Medicaid (1 - 10 of 1,026 items)
Private Health Insurance: In Most States and New Exchanges, Enrollees Continued to be Concentrated among Few Issuers in 2014 [Reissued on February 14, 2017]
GAO-16-724: Published: Sep 6, 2016. Publicly Released: Sep 6, 2016.
GAO found that enrollment in private health insurance plans remained concentrated among a small number of issuers in most states in 2014, including in the newly established exchanges. On average in each state and the District of Columbia, 11 or more issuers participated in each of three types of markets—individual, small group, and large group—from 2011 through 2014. However, in most states, t...
Medicaid: CMS Needs Better Data to Monitor the Provision of and Spending on Personal Care Services
GAO-17-169: Published: Jan 12, 2017. Publicly Released: Feb 13, 2017.
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 t...
Medicaid Managed Care: Improved Oversight Needed of Payment Rates for Long-Term Services and Supports
GAO-17-145: Published: Jan 9, 2017. Publicly Released: Feb 8, 2017.
Out of six states with Medicaid managed long-term services and supports (MLTSS) programs that GAO selected for review, five set clear financial incentives in their payment rates for managed care organizations (MCO) to provide care in the community versus in an institution. However, most of the selected states did not opt to link payments or penalties to MCO performance on MLTSS goals. These goals,...
Foster Care: HHS Has Taken Steps to Support States' Oversight of Psychotropic Medications, but Additional Assistance Could Further Collaboration
GAO-17-129: Published: Jan 5, 2017. Publicly Released: Feb 6, 2017.
State child welfare and Medicaid officials in seven selected states reported a variety of practices to support the appropriate use of psychotropic medications, which affect mood, thought, or behavior, for children in foster care. Practices include screening for mental health conditions, developing prescription guidelines, and monitoring a child's health while on medication. Additional state effort...
Medicaid: Program Oversight Hampered by Data Challenges, Underscoring Need for Continued Improvements
GAO-17-173: Published: Jan 6, 2017. Publicly Released: Feb 6, 2017.
GAO found that available Medicaid expenditure and utilization data do not provide CMS with sufficient information to consistently ensure that payments are proper or that beneficiaries have access to covered services. The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers the Medicaid program, relies on two key data s...
Medicaid: CMS Has Taken Steps, but Further Efforts Are Needed to Control Improper Payments
GAO-17-386T: Published: Jan 31, 2017. Publicly Released: Jan 31, 2017.
GAO's prior work has identified four Medicaid program integrity issues—where the program is vulnerable to improper payments such as those made for services that were not covered, were not medically necessary, or were not provided—as well as actions taken by the Centers for Medicare & Medicaid Services (CMS) to address the issues and additional actions that should be taken.Enrollment Verificati...
Medicare Advantage: Limited Progress Made to Validate Encounter Data Used to Ensure Proper Payments
GAO-17-223: Published: Jan 17, 2017. Publicly Released: Jan 19, 2017.
Since GAO issued its July 2014 report, the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS) has made limited progress to validate the completeness and accuracy of Medicare Advantage (MA) encounter data. CMS collects encounter data—detailed information about the care and health status of MA enrollees—to determine payments to MA organization...
Medicaid Personal Care Services: CMS Could Do More to Harmonize Requirements across Programs
GAO-17-28: Published: Nov 23, 2016. Publicly Released: Dec 22, 2016.
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 man...
Patient Protection and Affordable Care Act: Results of Enrollment Testing for the 2016 Special Enrollment Period
GAO-17-78: Published: Nov 17, 2016. Publicly Released: Dec 15, 2016.
The Patient Protection and Affordable Care Act (PPACA) requires that federal and state-based marketplaces verify application information—such as citizenship or immigration status—to determine eligibility for enrollment in a health plan, potentially including a subsidy. However, there is no specific legal requirement to verify the events that trigger a Special Enrollment Period (SEP), which is...
Nursing Homes: Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System
GAO-17-61: Published: Nov 18, 2016. Publicly Released: Dec 6, 2016.
GAO found that the Centers for Medicare & Medicaid Services (CMS) collects information on the use of the Nursing Home Compare website, which was developed with the goal of assisting consumers in finding and comparing nursing home quality information. CMS uses three standard mechanisms for collecting website information—website analytics, website user surveys, and website usability tests. These m...