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: The Department of Health and Human Services (HHS) agreed with this recommendation. In December 2017, HHS communicated its intent to review regulations and enhance its capacity to measure, monitor, and improve care and quality across a number of domains, including MLTSS. As of February 2020, HHS stated that it is developing guidance related to reporting on key information needed to oversee beneficiary access to care. GAO will continue to monitor the department's actions and any steps taken to address this recommendation.

Recommendation: To help ensure that HHS agencies and offices fully understand the requirements and processes for the temporary reassignment authority, their responsibilities under the authority, and that ASPR is adequately and comprehensively assessing the effect of the authority on public health emergency response and medical surge, the Secretary of HHS should direct ASPR to conduct outreach to HHS agencies and offices that administer programs eligible for the reassignment authority to inform them of their responsibilities and ASPR's expected time frames for reviewing and approving states' and tribes' requests for personnel reassignments, and inform them of their responsibilities and ASPR's expectations for reviewing states' and tribes' after-action reports.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS provided us with information on its efforts to share information about the temporary reassignment authority throughout the department. However, it is not clear that HHS has routed the temporary reassignment standard operation procedures, which provides instructions on how to request use of the authority and documentation and reporting requirements, with the HHS agencies that are likely to be primarily affected.

Recommendation: The EPA Administrator should direct the Office of Grants and Debarment (OGD) and program and regional offices, as appropriate, as part of EPA's ongoing streamlining initiatives and the development of a grantee portal, to incorporate expanded search capability features, such as keyword searches, into its proposed web-based portal for collecting and accessing performance reports to improve their accessibility.

Agency: Environmental Protection Agency
Status: Open

Comments: In correspondence to GAO, EPA reiterated its agreement with this recommendation. EPA also stated that its vision for grants management includes having grant recipients submit performance reports and other information to the agency through a web-based portal. The portal would incorporate capabilities such as key word searches to allow for easier access to performance report information. EPA expected this recommendation to be addressed by its new grants management system (GrantsSolutions). However, in January 2020, EPA officials told us that EPA had ceased its migration to GrantSolutions after determining the long-term costs were unsustainable and that the system lacked fundamental functionality necessary for core grant operations and to maintain appropriate internal controls. EPA is now migrating towards a modernized grants administration and management cloud solution. EPA expects this recommendation to be addressed when the new grants management system is fully implemented. EPA anticipates deployment of the new cloud solution in December 2020.

Recommendation: The EPA Administrator should direct OGD and program and regional offices, as appropriate, as part of EPA's ongoing streamlining initiatives and the development of a grantee portal, once EPA's new performance system is in place, to ensure that the Office of Water adopts software tools, as appropriate, to electronically transfer relevant data on program results from program-specific databases to EPA's national performance system.

Agency: Environmental Protection Agency
Status: Open

Comments: In correspondence to GAO, EPA reiterated its general agreement with this recommendation and stated that it will apply it, where appropriate and cost effective, to program-specific databases, not only the Office of Water databases. EPA noted that not all data from program-specific databases may be appropriate for direct electronic transfer to the national performance system; some individual grant data may need to be analyzed before being rolled up into national data. As of December 2018, EPA officials said that continued work on this recommendation is dependent upon EPA's Office of the Chief Financial Officer's deployment of a new performance tracking system and individual program funds for developing systems that interact with it. As of April 2020, GAO is following up with EPA on the status of this recommendation.

Recommendation: The EPA Administrator should direct OGD and program and regional offices, as appropriate, as part of EPA's ongoing streamlining initiatives and the development of a grantee portal, to clarify the factors project officers should consider when determining whether performance reports are consistent with EPA's environmental results directive.

