Federal law requires each state, under both fee-for-service and managed  care delivery models, to operate a claims processing system to record  information about the services provided and report this information to  CMS:
Provider claims and managed care encounter data are required to  include information about the service provided, including the general  type of service; a procedure code that identifies the specific service  provided; the location of the service; the date the service was  provided; and information about the provider who rendered the  service (e.g., provider identification number). Medicaid spending on long-term services and supports provided in home  and community settings has increased dramatically over time—to about  $80 billion in federal and state expenditures in 2014—while the share of  spending for care in institutions has declined, and HCBS spending now  exceeds long-term care spending for individuals in institutions (see fig. Together with federal statutes, the regulations  and guidance issued by CMS establish a broad federal framework for the  provision of personal care services. Federal Program Requirements for Maintaining Beneficiary Safety and Ensuring That Billed Services Are Provided Differ Significantly

In our 2016 report examining the federal program requirements for the  multiple programs under which personal care services are provided, we  found significant differences in federal requirements related to beneficiary  safety and ensuring that billed services are provided. These differences  may translate to differences in beneficiary protections across program  types. For example, states  implementing an HCBS Waiver program or a State Plan HCBS program  must:
Describe to CMS how the state Medicaid agency will determine that it  is assuring the health and welfare of beneficiaries. States implementing HCBS Waiver programs  and State Plan HCBS programs, for example, are required by CMS to  provide evidence that the state is only paying claims when services are  actually rendered, while the State Plan personal care services and  Community First Choice programs are not required to do so. We recommended that CMS  take additional steps to better harmonize and achieve a more consistent  application of program requirements, as appropriate, across the different  personal care services programs in a way that accounts for common risks  faced by beneficiaries and to better ensure billed services were provided. CMS agreed with these recommendations, and has sought input by  publishing a request for information on numerous topics related to  Medicaid home and community-based services, including input on how to  ensure beneficiary health and safety and program integrity across  different types of personal care services programs. Data on Personal Care Services Collected by CMS were Often Not Timely, Complete, Consistent, or Accurate Claims and Encounter Data Were Not Timely, Complete, or Consistent

In our 2017 report examining the data CMS uses to monitor the provision  of personal care services, we found that claims and encounter data  collected by CMS were not timely. Type of services provided. More than 400 unique procedure codes were used by the 35  states. Medicaid Expenditure Data Collected by CMS Were Not Always Accurate or Complete

In our 2017 report we found that Medicaid personal care services  expenditure data collected were not always accurate or complete,  according to our analysis of expenditure data collected by CMS from  states for calendar years 2012 through 2015. As illustrated in figure 4, nearly two-thirds of the reporting errors were a  result of states not separately identifying and reporting personal care  services expenditures using the correct reporting lines, as required by  CMS. We recommended that CMS take steps to improve the  collection of complete and consistent personal care services data and  better monitor the states’ provision of and spending on Medicaid personal  care services. Having various options for  providing personal care services provides flexibilities for states in how  they administer their programs and provide services to different groups of  beneficiaries. At the same time, our work has also found a patchwork of  federal requirements, resulting in varying levels of beneficiary safeguards  and requirements to ensure that billed services are actually provided. Similarly, the level of assurance that billed services are  actually provided could vary based on the type of program. Without better  data, CMS is hindered in effectively performing key management  functions related to personal care services, such as ensuring state claims  for enhanced federal matching funds are accurate. CMS has taken steps  to improve the data it collects from states, and to establish more  consistent administration of policies and procedures across the programs  under which personal care services are provided. This is a work of the U.S. government and is not subject to copyright protection in the  United States.
Why GAO Did This Study

Medicaid, a joint federal-state health care program, provides long-term services and supports for disabled and aged individuals, increasingly in home and community settings. Federal and state Medicaid spending on home- and community-based services was about $80 billion in 2014. Personal care services are a key component of this care. States can offer personal care services through many different types of programs, and each may be subject to different federal requirements established by statute, regulations, and guidance. The provision of personal care in beneficiaries' homes can pose safety risks, and these services have a high and growing rate of improper payments, including cases 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.
This statement highlights key issues regarding (1) the federal program requirements to protect beneficiaries' safety and ensure that billed services are provided, and (2) the usefulness of data collected by CMS for oversight. This testimony is based on reports GAO issued in 2016 and 2017. For these reports, GAO assessed CMS data on personal care services provided to beneficiaries and state spending. GAO also reviewed federal statutes, regulations, and guidance, and interviewed CMS officials.

What GAO Found

In its November 2016 report, GAO found a patchwork of federal requirements related to how states must protect the safety of beneficiaries in their personal care services programs and to how states ensure that billed services are actually provided. Personal care services help beneficiaries with basic activities of daily living such as bathing and dressing, in a home- or community-based setting. For two types of programs under which personal care services can be offered, states must describe to the Centers for Medicare & Medicaid Services (CMS) how they will ensure the health and welfare of beneficiaries. Similar requirements were not in place for several other programs GAO examined. In addition, for some but not all personal care services programs that GAO reviewed, states must provide evidence to CMS that the state is paying claims for services that have actually been provided. These differing federal program requirements result in uneven beneficiary safeguards and levels of assurances regarding states' beneficiary protections and oversight of billed services. GAO recommended that CMS take steps to harmonize and achieve a more consistent application of federal requirements across programs. CMS agreed with GAO's recommendation and sought input on how to do so by publishing a request for information.
In its January 2017 report, GAO found limitations in the data that CMS collects to monitor the provision of personal care services and to monitor state spending on services. For example:
Data on personal care services provided were often not timely, complete or consistent. The most recent data available during GAO's review (2016) were for 2012 and included data for only 35 states. Further, 15 percent of claims lacked provider identification numbers and 34 percent lacked information on the quantity of services provided. Data were also inconsistent as more than 400 different procedure codes were used by states to identify personal care services. Without timely, complete, and consistent data, CMS is unable to effectively oversee state programs and verify who is providing personal care services or the type, amount, and dates of services provided.
Data on states' spending on CMS's expenditure reports, the basis for states' receipt of federal matching funds, were not always accurate or complete. From 2012 through 2015, 17 percent of expenditure lines were not reported correctly by states, according to GAO's analysis. Nearly two-thirds of these errors were due to states not separately identifying personal care services expenditures, as required by CMS, from other types of expenditures. Inaccurate and incomplete data limit CMS's ability to, among other oversight functions, ensure federal matching funds are appropriate.
GAO made several recommendations to improve the data CMS collects to monitor the provision of and expenditures on personal care services. CMS agreed with some but not all of these recommendations.