Medicaid Home- and Community-Based Services: Evaluating COVID-19 Response Could Help CMS Prepare for Future Emergencies
Fast Facts
Medicaid home- and community-based services help beneficiaries with daily activities like bathing, dressing, and eating. To continue services during the pandemic and prevent the spread of COVID-19, the Centers for Medicare & Medicaid Services (CMS) allowed states to make temporary changes like providing more home-delivered meals or giving providers hazard pay.
CMS relied on states to monitor how these changes affected beneficiaries and make any mid-course corrections—but provided little guidance on doing so.
We recommended that CMS evaluate lessons learned from COVID-19 and develop plans for monitoring during future public health emergencies.
Highlights
What GAO Found
COVID-19 presented risks to Medicaid home- and community-based services (HCBS) programs, where providers help beneficiaries with daily activities, such as bathing, dressing, and eating. To maintain access to services and prevent disease spread, all states received approval for temporary changes to their HCBS programs from the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services. These changes enabled selected states to limit in-person contact to reduce the spread of the disease, but also led to new challenges to ensuring beneficiary health and welfare.
Examples of Temporary Changes to States' Medicaid Home- and Community-Based Services Due to COVID-19, as of December 2020
CMS focused on supporting states' implementation of temporary changes and conducted limited oversight of the effects of the changes. CMS's Pandemic Plan establishes the need for monitoring to make mid-course corrections and conducting evaluations after the pandemic to inform future emergency response.
- CMS relied on states to monitor during the emergency. CMS has no procedures for monitoring temporary changes during an emergency. Instead, states had the primary responsibility to monitor the effects of temporary changes during the COVID-19 emergency, according to CMS officials. CMS provided limited guidance to states on monitoring the changes, and did not request that states share any data, such as COVID-19 infections or deaths, with CMS. Without developing monitoring procedures in advance of future public health emergencies, CMS is unlikely to conduct necessary monitoring.
- CMS's plan for evaluating after the emergency is unclear. CMS officials told GAO that they intend to evaluate temporary changes made to HCBS programs, but had not developed plans to do so. Officials said they will continue to review regular state reporting on steps taken to ensure the overall quality of HCBS programs. However, this reporting may not provide useful information for evaluating how temporary changes affected access to HCBS or the prevention of disease spread, and some reports are not due for more than 3 years. Without a full evaluation, CMS may miss opportunities to better prepare for future emergencies.
Why GAO Did This Study
During emergencies, including COVID-19, CMS may approve certain temporary changes to states' Medicaid programs to ensure access to care. These changes are critical to beneficiaries who rely on HCBS to perform daily activities, such as eating, and who may face greater risk of COVID-19.
The CARES Act includes a provision for GAO to report on its ongoing COVID-19 monitoring and oversight efforts. In addition, GAO was asked to examine temporary changes to Medicaid in response to COVID-19. This report (1) describes temporary changes to Medicaid HCBS programs, including selected states' experience in making these changes; and (2) examines CMS's monitoring and evaluation of the effects of those changes.
GAO reviewed documentation of temporary changes approved by CMS and relevant CMS policies, procedures, and analyses. GAO also interviewed Medicaid officials from CMS and six states selected based on variation in Medicaid expenditures and geographic region. GAO assessed CMS's monitoring and evaluation activities using CMS's Pandemic Plan and federal internal control standards.
Recommendations
GAO is making two recommendations to CMS to (1) develop procedures to monitor temporary changes to HCBS programs during public health emergencies; and (2) evaluate the temporary changes after the COVID-19 emergency and address opportunities for improvement. The Department of Health and Human Services concurred with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | The CMS Administrator should develop procedures to monitor temporary changes to Medicaid HCBS programs during public health emergencies. This should include procedures for collecting and analyzing data during emergencies on the effects of these changes. (Recommendation 1) |
CMS concurred with this recommendation. As of August 2024, CMS had issued new Medicaid rules with requirements that could result in enhanced data on critical incidents and more functional state data systems when implemented. Officials indicated that those data could be leveraged for monitoring the effects of temporary changes to Medicaid HCBS programs during a public health emergency. We will continue to monitor CMS's efforts for evidence that the agency is developing procedures that link that new data to monitoring the effects of temporary flexibilities in use during future public health emergencies, or more generally, that CMS has developed procedures for monitoring those flexibilities going forward.
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| Centers for Medicare & Medicaid Services | The CMS Administrator should evaluate the temporary changes to Medicaid HCBS programs after the COVID-19 emergency and develop corrective action plans to address any opportunities for improvement it identifies. (Recommendation 2) |
CMS concurred with this recommendation. As of August 2024, CMS was learning about state views of the usefulness of the temporary flexibilities granted during COVID-19 through technical assistance conversations. The agency was also in the process of refining the application for home and community-based services waivers and drafting technical guidance to reflect lessons learned from flexibilities provided during COVID-19. As of August 2024, we continue to monitor CMS progress on this recommendation. To the extent that CMS assesses the efficacy of temporary flexibilities granted during COVID-19 and what might be done differently in future emergencies or if such an assessment drove the changes to the application and technical guidance, we will revisit closing this recommendation.
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