Agency: Environmental Protection Agency
Status: Open

Comments: In correspondence to GAO, EPA reiterated its agreement with this recommendation and stated that it will make conforming changes to the implementation guidance for the Environmental Results Order (directive). In December 2018, EPA stated that its existing environmental results directive may be superseded or incorporated into a different policy as part of the agency's migration to a new grants management system (GrantsSolutions). EPA stated that it would incorporate the recommendation into its new policy. However, in January 2020, EPA officials told us that EPA had ceased its migration to GrantSolutions after determining the long-term costs were unsustainable and that the system lacked fundamental functionality necessary for core grant operations and to maintain appropriate internal controls. EPA is now migrating towards a modernized grants administration and management cloud solution. EPA expects this recommendation to be addressed when the new grants management system is fully implemented. EPA anticipates deployment of the new cloud solution in December 2020.

Recommendation: The EPA Administrator should direct OGD and program and regional offices, as appropriate, as part of EPA's ongoing streamlining initiatives and the development of a grantee portal, to expand aspects of EPA's policy for certain categorical grants, specifically, the call for an explicit reference to the planned results in grantees' work plans and their projected time frames for completion, to all grants.

Agency: Environmental Protection Agency
Status: Open

Comments: In correspondence to GAO, EPA reiterated its agreement with this recommendation and stated that it will make conforming changes to existing policy. In December 2018, EPA stated that its existing policies may be superseded or incorporated into different policies as part of the agency's migration to a new grants management system (GrantsSolutions). EPA stated that it would incorporate the recommendation into its new policy. However, in January 2020, EPA officials told us that EPA had ceased its migration to GrantSolutions after determining the long-term costs were unsustainable and that the system lacked fundamental functionality necessary for core grant operations and to maintain appropriate internal controls. EPA is now migrating towards a modernized grants administration and management cloud solution. EPA expects this recommendation to be addressed when the new grants management system is fully implemented. EPA anticipates deployment of the new cloud solution in December 2020.

Recommendation: The EPA Administrator should direct OGD and program and regional offices, as appropriate, as part of EPA's ongoing streamlining initiatives and the development of a grantee portal, to incorporate built-in data quality controls for performance reports into the planned web-based portal based on EPA's environmental results directive.

Agency: Environmental Protection Agency
Status: Open

Comments: In correspondence to GAO, EPA reiterated its general agreement with this recommendation. However, EPA emphasized that identifying and deploying appropriate data quality controls is a long-term effort subject to budgetary considerations, completion of its new grants management system, and extensive collaboration with internal and external stakeholders. EPA officials said that the agency expected this recommendation to be addressed by its new grants management system (GrantsSolutions). However, in January 2020, EPA officials told us that EPA had ceased its migration to GrantSolutions after determining the long-term costs were unsustainable and that the system lacked fundamental functionality necessary for core grant operations and to maintain appropriate internal controls. EPA is now migrating towards a modernized grants administration and management cloud solution. EPA expects this recommendation to be addressed when the new grants management system is fully implemented. EPA anticipates deployment of the new cloud solution in December 2020.

Recommendation: To promote the transition to improved crash test standards, to strengthen FHWA's oversight of the roadside safety hardware's crash-testing process, and to make more information available to states and industry on how roadside safety hardware performs in actual conditions, the Secretary of Transportation should direct the Administrator of FHWA to provide additional guidance to crash test labs and accreditation bodies to ensure that labs have a clear separation between device development and testing in cases where lab employees test devices that were developed within their parent organization.

Agency: Department of Transportation
Status: Open

Comments: As of January 2020, FHWA has not determined what actions, if any, it plans to take to address this recommendation. During 2019, FHWA officials stated that the agency was planning, in consultation with state departments of transportation, to establish a mechanism for third party verification of results from crash-test labs. The initial plan was to work with an outside organization that would assume responsibility for third party verification by mid to late 2020. This outside organization was to be responsible for developing guidelines with respect to lab independence and dealing with cases where a testing lab and a hardware developer are owned by the same parent company. According to FHWA officials, while the agency engaged with two outside organizations, it has not been able to establish a mechanism for third party verification of results through an outside organization and is considering additional options. As a result, FHWA is re-evaluating actions to address this recommendation.

