Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the scope of the department's centralized database on problematic sexual behavior in children and youth, which is under development, to also track information on all incidents involving the abuse of a child (physical, sexual, emotional, and neglect) reported to the Family Advocacy Program or investigated by a military law enforcement organization, regardless of whether the offender was another child, an adult, or someone in a noncaregiving role at the time of the incident. (Recommendation 1)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD did not concur with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should, as part of the ongoing development of the centralized database, identify and define the elements to be tracked by each responsible organization, such as the Family Advocacy Program and military law enforcement. (Recommendation 2)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should develop a plan for how it will use the data it will collect in the centralized database to help ensure data-driven decision-making is used to inform program efforts. (Recommendation 3)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should establish a reliable schedule for the development and implementation of the centralized database on problematic sexual behavior in children and youth that includes key activities, the timeframes and resources needed to execute them, and GAO-identified practices for developing and maintaining a reliable schedule. (Recommendation 4)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should direct the service Family Advocacy Programs and military law enforcement organizations to document in their respective databases the date that they notified the other entity of a reported incident of child abuse. (Recommendation 5)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should issue guidance that describes the process through which the service Family Advocacy Programs are to receive and incorporate information into their central registries regarding child abuse allegations and determinations involving their servicemembers and dependents that were recorded by another service's installation Family Advocacy Program. Such guidance should include a mechanism to monitor that the process is occurring consistently. (Recommendation 6)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 7)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 8)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps develops a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 9)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should develop a process to monitor how reported incidents of child abuse are screened at installations to help ensure that all reported child abuse incidents that should be presented to an Incident Determination Committee are consistently presented and therefore tracked. (Recommendation 10)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Department of Defense Education Activity, clarifies Department of Defense Education Activity guidance to define what types of incidents must be reported as "serious incidents" to help ensure that all serious incidents of which Department of Defense Education Activity leadership needs to be informed are accurately and consistently reported by school administrators. (Recommendation 11)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should expand the voting membership of the Incident Determination Committee to include medical personnel with the requisite knowledge and experience. (Recommendation 12)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 13)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 14)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps establishes efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 15)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should establish efforts to comprehensively inform victims' families about how reported incidents of child abuse will be addressed following the report, such as a comprehensive guide that explains the process the Family Advocacy Program and military law enforcement organizations will follow, and available victim services. (Recommendation 16)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Secretaries of the military departments, should clarify, in guidance, the circumstances under which commanders may exercise their authority to remove a child from a potentially unsafe home on an overseas installation. (Recommendation 17)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Director of the Defense Health Agency, establishes processes that help ensure children who are sexually abused overseas have timely access to a certified pediatric sexual assault forensic examiner to conduct the examination. Initiatives could include certifying pediatricians or adult sexual assault forensic examiners as pediatric examiners during mandatory training or establishing shared regional assets. (Recommendation 18)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of Defense, in collaboration with the Deputy Attorney General, should seek avenues to improve communication between the military criminal investigative organizations and United States Attorneys for relevant cases involving child victims to help ensure that investigators are notified when prosecution is declined, including the reasons for the declination when appropriate, such as details about any investigative deficiencies. (Recommendation 19)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Army should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Army installations and thereby increase awareness of those services across the department. (Recommendation 20)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Army partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should continue to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Navy installations and thereby increase awareness of those services across the department. (Recommendation 21)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy partially concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Navy should ensure that the Commandant of the Marine Corps continues to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Marine Corps installations and thereby increase awareness of those services across the service. (Recommendation 22)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Navy concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Secretary of the Air Force should seek to develop a memorandum of understanding with the National Children's Alliance that makes children's advocacy center services available to all Air Force installations and thereby increase awareness of those services across the department. (Recommendation 23)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Air Force concurred with this recommendation. As of April 2020, this recommendation remains open.

Recommendation: The Administrator of CMS should ensure the agency's Medicaid third-party liability guidance is consistent with federal law related to

• the requirement for states to apply cost avoidance procedures to claims for labor, delivery, and postpartum care services,
• the requirement for states to make payments without regard to potential third-party liability for pediatric preventive services unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for 90 days, and
• state flexibility to make payments without regard to potential third-party liability for pediatric services provided to child support enforcement beneficiaries. (Recommendation 1)

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

Comments: On November 14, 2019, CMS issued an Informational Bulletin providing further guidance to Medicaid Bipartisan Budget Act (BBA) of 2018 and changes to Medicaid Provisions Passed in April 2019-Third Party Liability in Medicaid and CHIP. The intent of the information Bulletin is to further clarify CMS guidance issued in the agency's June 2018 Bulletin on key provisions related to third party liability in Medicaid and CHIP. The Bulletin also addresses April 2019 changes to the Bipartisan Budget Act of 2013. The bulletin clarifies CMS guidance on two of the three issues we identified in our 2019 report. The bulletin notes that (1) effective February 9, 2018 a state is required to use standard coordination of benefits cost avoidance when processing claims for prenatal services which now includes labor and delivery and postpartum care claims, and (2) effective October 1, 2019, a state is required to make payments without regard to third party liability for pediatric preventive services unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for 90 days. However, with regard to the third issue, the bulletin notes that, effective April 18, 2019, a state is allowed 100 days to pay claims related to child support enforcement, but does not note that states may choose to make payment within 30 days, if the state determines doing so is cost-effective and necessary to ensure access to care. We will continue to monitor CMS guidance on payments related to child support enforcement to assess whether the recommendation is fully implemented.

Recommendation: The Administrator of CMS should determine the extent to which state Medicaid programs are meeting federal third-party liability requirements and take actions to ensure compliance as appropriate. Such actions can include ensuring that state plans reflect the law. (Recommendation 2)

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

Comments: As of February 2020, we are unaware of any actions taken by CMS to implement this recommendation.

Recommendation: To assist states that rely on or are planning to contract with an MCO to administer Medicaid prescription benefits, and to help provide effective oversight of psychotropic medications prescribed to children in foster care, the Secretary of Health and Human Services should issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs.

Agency: Department of Health and Human Services
Status: Open

Comments: In an October 2018 written response, Health and Human Services (HHS) noted that they released 2017-2018 Drug Utilization Review Summaries for Prescription Drug Fee-For-Service Programs as it relates to national statistics on state oversight of psychotropic medications, as well as new state requirements to report on their Medicaid managed care organizations. However, as of August 2019, HHS confirmed they have not issued any guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs, as we recommended. We continue to believe that additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment is needed to help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.