Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs
Fast Facts
Personal care attendants help older and disabled Americans with daily tasks—such as bathing or eating. How do states ensure that care provided through Medicaid is safe, and that attendants aren't paid for phantom services?
While all states we reviewed monitored for safety, the frequency and means of check-ins varied across states, and sometimes within a state across personal care programs. We also found variation in states' safeguards against paying for services that weren't provided.
On the federal side, we found the Medicaid rules varied across different types of personal care programs. We recommended reducing that variation.
Photo of clasped, elderly hands.
Highlights
What GAO Found
Four states that GAO reviewed varied in how they implemented safeguards to protect beneficiaries receiving in-home personal care services from harm and in their methods to help ensure billed services were actually provided. For example, to help keep beneficiaries safe, the four selected states—California, Maryland, Oregon, and Texas—reported that they monitored beneficiaries by having case managers or nurses periodically check in with beneficiaries, but the frequency and means, such as in-person or by phone, varied among the states and in some cases across programs within a state. The four states also reported using different methods to help ensure that billed services were actually provided. For example, to track attendants' work time, two states required beneficiaries to sign paper timesheets for the attendants, and two states used electronic visit verification timekeeping systems for some or all programs.
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), has taken several steps to improve oversight of states' personal care service programs and harmonize requirements but has not collected required state reports or addressed significant differences in program requirements. Since 2010, CMS steps to improve oversight of states' programs include enhancing guidance and conducting webinars to help states address improper payments. To manage risk inherent in the provision of these services, and in keeping with statutory direction to improve coordination of these programs, CMS has taken steps to better harmonize requirements across programs including directing states to follow agency guidance issued for one type of program when implementing a similar type of program. However:
- CMS has not systematically collected required states' reports on personal care services provided under two programs, although CMS stated that guidance for states to submit the reports is under development. Collecting these reports could improve oversight by providing CMS and Congress with information on programs' effects on beneficiaries' health and welfare.
- CMS harmonization efforts have not addressed the significant differences across federal program requirements specific to beneficiary safety and ensuring that billed services are provided. Consequently, the safeguards and level of assurance that CMS has regarding states' beneficiary protections and oversight of billed services can vary by program. For example, one reviewed state requires quarterly or biannual beneficiary monitoring for most programs; but one program monitors annually as federal requirements do not require more frequent monitoring. Similarly, requirements to help ensure billed services are actually provided vary widely among states and programs, contributing to uneven assurances and oversight across programs.
Home- and community-based services, including personal care services, are growing in significance and in demand. A more consistent administration of policies and procedures across programs could help the federal government and states better manage risks to beneficiaries and protect the integrity of the program.
Why GAO Did This Study
The number of people receiving in-home personal care services—such as assistance with bathing and dressing—from Medicaid is expected to grow. States can offer these services through one or more programs under which home- and community-based services can be provided, each with different federal requirements. The provision of personal care in beneficiaries' homes can pose risks to safety, and these services have a high rate of improper payments, including instances where services for which the state was billed were not provided. In recent years Congress has directed HHS to improve coordination of these programs, which could harmonize requirements—that is, implement a more consistent administration of policies and procedures—and enhance oversight.
GAO was asked to review oversight of Medicaid personal care services. GAO examined: (1) how selected states ensure that beneficiaries receiving services are safe from harm and that billed services are provided; and (2) steps CMS has taken since 2010 to improve oversight and harmonize requirements across programs. GAO reviewed policies in four states with varied programs; reviewed laws, guidance and documents; and interviewed CMS officials.
Recommendations
GAO recommends that the Acting Administrator of CMS (1) collect and analyze required state reports on personal care services and (2) take steps to further harmonize federal program requirements, as appropriate, across programs providing these services. HHS concurred with both recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | To achieve a better understanding of the effect of certain Personal care services (PCS) services on beneficiaries and a more consistent administration of policies and procedures across PCS programs, the Acting Administrator of CMS should collect and analyze states' required information on the impact of the Participant-Directed Option and Community First Choice programs on the health and welfare of beneficiaries as well as the state quality measures for the Participant-Directed Option and Community First Choice programs. |
The Centers for Medicare & Medicaid Services (CMS) concurred with GAO's recommendation. On December 30, 2016, the agency issued guidance on the Community First Choice program to assist states in submitting information to CMS on the health and welfare of beneficiaries. In March 2019, CMS officials stated that the agency is currently developing the process for states to report this information to CMS. Agency officials also stated they are exploring the value of collecting this information for the Participant-Directed Option program given the limited number of states currently operating under this authority. In February 2020, CMS officials stated that the agency continues to develop policy related to this recommendation. In March 2022, CMS officials stated that CMS's work on Community First Choice data collection and development of a plan for the Participant-Directed Option program had been interrupted by the COVID-19 pandemic. In March 2023, CMS officials stated that the agency has requested funding in fiscal year 2023 to secure a contractor to develop reporting requirements, standards, and templates that CMS can distribute to states to meet this requirement. Officials said work on this task is paused until contract resources can procured. In addition, officials said potential amendments to Community First Choice program reporting requirements are under development as part of a larger initiative to standardize reporting across home- and community-based services authorities. In September 2023, CMS officials stated that the agency has included provisions in the Ensuring Access to Medicaid Services (CMS 2442-P) Notice of Proposed Rulemaking to standardize data collection across all 1915 authorities, including the Participant-Directed Option and Community First Choice programs. The regulation is expected to be finalized in spring 2024 with sub-regulatory guidance issued throughout 2024 and possibly 2025. CMS officials provided an estimated completion date of December 31, 2024. GAO will continue to monitor the implementation of this recommendation.
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| Centers for Medicare & Medicaid Services | To achieve a better understanding of the effect of certain PCS services on beneficiaries and a more consistent administration of policies and procedures across PCS programs, the Acting Administrator of CMS should take steps to harmonize requirements, as appropriate, across PCS programs in a way that accounts for common risks faced by beneficiaries and to better ensure that billed services are provided. |
The Centers for Medicare & Medicaid Services (CMS) concurred with GAO's recommendation. Since our report, CMS has summarized PCS delivery model requirements to states through guidance, agency training, and presentations to account for common beneficiary risks and to ensure billed services are provided. CMS cited several examples of actions the agency has taken to summarize requirements, including: (1) issuing a 2016 informational bulletin that encourages states to strengthen program integrity efforts across PCS programs, which also addresses health and safety issues; and (2) developing technical assistance, training series, and other support to help states implement required electronic visit verification for Medicaid PCS across all programs by 2020. CMS has also worked with states and stakeholders to strengthen quality oversight of home and community-based services (HCBS) in part by issuing a June 2018 informational bulletin that is the first in a series on how states can ensure beneficiary health and welfare for HCBS beneficiaries; these efforts also have implications for beneficiaries receiving PCS. Finally, CMS officials stated that they will continue to provide additional guidance, training, and support to strengthen beneficiary health and safety protections.
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