Medicaid spending on long-term services  and supports provided in home and community settings has increased  dramatically over time—to about $80 billion 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. 1). According to numerous HHS OIG  reviews and CMS’s annual review of Medicaid improper payments, the  provision of Medicaid personal care services is at high risk for improper  payments. Two CMS Systems Collect Data on the Provision of and Spending on Personal Care Services, and the Data Suggest Wide Variations among States

Two CMS data systems collect Medicaid data from providers’ records of  services rendered and total Medicaid expenditures by broad Medicaid  categories of service, including for personal care services. The Medicaid Statistical  Information System (MSIS) was established to collect detailed information  on the services rendered to individual Medicaid beneficiaries. The  Medicaid Budget and Expenditure System (MBES) was established for  states to report total aggregate expenditures for Medicaid services across  broad service categories. Limitations in Data Hinder CMS Oversight of Personal Care Services, and Planned Improvements May not Address Data Limitations

CMS’s two data systems provide some basic and aggregate information  on the provision of and spending on personal care services. However, in  order to provide effective oversight, CMS needs detailed data on personal  care services that are timely, complete, consistent, and accurate,  including data on who provided the service, the type and amount of  services provided, when services were provided, and the amount the  state paid for services. We found that the detailed data collected by the  two systems were not always timely, complete, consistent, or accurate,  which limits the usefulness of these data for CMS oversight. This happens for two  reasons. More than 400 unique  procedure codes were used by the 35 states. As illustrated in figure 11, 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. First, CMS is developing an enhanced Medicaid  claims data system—called the Transformed-Medicaid Statistical  Information System (T-MSIS)—that will replace MSIS. According to CMS officials, the new division is intended to: work with states to help ensure the completeness and consistency of  claims data as states transition to T-MSIS,  improve the quality of the data by analyzing the data for anomalies  and errors that can be corrected, build the agency’s capacity to use the data for program monitoring,  oversight, and reporting, and provide data analysis support for different CMS program offices,  including the offices that oversee states’ personal care services  programs. Timely, relevant, and reliable data are  needed for decision making, external reporting, and monitoring program  operations—for example, to conduct management functions such as  tracking the growth in use of and spending on specific Medicaid services;  to identify trends related to utilization and payments per service, provider,  and beneficiary; and to identify areas at higher risk for fraud, waste, and  abuse. Without complete and consistent federal data collected from  states, CMS is unable to conduct effective oversight and perform key  management functions specific to personal care services, such as  ensuring that states report personal care services expenditures correctly;  claims for enhanced federal matching funds are accurate, verifying states’  historical spending levels for determining maintenance of expenditure  requirements, linking payments from claims with reported expenditures,  or providing technical assistance to states to identify improper personal  care services payments. We found that the data collected from states were often incomplete,  inconsistent, or inaccurately reported. Recommendations for Executive Action

To improve the collection of complete and consistent personal care  services data and better ensure CMS can effectively monitor the states’  provision of and spending on Medicaid personal care services, we  recommend CMS take the following four steps:
Establish standard reporting guidance for personal care services  collected through T-MSIS to ensure that key data reported by states,  such as procedure codes, provider identification numbers, units of  service, and dates of service, are complete and consistent;
Better ensure, for all types of personal care services programs, that  data on provision of personal care services and other HCBS services  collected through T-MSIS claims can be specifically linked to the  expenditure lines on the CMS-64 that correspond with those particular  types of HCBS services;
Better ensure that personal care services data collected from states  through T-MSIS and MBES comply with CMS reporting requirements;  and
Develop plans for analyzing and using personal care services data for  program management and oversight. HHS did not explicitly agree  or disagree with the two other recommendations—that the agency  establish standard reporting guidance and improve the linkages between  CMS-64 and T-MSIS data on personal care services.
Why GAO Did This Study

A growing share of long-term care spending under Medicaid, a joint federal-state health care program, is for services provided in home and community settings. Medicaid spending on these services—about $80 billion in 2014—now exceeds spending on institutional long term care. Personal care services are key components of long-term, in-home care, providing assistance with basic activities, such as bathing, dressing, and toileting, to millions of individuals seeking to retain their independence and to age in place. However, these services are also at high risk for improper payments, including fraud.
Given the expected increase in the demand for and spending on personal care services and risk of improper payments, GAO was asked to examine available data on personal care services and CMS's use of the data. This report: (1) describes the CMS systems that collect data on personal care services and what the data reveal, and (2) examines the extent to which data from these systems can be used for oversight. GAO reviewed information from two CMS data systems, reviewed relevant federal guidance and documents, and interviewed officials and researchers.

What GAO Found

Two data systems managed by the Centers for Medicare & Medicaid Services (CMS)—the federal agency that oversees Medicaid—collect information from states on the provision of and spending on personal care services:
The Medicaid Statistical Information System (MSIS) collects detailed information from provider claims on services rendered to individual Medicaid beneficiaries and state payments for these services.
The Medicaid Budget and Expenditure System (MBES) collects states' total aggregate Medicaid expenditures across 80 broad service categories.
Information from these two CMS data systems can be used in the aggregate to describe broadly the provision of and spending on Medicaid personal care services. For example, MBES data show that total fee-for-service spending on these services was at least $15 billion in 2015—up $2.3 billion from 2012.
However, the usefulness of the data collected from these two systems for CMS oversight is limited because of data gaps and errors. To provide effective oversight, including decision making, external reporting, and monitoring program operations, CMS needs timely, relevant and reliable data on personal care services rendered and the amount paid. GAO found that the data collected did not always meet these standards. For example:
MSIS data were not timely, complete, or consistent. The most recent data available at the time of GAO's audit were for 2012 and only included data for 35 states. Further, 15 percent of claims lacked provider identification numbers, over 400 different procedure codes were used to identify the services, and the quantity and time periods varied widely. Without good data, CMS is unable to effectively monitor who is providing personal care services or the type, amount, and dates of services. CMS may also face challenges determining whether beneficiaries were eligible for services and assessing the reasonableness of the amount of services claimed.
MBES data were not always accurate or complete. From 2012 through 2015, GAO found that 17 percent of expenditure lines were not reported correctly. Nearly two-thirds of these errors were due to states not separately identifying personal care services expenditures, as required by CMS. Inaccurate and incomplete reporting limits CMS's ability to ensure federal matching funds are provided consistent with states' approved programs.
CMS is developing a new Medicaid claims system to replace MSIS and recently established a new office to support CMS's use of Medicaid data for program management and monitoring. However, CMS has not issued guidance related to reporting of personal care services that addresses the gaps GAO identified, or developed plans to use the data for oversight purposes. Without improved data and plans for how it can be used for oversight, CMS could continue to lack critical information on personal care service expenditures.
HHS agreed with two of GAO's recommendations to ensure state compliance with reporting requirements and develop plans to use the data. HHS neither agreed nor disagreed with two others.

What GAO Recommends

GAO recommends that CMS improve personal care services data by: establishing standard reporting guidance for key data; ensuring linkage between data on the provision of services and reported expenditures; ensuring state compliance with reporting requirements; and developing plans to use data for oversight.