Long-Term Care: Federal Oversight of Growing Medicaid Home and Community-Based Waivers Should Be Strengthened
GAO-03-576
Published: Jun 20, 2003. Publicly Released: Jul 07, 2003.
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Highlights
Home and community-based settings have become a growing part of states' Medicaid long-term care programs, serving as an alternative to care in institutional settings, such as nursing homes. To cover such services, however, states often obtain waivers from certain federal statutory requirements. GAO was asked to review (1) trends in states' use of Medicaid home and community-based service (HCBS) waivers, particularly for the elderly, (2) state quality assurance approaches, including available data on the quality of care provided to elderly individuals through waivers, and (3) the adequacy of federal oversight of state waivers. GAO is recommending that the Administrator of CMS take steps to (1) better ensure that state quality assurance efforts are adequate to protect the health and welfare of HCBS waiver beneficiaries, and (2) strengthen federal oversight of the growing HCBS waiver programs. Although CMS raised certain concerns about aspects of the report, such as the respective state and federal roles in quality assurance and the potential need for additional federal oversight resources, CMS generally concurred with the recommendations.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | To ensure that state quality assurance efforts are adequate to protect the health and welfare of HCBS waiver beneficiaries, the Administrator of CMS should develop and provide states with more detailed criteria regarding the necessary components of an HCBS waiver quality assurance system. |
In response to GAO's recommendation, CMS refined and finalized the CMS quality framework in December 2003, providing states with a uniform format to describe components of their quality assurance and improvement program for HCBS waivers. CMS awarded grants to 19 states in 2004 for projects to improve state quality assurance and improvement systems for waivers. CMS also worked with experts and relevant stakeholders to identify key components of state quality management systems and developed a revised application for all HCBS waivers which incorporates additional quality expectations. The revised draft waiver application incorporating stakeholder comments was released for states' use in May 2005, with a web-based version to be available on-line in January 2006. CMS conducted six nationwide training sessions on the revised application and to clarify CMS's expectations for states' quality management approaches. In addition, CMS issued six "promising practices" briefs in July 2003 to disseminate information on effective quality assurance methods used by states, and two additional publications on components of quality management in early 2005.
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| Centers for Medicare & Medicaid Services | To ensure that state quality assurance efforts are adequate to protect the health and welfare of HCBS waiver beneficiaries, the Administrator of CMS should require states to submit more specific information about their quality assurance approaches prior to waiver approval. |
In response to GAO's recommendation, CMS worked with national associations representing state Medicaid, aging, and developmental disabilities directors to identify key components of state quality management systems. Using that information as well as a national inventory of state quality assurance and improvement strategies issued in January 2004, CMS developed a revised application for all HCBS waivers which includes additional quality expectations. The application now includes a section requiring states to describe their systems for assuring, measuring, and improving quality in the waiver program. The revised draft application incorporating stakeholder comments was released for states' use in May 2005 while CMS proceeds with formal clearance and publication.
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| Centers for Medicare & Medicaid Services | To ensure that state quality assurance efforts are adequate to protect the health and welfare of HCBS waiver beneficiaries, the Administrator of CMS should ensure that states provide sufficient and timely information in their annual waiver reports on their efforts to monitor quality. |
In response to GAO's recommendation, CMS developed a revised annual reporting form to gather more specific information on states' quality assurance monitoring. This effort was conducted in collaboration with its regional offices and national associations representing state Medicaid, aging, and developmental disabilities directors. In addition, CMS developed an electronic database allowing the agency to track the timeliness of annual report submissions. Once the revised annual reporting form is approved by OMB, anticipated in spring 2006, CMS will require states to submit their annual waiver reports electronically beginning in 2007.
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| Centers for Medicare & Medicaid Services | To strengthen federal oversight of the growing HCBS waiver programs and to ensure the health and welfare of HCBS waiver beneficiaries, the Administrator should ensure allocation of sufficient resources and hold regional offices accountable for conducting thorough and timely reviews of the status of quality in HCBS waiver programs. |
In response to GAO's recommendation, CMS conducted a review of CMS resources and previous review strategies for waiver oversight. Following that review, the agency developed and implemented standardized procedural guidance in January 2004 for more thorough and timely completion of waiver reviews by regional offices. The agency claims that the standardization and streamlining of the process will make it more efficient while also strengthening the focus on critical areas in waiver quality. In order to hold regional offices more accountable for waiver oversight, the agency initiated a system of semi-annual quality and review training for regional office staff and added waiver oversight as a standing agenda item to monthly central/regional office conference calls. Monthly reports on the timeliness of reviews and the use of new procedures are prepared by CMS and shared with regional office staff. Regular updates on the results of CMS' tracking processes are shared with regional office administrators.
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| Centers for Medicare & Medicaid Services | To strengthen federal oversight of the growing HCBS waiver programs and to ensure the health and welfare of HCBS waiver beneficiaries, the Administrator should develop guidance on the scope and methodology for federal reviews of state waiver programs, including a sampling methodology that provides confidence in the generalizability of the review results. |
In response to GAO's recommendation, CMS developed and implemented standardized procedural guidance for use by regional offices in assessing HCBS waivers. The guidance specifies the evidence to be obtained from states, procedures for regional office review of the evidence, procedures for on-site collection of additional information if necessary, and criteria for determining whether the state's efforts are adequate to protect the health and welfare of waiver beneficiaries. As the guidance does not require on-site review of client records by the regional office, no discussion of a sampling methodology for regional office reviews is included. The original guidance was issued in January 2004 and revised in May 2004. Further revisions to the guidance will be developed following adoption of a new waiver application form and revised annual quality reporting form.
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