level data, and (3) the status of ADAP waiting lists. GAO reviewed reports and agency documents and interviewed federal officials, officials from 13 state and 5 local health departments chosen based on location and number of cases, and other individuals knowledgeable about HIV/AIDS.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services 1. To help ensure that HRSA is able to implement the unobligated balance provisions in a timely manner, and to obtain timely and accurate information on grantees' unobligated balances, the Secretary of HHS should instruct the administrator of HRSA to identify the causes of grantees' difficulties in providing a timely and accurate accounting of their unobligated balances.
Closed - Implemented
HRSA has provided reasons that Ryan White Part A and B grantees were unable to provide a timely and accurate accounting of their unobligated balances including: 1) Part A and B grantees must compile information for HRSA on their direct financial transactions and the transactions of their subcontractors. The grantees are often delayed by the subcontractors and therefore require additional time to complete a timely accounting of their total balances (direct balances and those of the subcontractors) on their federal financial report (FFR). Additionally, HRSA reports that it takes time for HRSA administrative staff to work with the grantees to reconcile their FFRs with HRSA's accounting of their drawdown requests with the HRSA payment management system. Often there were timing differences between those two systems which HRSA has recently sought to align in order to assist grantees with aligning these two systems. Finally, GAO reported that grantees were given extensions in the submission of their FFRs that contained the unobligated balance information. Due to these often lengthy extensions, HRSA was unable use the information they needed from the FFRs complete all of the steps necessary to meet their statutory requirements in regards to the grantees unobligated balance provisions. However, in July 2012, HRSA established that grantees would no longer be granted extensions for submission of their FFRs. Therefore, HRSA would be able to have all the information they needed from grantees within the timeframe necessary to meet the statutory requirements.
Department of Health and Human Services 2. To help ensure that HRSA is able to implement the unobligated balance provisions in a timely manner, and to obtain timely and accurate information on grantees' unobligated balances, the Secretary of HHS should instruct the administrator of HRSA ensure that grantees adhere to deadlines for submission of their unobligated balances by developing steps to assist them in overcoming the causes of difficulties identified in accounting for unobligated balances.
Closed - Implemented
HRSA has taken steps to address two components of the unobligated balance finding in our report. First, we reported that grantees often asked for lengthy extensions in their federal financial report (FFR) submissions in order to obtain necessary information from their subcontractors which was needed for the FFR. HRSA granted these extensions even though they needed information from the FFR to complete their unobligated balance statutory requirements. HRSA issued a letter to grantees in July 2012 that ended all extensions for submission of grantees' FFRs, thereby allowing HRSA the time it needed to complete the statutory requirements. Second, HRSA stated that one of the causes of the grantees untimely unobligated balance submissions was the time it took for HRSA staff to reconcile the grantees' drawdown requests with the grantees accounting on their FFR. They also stated that their were timing differences between these two reports. HRSA has aligned the submission date for the FFR with the submission date for the payment management system to eliminate timing issues that could lead to significant discrepancies between HRSA's accounting of the grantees' funds and the grantees' accounting on the FFR that could affect the grantees' unobligated balances. HRSA also provided technical assistance webinars to Ryan White Part A and B grantees to explain these two changes and address other challenges they faced in regards to their unobligated balances.

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