Recommendation: To promote the transition to improved crash test standards, to strengthen FHWA's oversight of the roadside safety hardware's crash-testing process, and to make more information available to states and industry on how roadside safety hardware performs in actual conditions, the Secretary of Transportation should direct the Administrator of FHWA to develop a process for third-party verification of results from crash-test labs.

Agency: Department of Transportation
Status: Open

Comments: As of January 2020, FHWA has not determined what actions, if any, it plans to take to address this recommendation. During 2019, FHWA officials stated that the agency was planning, in consultation with state departments of transportation, to establish a mechanism for third party verification of results from crash-test labs. The initial plan was to work with an outside organization that would assume responsibility for third party verification by mid to late 2020. According to FHWA officials, while the agency engaged with two outside organizations, it has not been able to establish a mechanism for third party verification of results through an outside organization and is considering additional options. As a result, FHWA is re-evaluating actions to address this recommendation.

Recommendation: To promote the transition to improved crash test standards, to strengthen FHWA's oversight of the roadside safety hardware's crash-testing process, and to make more information available to states and industry on how roadside safety hardware performs in actual conditions, the Secretary of Transportation should direct the Administrator of FHWA to support additional research and disseminate results on roadside safety hardware's in-service performance, either as part of future phases of FHWA's current pilot study on guardrail end terminals' performance or as part of FHWA's broader research portfolio.

Agency: Department of Transportation
Status: Open

Comments: As of January 2020, FHWA officials stated that the agency expects the pilot program report to be issued in December 2020, but it will not report results because the sample sizes were too small. In addition, officials told us that no further research into in-service performance evaluations are planned.

Recommendation: To ensure that FHFA has adequate authority to ensure the safety and soundness of the enterprises and to clarify its supervisory role, Congress should consider granting FHFA explicit authority to examine third parties that do business with and play a critical role in the operations of the enterprises.

Agency: Congress
Status: Open

Comments: As of March 2020, Congress has not taken action on this matter.

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: As of July 2019, HHS officials reported that they are waiting for a policy decision from leadership concerning non-emergency medical transportation. GAO will continue to monitor and update the status of this recommendation.

Recommendation: To help federal, state, local, and private sector decision makers access and use the best available climate information, the Executive Office of the President should designate a federal entity to develop and periodically update a set of authoritative climate change observations and projections for use in federal decision making, which state, local, and private sector decision makers could also access to obtain the best available climate information.

Agency: Executive Office of the President
Status: Open

Comments: As of January 2020, the Executive Office of the President has yet to take action in response to this recommendation.

Recommendation: To help federal, state, local, and private sector decision makers access and use the best available climate information, the Executive Office of the President should designate a federal entity to create a national climate information system with defined roles for federal agencies and nonfederal entities with existing statutory authority.

Agency: Executive Office of the President
Status: Open

Comments: As of January 2020, the Executive Office of the President has yet to take action in response to this recommendation.

Recommendation: To help districts address key challenges in meeting MOE and mitigate unintended consequences that may affect services for students with disabilities, while preserving the safeguard for funding for students with disabilities, Congress should consider options for a more flexible MOE requirement. This could include adopting a less stringent MOE requirement to align with the MOE requirements in other education programs or adding to or modifying exceptions. For example, current exceptions could be changed to allow one-time increases in spending without changing a district's MOE baseline in order to encourage pilot innovations or to allow certain spending decreases (e.g., state caps on teacher benefits), as long as a district can demonstrate the decrease does not negatively affect services.

Agency: Congress
Status: Open

Comments: As of February 2020, Congress has not taken legislative action on this issue.

Recommendation: To improve the effectiveness of its oversight of eligibility determinations, the Administrator of CMS should conduct reviews of federal Medicaid eligibility determinations to ascertain the accuracy of these determinations and institute corrective action plans where necessary.

