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Open Recommendations (114 total)

Medicaid Managed Care: Additional Federal Action Needed to Fully Leverage New Appeals and Grievances Data

GAO-24-106627
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should implement its planned actions for analyzing the Medicaid managed care appeals and grievances data, using it for oversight, and making it publicly available. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Managed Care: Additional Federal Action Needed to Fully Leverage New Appeals and Grievances Data

GAO-24-106627
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should require states to report on the outcomes of Medicaid managed care appeals (e.g., the extent to which they were decided in favor of enrollees) and number of denials. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should enhance the agency's fiscal guardrails for approving state directed payments by establishing a definition of, and standards for, assessing whether directed payments result in payment rates that are reasonable and appropriate, and communicating those to states; determining whether additional limits are needed; and requiring states to submit data on actual spending amounts at renewal. (Recommendation 1)
Open
As of April 2024, GAO continues to monitor CMS progress toward implementing this recommendation.

Medicaid Managed Care: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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3 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should make publicly available all approval documents related to new and renewed state directed payments, including application attachments, state evaluation plans, and evaluation results. (Recommendation 4)
Open
As of April, GAO continues to monitor CMS progress toward implementing this recommendation.
Centers for Medicare & Medicaid Services The Administrator of CMS should consider interim evaluation results or other performance information from states at renewal to gain more timely information on whether state directed payments are advancing quality goals. (Recommendation 2)
Open
As of April 2024, GAO continues to monitor CMS progress toward implementing this recommendation.
Centers for Medicare & Medicaid Services The Administrator of CMS should require states to consider health equity priorities in designing evaluations of state directed payments. (Recommendation 3)
Open
As of April 2024, GAO continues to monitor CMS progress toward implementing this recommendation.

Medicaid Program Integrity: Opportunities Exist for CMS to Strengthen Use of State Auditor Findings and Collaboration

GAO-23-105881
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should annually examine state auditors' Medicaid findings to identify trends across states and use this information to inform oversight activities and audit processes. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid Program Integrity: Opportunities Exist for CMS to Strengthen Use of State Auditor Findings and Collaboration

GAO-23-105881
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should build on the agency's efforts to collaborate with state auditors on Medicaid oversight activities. These collaboration efforts should include continuing to identify potential updates to the Compliance Supplement, having regular discussions to address auditor training needs, annually sharing information on trends in audit findings and program risks, and increasing auditor awareness of actions taken to address single audit findings. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Part D: CMS Should Monitor Effects of Rebates on Plan Formularies and Beneficiary Spending

GAO-23-105270
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should monitor the effect of rebates on plan sponsor formulary design and on Medicare and beneficiary spending to assess whether rebate practices are likely to substantially discourage enrollment by certain beneficiaries.
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid: CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program

GAO-23-106025
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should conduct a study to determine whether it is cost effective to require states to include payments to managed care organizations and their providers as part of the RAC program. (Recommendation 4)
Open
In its comments on our draft report, CMS stated that it disagreed with this recommendation. CMS said that states are permitted to tailor their Recovery Audit Contractor (RAC) programs to their specific needs and environment. In addition, CMS said states have many other ways to oversee managed care improper payments. While CMS suggested that we remove our recommendation, we stand by our suggested course of action. CMS already has established a framework that allows states to request exemptions from the RAC program to address their specific needs and environment, irrespective of whether managed care is required to be included in Medicaid RAC program. CMS further stated that it must be mindful of time and resources, and that conducting a study regarding the cost-effectiveness of requiring all states to include managed care in their RAC programs may not be the most efficient use of time and resources. CMS stated that many states with large managed care populations have reported that the contingency fee payment methodology is not financially feasible for managed care encounters. While it is important that CMS use its resources efficiently, it is also essential that states use Medicaid funds effectively. CMS plays a key role in helping ensure that states make Medicaid payments appropriately. As part of this role, CMS can determine whether including managed care payments in the RAC program would be cost effective for the overall program. If the RAC scope was to include managed care claims, this could generate sufficient revenue to support a RAC program. Therefore, we continue to believe that our recommendation for CMS to conduct a cost-effectiveness study is valid. In March 2024, HHS reiterated its position and stated the current regulatory flexibility allows states to review managed care encounters if they determine it to be appropriate, and HHS believes this flexibility is critical to the Medicaid RAC framework. We will continue to monitor CMS's actions to address this recommendation.
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