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Open Recommendations (113 total)

Health Insurance Marketplaces: CMS Has Limited Assurance That Premium Tax Credits Exclude Certain State Benefit Costs

GAO-25-107220
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should conduct a risk assessment to determine whether its oversight approach is sufficient to ensure that APTCs exclude the costs of non-EHB mandated benefits or whether additional oversight is needed. CMS should make changes as appropriate based on the results of this assessment. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Health Care Transparency: CMS Needs More Information on Hospital Pricing Data Completeness and Accuracy

GAO-25-106995
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1 Open Recommendations
Agency Affected Recommendation Status
Centers for Medicare & Medicaid Services The Administrator of CMS should assess whether hospital price transparency machine-readable files are sufficiently complete and accurate to be usable for supporting CMS's program goal and implement any additional cost-effective enforcement activities as needed. Such an assessment could include soliciting stakeholder feedback or conducting a study of hospital file completeness and accuracy. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

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
As of September 2024, we have not received an update from HHS on action taken to address this recommendation. When we confirm what action 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 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.

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 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.

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
HHS partially concurred with this recommendation. In November 2024, CMS indicated it will provide written guidance on its expectations for how states are to monitor the appropriateness of managed care plans' prior authorization decisions in 2025 and collect information in the Managed Care Program Annual Report to confirm whether states are meeting those expectations. We will continue to monitor CMS actions in response to this recommendation.

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
HHS partially concurred with this recommendation. In November 2024, the agency informed us that this recommendation requires rulemaking and CMS will consider addressing this recommendation in the next available managed care notice of proposed rulemaking. We will continue to monitor CMS actions to respond to this recommendation.

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 – Partially Addressed
HHS agreed with this recommendation and has begun taking steps to address it. As of September 2024, CMS has added appeal outcomes as required data elements to the Managed Care Program Annual Report (MCPAR), which will apply to all MCPARs beginning in June 2025. In addition, officials told us that CMS plans to add additional fields to capture the number of denials in Fall 2024 and that these fields will likely be required for MCPARs submitted starting in June 2026. We will review the MCPAR when CMS has added the denials fields and determine whether to close the recommendation at that time.

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 – Partially Addressed
HHS agreed with this recommendation and has begun taking steps to address it. In July 2024, CMS began posting states' Managed Care Program Annual Reports for performance year 2023 on Medicaid.gov and officials told us they will continue to post newly received reports on a regular basis. Additionally, in August 2024, CMS released Technical Guidance on data fields related to appeals and grievances to help states improve the consistency and quality of submitted data. This is a positive step toward making the data more complete and reliable so that it can be used for oversight. We will continue to monitor CMS's plans and actions for analyzing the appeals and grievances data and using it for oversight.
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