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

Comments: The Department of Health and Human Services (HHS) has taken some steps to improve the accuracy of Medicaid eligibility determinations, as GAO recommended in October 2015, but has not yet conducted a systematic review of federal eligibility determinations. In July 2017, HHS issued its final rule on the Payment Error Rate Measurement (PERM) program, and stated that it would include reviews of federal eligibility determinations in states that have delegated that authority. In December 2017, HHS provided information noting that the first cycle of the revised PERM includes two states where there were federal eligibility determinations. However, as HHS confirmed in December 2019, the random sample of eligibility determinations reviewed in the first cycle of the revised PERM did not include any federal eligibility determinations. As such, the PERM has not systematically reviewed federal determinations, and we maintain that further reviews are needed to help ensure that only individuals eligible for Medicaid are receiving benefits. We will continue to monitor HHS to determine if HHS is ascertaining the accuracy of federal eligibility determinations and taking corrective action where necessary.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should take steps to ensure that states report accurate provider-specific payment data that include accurate unique national provider identifiers (NPI).

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would promote state accountability, improve federal oversight, and strengthen the fiscal integrity of the Medicaid program. Among other things, the proposed rule would require states to report supplemental payments made to individual providers; furthermore, it would require states to include the National Provider Identifier (NPI) number-a unique 10-digit identification number assigned to health care providers. GAO will continue to monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent it addresses the recommendation.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should develop a policy establishing criteria for when such payments at the provider level are economical and efficient.

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would require states to demonstrate to CMS that supplemental payments to individual providers are economical and efficient and also require states to end and then seek CMS approval to renew supplemental payments every three years. GAO will monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.

Recommendation: To improve CMS's oversight of Medicaid payments, the Administrator of CMS should, once criteria are developed, develop a process for identifying and reviewing payments to individual providers in order to determine whether they are economical and efficient.

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

Comments: In November 2019, CMS issued a proposed rule that the agency said would require states to demonstrate to CMS that supplemental payments to individual providers are economical and efficient and also require states to end and then seek CMS approval to renew supplemental payments every three years. GAO will monitor the status of the proposed rule and will review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.

Recommendation: In order to clarify the federal role related to freight-related local traffic congestion, in implementing MAP-21 and any subsequent reauthorization, the Secretary of Transportation should include in the National Freight Strategic Plan a written statement articulating the federal role in freight-related local congestion impacts, by clearly identifying potential objectives and goals (under the general area DOT has established for the Freight Transportation Conditions and Performance Report of reducing adverse environmental and community impacts) for mitigating local congestion caused by national freight movements and the type of role federal and state stakeholders could play in achieving each objective and goal, and including a written strategy for improving the availability of national data needed to quantify, assess, and establish measures on freight trends and impacts on local traffic congestion.

Agency: Department of Transportation
Status: Open
Priority recommendation

Comments: DOT concurred with this recommendation. To fully implement this recommendation, DOT should complete and issue a National Freight Strategic Plan. As part of the development of the National Freight Strategic Plan, DOT should articulate the federal role, objectives, and goals in mitigating local congestion caused by national freight movements. DOT stated that it is continuing work on the National Freight Strategic Plan and intends to release the plan in 2020.

Recommendation: To reduce the varying interpretations of LRRA, which have led to uncertainty and disagreements among RRGs and state insurance regulators, and at the same time continue to facilitate the formation and efficient operation of RRGs, Congress may wish to consider clarifying certain LRRA provisions. For example, clarifying whether (1) RRG registration requirements beyond those currently specified in LRRA are permitted in nondomiciliary states and (2) fees in addition to premium and other taxes could be charged to RRGs by nondomiciliary states in which they operate. Congress may also wish to consider providing a more specific definition of the types of insurance coverage permitted under LRRA.

Agency: Congress
Status: Open

Comments: As of September 2020, Congress had not taken actions to clarify the provisions we had noted within the Liability Risk Retention Act as causing some uncertainty among risk retention groups and state insurance regulators.

Recommendation: To ensure that federal funding efficiently and effectively responds to the countercyclical nature of the Medicaid program, Congress may wish to consider enacting an FMAP formula that is targeted for variable state Medicaid needs and provides automatic, timely, and temporary increased FMAP assistance in response to national economic downturns.

