October 21, 2021

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Medicaid Long-Term Services and Supports: Access and Quality Problems in Managed Care Demand Improved Oversight

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<div>At the state and federal levels, GAO found weaknesses in the oversight of Medicaid managed long-term services and supports (MLTSS), which assist individuals with basic needs like bathing or eating. Through various monitoring approaches, six selected states identified significant problems in their MLTSS programs with managed care organization (MCO) performance of care management, which includes assessing beneficiary needs, authorizing services, and monitoring service provision to ensure quality and access to care. State efforts may not be identifying all care management problems due to limitations in the information they use to monitor MCOs, allowing some performance problems to continue over multiple years. Performance Problems in Managed Care Organization (MCO) Care Management, Identified by Selected States GAO found that the Centers for Medicare & Medicaid Services' (CMS) oversight of state implementation of its 2016 requirements, and of access and quality in MLTSS more broadly, was limited. This hinders the agency's ability to hold states and MCOs accountable for quality and access problems beneficiaries may face. Oversight did not detect quality and access problems. GAO identified cases where CMS learned about problems not through its regular oversight, but instead from beneficiary complaints, media reports, or GAO. CMS officials said that states had not reported these problems to the agency. Lack of national oversight strategy and assessment of problems in MLTSS. Weaknesses in oversight reflect a broader area of concern—namely, that CMS lacks a strategy for oversight. CMS also has not assessed the nature and extent of access and quality problems across states. Without a strategy and more robust information, CMS risks being unable to identify and help address problems facing beneficiaries. As of July 2020, CMS had convened a new workgroup focused on MLTSS oversight, though the goals and time frames for its work were unclear. An increasing number of states are using managed care to deliver long-term services and supports in their Medicaid programs, thus delegating decisions around the amounts and types of care beneficiaries receive to MCOs. Federal guidance requires that MLTSS programs include monitoring procedures to ensure the appropriateness of those decisions for this complex population, which includes adults and children who may have physical, cognitive, and mental disabilities. GAO was asked to review care management in MLTSS programs. Among other things, this report examines state monitoring of care management, and CMS oversight of state implementation of 2016 requirements related to MLTSS quality and access. GAO examined documentation of monitoring procedures and problems identified in six states selected for variation in program age and location. GAO reviewed federal regulations and oversight documents, interviewed state and federal Medicaid officials, and assessed CMS's policies and procedures against federal internal control standards. GAO is making two recommendations to CMS to (1) develop a national strategy for overseeing MLTSS, and (2) assess the nature and prevalence of MLTSS quality and access problems across states. CMS did not concur with the recommendations. GAO maintains the recommendations are warranted, as discussed in this report. For more information, contact at (202) 512-7114 or yocomc@gao.gov.</div>

What GAO Found

At the state and federal levels, GAO found weaknesses in the oversight of Medicaid managed long-term services and supports (MLTSS), which assist individuals with basic needs like bathing or eating.

Through various monitoring approaches, six selected states identified significant problems in their MLTSS programs with managed care organization (MCO) performance of care management, which includes assessing beneficiary needs, authorizing services, and monitoring service provision to ensure quality and access to care. State efforts may not be identifying all care management problems due to limitations in the information they use to monitor MCOs, allowing some performance problems to continue over multiple years.

Performance Problems in Managed Care Organization (MCO) Care Management, Identified by Selected States

GAO found that the Centers for Medicare & Medicaid Services’ (CMS) oversight of state implementation of its 2016 requirements, and of access and quality in MLTSS more broadly, was limited. This hinders the agency’s ability to hold states and MCOs accountable for quality and access problems beneficiaries may face.

  • Oversight did not detect quality and access problems. GAO identified cases where CMS learned about problems not through its regular oversight, but instead from beneficiary complaints, media reports, or GAO. CMS officials said that states had not reported these problems to the agency.
  • Lack of national oversight strategy and assessment of problems in MLTSS. Weaknesses in oversight reflect a broader area of concern—namely, that CMS lacks a strategy for oversight. CMS also has not assessed the nature and extent of access and quality problems across states. Without a strategy and more robust information, CMS risks being unable to identify and help address problems facing beneficiaries. As of July 2020, CMS had convened a new workgroup focused on MLTSS oversight, though the goals and time frames for its work were unclear.

Why GAO Did This Study

An increasing number of states are using managed care to deliver long-term services and supports in their Medicaid programs, thus delegating decisions around the amounts and types of care beneficiaries receive to MCOs. Federal guidance requires that MLTSS programs include monitoring procedures to ensure the appropriateness of those decisions for this complex population, which includes adults and children who may have physical, cognitive, and mental disabilities.

GAO was asked to review care management in MLTSS programs. Among other things, this report examines state monitoring of care management, and CMS oversight of state implementation of 2016 requirements related to MLTSS quality and access. GAO examined documentation of monitoring procedures and problems identified in six states selected for variation in program age and location. GAO reviewed federal regulations and oversight documents, interviewed state and federal Medicaid officials, and assessed CMS’s policies and procedures against federal internal control standards.

What GAO Recommends

GAO is making two recommendations to CMS to (1) develop a national strategy for overseeing MLTSS, and (2) assess the nature and prevalence of MLTSS quality and access problems across states. CMS did not concur with the recommendations. GAO maintains the recommendations are warranted, as discussed in this report.

For more information, contact at (202) 512-7114 or yocomc@gao.gov.

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