In interviews with GAO, a majority of Medicaid officials from the 50 states and the District of Columbia (hereafter, states) identified federal Medicaid policies—including laws, regulations, and procedures—in four program areas that posed a significant or moderate challenge to effective program administration. Of note: (1) Coverage exclusions and care coordination. Officials from 47 states id

Dual-eligible beneficiaries are Medicare beneficiaries who are also enrolled in the Medicaid program in their state. In certain states, they may receive both types of benefits through private managed care plans. As of January 2019, about 386,000 such individuals were enrolled in both a private Medicare plan known as a dual-eligible special needs plan (D-SNP) and a Medicaid managed care organizati

Most state Medicaid programs reported that they increased the rates paid to physicians and other health care providers for services that treat substance use disorders (SUD), such as medication or behavioral therapy. Specifically, over 80 percent of all states increased rates for at least one SUD service from 2014 to 2019. About two-thirds of states' rate increases were targeted specifically to SU

The 340B Drug Pricing Program (340B Program) and the Medicaid Drug Rebate Program require manufacturers to provide discounts on outpatient drugs in order to have their drugs covered by Medicaid. These discounts take the form of reduced sales prices for covered entities participating in the 340B Program—eligible hospitals and federal grantees—and rebates on drugs dispensed to Medicaid benefici

Officials from seven selected states that GAO interviewed described challenges they faced implementing new Medicaid provider screening and enrollment requirements, established by the Patient Protection and Affordable Care Act (PPACA) in 2010 and the 21st Century Cures Act in 2016. These challenges included establishing procedures for risk-based screenings, using federal databases and collecting r

Medicaid demonstrations enable states to test new approaches to provide Medicaid coverage and services. Since January 2018, the Centers for Medicare & Medicaid Services (CMS) has approved nine states' demonstrations that require beneficiaries to work or participate in other activities, such as training, in order to maintain Medicaid eligibility. The first five states that received CMS approval fo

GAO previously reported that in fiscal years 2009 through 2011, the most expensive 5 percent of Medicaid beneficiaries accounted for nearly half of the expenditures for all beneficiaries; others have also found that a small percentage of beneficiaries account for a disproportionately large share of Medicaid program expenditures. These high-expenditure beneficiaries are an extremely diverse popula

The prevalence of obesity—that is, body weight higher than what is considered a healthy weight for a given height—was about 38 percent among all U.S. adults, according to the latest available national estimates at the time of GAO's analysis. This prevalence was similar for adults with different types of health insurance. Treatment for adults with obesity may include one or more of nine prescr

Medicaid demonstrations allow states flexibility to test new approaches for providing coverage and delivering Medicaid services. Since 2012, the Centers for Medicare & Medicaid Services (CMS), which oversees demonstrations, has developed procedures to improve the transparency of the approval process. For example, CMS reviews demonstration applications (including for new demonstrations, extensions

The Centers for Medicare & Medicaid Services (CMS) requires states to collect service utilization data--known as encounter data--from Medicaid managed care organizations (MCO). GAO found that, in 2017, all eight selected states it reviewed checked MCO-submitted encounter data for reasonableness--that is, they checked that the data contained valid values, were submitted in a timely manner, and ref