Agency: Congress
Status: Open

Comments: As of September 2020, no legislation had been enacted. GAO has testified on at least one bill that had been introduced in the Congress that would implement this Matter for Congressional Consideration. On February 10, 2016, GAO testified on considerations related to the Medicaid funding formula. See Medicaid: Changes to Funding Formula Could Improve Allocation of Funds to States GAO-16-377T January 26, 2016. We also cited this report in our discussion on Medicaid funding during economic downturns in Medicaid: Key Policy and Data Considerations for Designing a Per Capita Cap on Federal Funding (GAO-16-726). We cited this Matter in Opportunities to Improve the Federal Recovery and Response Efforts (GAO-20-625) and in COVID-19: Brief Update on Initial Federal Response to the Pandemic (GAO-20-708).

Recommendation: To establish accountability for meeting the programs' goal of increasing the participation of traditionally underrepresented groups in the highway construction workforce, the Secretary of Transportation should direct the FHWA Administrator to create and implement an oversight mechanism that (1) holds states accountable for meeting federal training criteria and (2) clearly stipulates how FHWA will assess state program effectiveness, including what type of program achievement data states are to submit and how such data will be used. This oversight mechanism should include assessing the effectiveness of its division offices in overseeing state activities.

Agency: Department of Transportation
Status: Open

Comments: FHWA has taken initial steps to implement a mechanism for state oversight, which includes collecting program implementation information from each state. FHWA plans to convene a working group to review this information and provide feedback to states on their programs. FHWA officials then anticipate sharing best practices and essential requirements for the program through webinars and other technical assistance. As of August 2019, FHWA has gathered information from states and is in the early stages of implementing this oversight mechanism.

Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should resume data verification audits to routinely evaluate the quality of selected drinking water data on health-based and monitoring violations that the states provide to EPA. These audits should also evaluate the quality of data on the enforcement actions that states and other primacy agencies have taken to correct violations.

Agency: Environmental Protection Agency
Status: Open
Priority recommendation

Comments: As of July 2020 there has been no change in the status of this recommendation. EPA, as of September 2019, had not resumed data verification audits to routinely evaluate the quality of the data states provide to the agency. The Safe Drinking Water Information System (SDWIS) Prime and the Compliance Monitoring Data Portal (CMDP) will replace the data verification audits in the future. EPA has made SDWIS Prime available through incremental interim releases to state drinking water agencies for exploring and testing but does not expect to fully release it until mid-2020. However, as of August 2019, SDWIS Prime was unavailable while EPA awaited progress on the SDWIS Modernization Project plan. According to EPA, the CMDP will enable utilities and laboratories to report data electronically to primacy agencies with fewer errors and in a more efficient manner; but it is not clear when it will be fully operational. According to data provided by EPA in September 2019, 10 states were using CMDP to varying degrees. EPA information identified another 6 states that plan to transition to CMDP between September and December 2019, 2 states that plan to transition in 2020, and 12 others that may transition in the future. In the meantime, EPA indicated that the agency will complete nine file reviews in 2019 to verify data in agencies that do not currently use CMDP. EPA's actions may improve its ability to oversee states' implementation of the act and provide more complete and accurate information on compliance, but because EPA's systems to replace data verification audits are not yet fully in place, we are keeping this recommendation open.

Recommendation: To improve EPA's ability to oversee the states' implementation of the Safe Drinking Water Act and provide Congress and the public with more complete and accurate information on compliance, the Administrator of EPA should work with the states to establish a goal, or goals, for the completeness and accuracy of data on monitoring violations. In setting these goals, EPA may want to consider whether certain types of monitoring violations merit specific targets. For example, the agency may decide that a goal for the states to completely and accurately report when required monitoring was not done should differ from a goal for reporting when monitoring was done but not reported on time.

