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Open Recommendations (120 total)

Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect Lessons Learned after COVID-19

GAO-24-106883
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should document and implement the oversight practices the agency learned during unwinding were needed for preventing and detecting state compliance issues with redetermination requirements. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Hospice: CMS Needs to Fully Implement Statutory Provisions and Prioritize Certain Overdue Surveys

GAO-24-106442
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2 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS Administrator should instruct SAs and AOs to prioritize the completion of standard surveys for hospices that are overdue for a survey based on potential risk factors, which could include the amount of time overdue or evidence of past quality issues. (Recommendation 4)
Open
CMS disagreed with this recommendation. However, in June 2024, the agency shared that it had recently received supplemental funding to assist with the overdue hospice standard surveys and was exploring ways to use contracted surveyors to assist the SAs with the backlog by prioritizing the states with hospices that are most at risk for not complying with health and safety standards. As of July 2024, CMS had not yet instructed SAs and AOs to prioritize the completion of their overdue hospice surveys based on potential risk factors, and we consider this recommendation open. We will continue to monitor agency action in this area.
Centers for Medicare & Medicaid Services The CMS Administrator should make hospice survey results publicly available on Care Compare such that the information is prominent, easily accessible, and readily understandable. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Hospice: CMS Needs to Fully Implement Statutory Provisions and Prioritize Certain Overdue Surveys

GAO-24-106442
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The CMS Administrator should fully implement efforts to measure and reduce inconsistency in survey results among all surveyors, including SAs and AOs. (Recommendation 3)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicaid: Managed Care Plans’ Prior Authorization Decisions for Children Need Additional Oversight

GAO-24-106532
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should clearly define whether managed care plans can require prior authorization for EPSDT services when the state does not have such requirements. This should include defining the term "non-quantitative treatment limits" as it relates to managed care plans providing medically necessary services to children in a manner no more restrictive than that used in the state Medicaid program. (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 Plans’ Prior Authorization Decisions for Children Need Additional Oversight

GAO-24-106532
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should communicate in writing expectations for how states are to monitor the appropriateness of managed care plans' prior authorization decisions and take steps to confirm whether states are meeting those expectations. Such communication should include expectations related to monitoring prior authorization decisions of EPSDT services for children. (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: 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: 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: Rapid Spending Growth in State Directed Payments Needs Enhanced Oversight and Transparency

GAO-24-106202
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2 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.
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