Agency: Environmental Protection Agency
Status: Open

Comments: As of July 2020 there has been no change in the status of this recommendation. EPA is developing the Safe Drinking Water Information System (SDWIS) Prime, with several efforts underway as of September 2019 as we noted under recommendation 1, but until it is fully operational, EPA will not be able to work with states to establish a national goal for the quality of monitoring violations. EPA noted in 2017 that it expected SDWIS Prime to enable the agency and primacy agencies to better understand the nature of system violations and consider developing goals for monitoring and reporting violations. However, according to EPA, SDWIS Prime will not be released until mid-2020. EPA indicated plans to modify the Annual Public Water System Supervision (PWSS) Program Review requirements but the agency states that it is dependent on approval by the Office of the Inspector General. Despite the ongoing delays to address the call in the recommendation for establishing new goals, we are keeping this recommendation open while EPA continues its efforts to implement SDWIS Prime.

Recommendation: To ensure that information entered into CMS's complaints database is reliable and consistent, the Administrator of CMS should identify issues with data quality and clarify guidance to states about how particular fields in the database should be interpreted, such as what it means to substantiate a complaint.

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

Comments: HHS concurred with this recommendation. In November 2014, CMS officials reported that the agency's Survey and Certification Group was in the early stages of a planned multi-year review of all of its business processes, including those related to nursing home complaint investigations. Officials stated that, as part of that review, agency staff would seek to provide clarification on all aspects of the complaint process, including what it means to substantiate a complaint. In July 2019 CMS officials said some actions have been taken and that they would forward us information. We will update the status of this recommendation when we receive additional information.

Recommendation: To strengthen CMS's assessment of state survey agencies' performance in the management of nursing home complaints, the Administrator of CMS should conduct additional monitoring of state performance using information from CMS's complaints database, such as additional timeliness measures.

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

Comments: In November 2014, CMS officials reported that the fiscal year 2014 protocol for assessment of state agency performance includes a new measure that tracks how soon after the completion of a complaint investigation a state agency uploads data from that investigation to CMS's complaint tracking system. However, the protocol does not call for assessment of the number of days by which state survey agencies miss the deadlines for some complaint investigations--a measure that we suggested could provide a more comprehensive picture of state agency performance. In July 2019 CMS officials said some actions have been taken and that they would forward us information. We will update the status of this recommendation when we receive additional information.

Recommendation: To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should clarify guidance to the state survey agencies about the minimum information that should be conveyed to complainants at the close of an investigation.

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

Comments: HHS agreed that CMS needed to take steps to strengthen and increase accountability of state survey agencies' management of nursing home complaints. In November 2014, CMS officials reported that while they believed the CMS State Operations Manual, which specifies procedures for addressing complaints, provides significant guidance regarding the information that state agencies should convey to complainants at the close of an investigation, they would review the guidance to identify any needed changes. In July 2019 CMS officials said some actions have been taken and that they would forward us information. We will update the status of this recommendation when we receive additional information.

Recommendation: To strengthen and increase accountability of state survey agencies' management of the nursing home complaints process, the Administrator of CMS should provide guidance encouraging state survey agencies to prioritize complaints at the level that is warranted, not above that level.

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

Comments: HHS agreed that CMS needed to take steps to strengthen and increase accountability of state survey agencies' management of the nursing home complaints process and stated that CMS would provide clarification and guidance to states to ensure complaints were prioritized at the appropriate level. However, in CMS's fiscal year 2014 protocol for assessment of state agency performance, the prioritization standard still required only that complaints be assigned a priority level at or above the level assigned by CMS reviewers. We remain concerned that defining the standard this way may create an incentive for survey agencies to prioritize some complaints at a higher level than is warranted--which could increase workload and potentially jeopardize the timeliness of investigations that warrant the higher priority level. In July 2019 CMS officials said some actions have been taken and that they would forward us information. We will update the status of this recommendation when we receive additional information.

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 August 2019, CMS stated that the agency's long-term plan is to use the Transformed Medicaid Statistical Information System (T-MSIS) to analyze information on children's receipt of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. As of June 2020, CMS had developed a new CMS-416 reporting form that gives states the option of having CMS calculate the measures for the report using T-MSIS. CMS stated that it intends to implement this option for states for fiscal year 2020 CMS-416 reports, which are due in April 2021. As of August 2020, the new CMS-416 form was undergoing Paperwork Reduction Act review. CMS is also exploring using T-MSIS to generate the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP, some of which are included in the CHIP annual report. As of June 2020, CMS had begun a pilot test to generate five of the Core Set measures using 2018 T-MSIS data. GAO considers this recommendation open and will continue to monitor CMS's progress towards its long-term goal of using T-MSIS to monitor children's receipt of EPSDT services.

Recommendation: To strengthen formal collaboration efforts, the Secretary of Transportation should direct the Administrator of the Federal Transit Administration, and the Secretary of Housing and Urban Development should direct the appropriate program offices, to develop a plan to ensure that data collected on the various programs of the agencies related to affordable housing and transit are sufficient to measure the agencies' performance toward goals and outcomes established in the HUD-FTA action plan and the Partnership for Sustainable Communities.

Agency: Department of Housing and Urban Development
Status: Open

Comments: On November 30, 2009, we received a response from HUD stating that actions were planned or underway to address this and the other recommendation in this report. As of July 2019, we are reviewing additional documentation provided by DOT and HUD on actions they have taken.

Recommendation: To strengthen formal collaboration efforts, the Secretary of Transportation should direct the Administrator of the Federal Transit Administration, and the Secretary of Housing and Urban Development should direct the appropriate program offices, to develop a plan to ensure that data collected on the various programs of the agencies related to affordable housing and transit are sufficient to measure the agencies' performance toward goals and outcomes established in the HUD-FTA action plan and the Partnership for Sustainable Communities.

Agency: Department of Transportation: Federal Transit Administration
Status: Open

Comments: On November 30, 2009, we received a response from HUD stating that actions were planned or underway to address this and the other recommendation in this report. As of July 2019, we are reviewing additional documentation provided by DOT and HUD on actions they have taken.

Recommendation: To improve the effectiveness of the federal investment in surface transportation, meet the nation's transportation needs, and ensure a sustainable commitment to transportation infrastructure, Congress may wish to consider reexamining and refocusing surface transportation programs to be responsive to these principles so that they institute tools and approaches to that emphasize the return on the federal investment.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet acted on this recommendation. The Fixing America's Surface Transportation Act (FAST Act; P.L. 114-94), signed into law in December 2015, is due to be reauthorized in fiscal year 2021.

Recommendation: To improve the effectiveness of the federal investment in surface transportation, meet the nation's transportation needs, and ensure a sustainable commitment to transportation infrastructure, Congress may wish to consider reexamining and refocusing surface transportation programs to be responsive to these principles so that they address the current imbalance between federal surface transportation revenues and spending.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet acted on this recommendation. The Fixing America's Surface Transportation Act (FAST Act; P.L. 114-94), signed into law in December 2015, did not address the current imbalance between federal surface transportation revenues and spending. The Act is due to be reauthorized in fiscal year 2021.

Recommendation: Congress may wish to consider requiring increased attention to fiscal responsibility in the approval of section 1115 Medicaid demonstrations by requiring the Secretary of HHS to improve the demonstration review process through steps such as (1) clarifying criteria for reviewing and approving states' proposed spending limits, (2) better ensuring that valid methods are used to demonstrate budget neutrality, and (3) documenting and making public material explaining the basis for any approvals.

Agency: Congress
Status: Open

Comments: As of April 2020, there had been no legislation introduced to require HHS to improve the Medicaid demonstration review process. However, HHS has taken some action to address some aspects of GAO's recommendation. CMS established new policies that addressed certain problems GAO had identified and issued written guidance on the process and criteria used to approved states' proposed spending limits. Not all problems identified by GAO were addressed by the new CMS policy, thus legislation to require HHS to improve the Medicaid demonstration review process, as GAO recommended in January 2008, continues to be a viable matter for consideration.

Recommendation: Congress may wish to consider addressing whether demonstrations that allow states to operate public managed care organizations and retain excess revenue to support programs previously funded by the state--including the Vermont demonstration--are within the scope of the Secretary of HHS's authority under section 1115 of the Social Security Act.

Agency: Congress
Status: Open

Comments: As of April 2020, Congress had not passed legislation in response to our matter for congressional consideration.

Recommendation: To enhance the transparency of CMS oversight and clarify and communicate the types of allowable state financing arrangements, the Administrator of CMS should provide each state CMS reviews under its initiative with specific and written explanations regarding agency determinations on the allowability of various arrangements for financing the nonfederal share of Medicaid payments and make these determinations available to all states and interested parties.

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

Comments: CMS has taken steps to provide states with specific and written explanations regarding agency determinations on whether various arrangements for financing the nonfederal share of Medicaid payments are allowable and making those determinations available to states and interested parties. In November 2019, CMS issued a proposed rule that the agency said would promote state accountability, improve federal oversight, and strengthen fiscal integrity of the Medicaid program. The proposed rule would establish new policies and codify existing policies related to the sources of funds that states use to finance the nonfederal share of Medicaid payments. For example, the rule is intended to provide CMS and states with better information and guidance to identify existing and emerging state financing issues, provide more clarity on allowable financing arrangements and promote state accountability. GAO will continue to monitor the status of the proposed rule, as well as review a final rule, if one is issued, to determine the extent to which it addresses the recommendation.

Recommendation: In order to put the Emergency Relief program on a sound financial footing, Congress may wish to consider the expected future demands on the program and reexamine the appropriate level and sources of funding--including whether to increase the $100 million annual authorized funding and whether the Highway Trust Fund, the General Fund, or some combination would allow the program to accomplish its purpose in a fiscally sustainable manner.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet taken action on this recommendation. The Emergency Relief Program is due to be reauthorized in 2020.

Recommendation: Congress may also wish to consider tightening the eligibility criteria for Emergency Relief funding, either through amending the purpose of the Emergency Relief program, or by directing FHWA to revise its program regulations. Revised criteria could include limitations on the use of Emergency Relief funds to fully finance projects with scope and costs that have grown as a result of environmental and community concerns.

Agency: Congress
Status: Open

Comments: As of November 2019, Congress has not yet taken action on this recommendation. The Emergency Relief Program is due to be reauthorized in 2020.

Recommendation: To help further the progress toward meeting the goals of IPIA and determining states' role in assisting federal agencies to report a national improper payment estimate on federal programs, the Director, Office of Management and Budget, should expand IPIA guidance to provide criteria that federal agencies should consider when developing a plan or methodology for estimating a national improper payment estimate for state-administered programs, such as criteria that address the nature and extent of data and documentation needed from the states to calculate a national improper payment estimate.

Agency: Executive Office of the President: Office of Management and Budget
Status: Open

Comments: The Office of Management and Budget (OMB) concurred with this recommendation. Since the issuance of the GAO report, OMB has made several revisions to its OMB Circular No. A-123, Appendix C "Requirements for Effective Measurement and Remediation of Improper Payments." The latest revision is dated June 26, 2018. The intent of OMB Circular No. A-123, Appendix C, is to ensure that federal agencies focus on prevention and have the proper incentives to improve their improper payment rates. In August 2020, OMB provided us its improper payment guidance on sampling and estimation in place at the time of the GAO audit. Based on this documentation, we sent a follow-up request to OMB for additional information. We are currently waiting to hear back from OMB so we can continue with our review. We will continue to monitor the agency's actions to address this 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: As of January 2020, the Department of Health and Human Services (HHS) had taken some action to address GAO's 2002 recommendation. In August 2018, HHS issued written guidance through a State Medicaid Directors Letter documenting four key changes it made in 2016 to its budget neutrality policy. These changes addressed some, but not all of the questionable methods GAO identified in its reports. To fully address this recommendation, HHS should also address these other questionable methods, such as setting demonstration spending limits based on hypothetical costs-what the state could have paid-rather than payments actually made by the state. GAO has found that the use of hypothetical costs has the potential to inflate spending limits and thus threatens budget neutrality of demonstrations