You are given two reports by the government agency.  

Report 1:
Federal agencies provide a range of assistance to individual survivors; state, territorial, and local governments; and nongovernmental entities after major disasters, including natural disasters and terrorist attacks. Types of aid can include, but are not limited to, operational, logistical, and technical support; financial assistance through grants, loans, and loan guarantees; and the provision of federally owned equipment and facilities. Many, but not all, programs are available after the President issues a major disaster declaration pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) authority. More limited aid is available under a Stafford Act emergency declaration, a declaration issued by a department or agency head, or on an as needed basis. This report only identifies programs frequently used to provide financial assistance in the disaster response and recovery process. It provides brief descriptive information to help congressional offices determine which programs merit further consideration in the planning, organization, or execution of the disaster response and recovery process. Most of the programs listed here are authorized as assistance programs and are listed at the General Services Administration (GSA) website beta.SAM.gov. The list does not include operational or technical assistance that some agencies provide in emergency or disaster situations. It is also not inclusive of all forms of financial disaster assistance that may be available to every jurisdiction in every circumstance, as unique factors often trigger unique forms of assistance. Congress may, and frequently has, authorized specific forms of financial assistance on a limited basis following particular disasters. Programs discussed in this report satisfy one or more of the following criteria: Congress expressly designated the program to provide financial assistance for disaster relief or recovery. The program is applicable to most disaster situations, even if not specifically authorized for that purpose. The Federal Emergency Management Agency (FEMA) and other federal agencies have frequently used the program to provide financial assistance. The program is potentially useful for addressing short-term and long-term recovery needs (e.g., assistance with processing survivor benefits or repair of public facilities). Most of the programs listed in this report are specifically authorized for use during situations occurring because of a disaster. General assistance programs that may apply to disaster situations are described at the end of the report (see " General Assistance Programs "). As Congress and the Administration respond to domestic needs arising from major disasters, some conditions of these programs may be changed. For the most up-to-date information on a particular program, please contact the CRS analyst or department or agency program officers listed in the report. The Individuals and Households Program (IHP) is the primary vehicle for FEMA assistance to individuals and households after the President issues an emergency or major disaster declaration, when authorized. It is intended to meet basic needs and support recovery efforts, but it cannot compensate disaster survivors for all losses. Congress appropriates money for the IHP (and most other aid authorized by the Stafford Act) to the Disaster Relief Fund. IHP assistance is available in the form of financial and direct assistance to eligible individuals and households who, as a result of a disaster, have uninsured or under-insured necessary expenses and serious needs that cannot be met through other means or forms of assistance. Program funds have a wide range of eligible uses, including different forms of temporary housing assistance; housing repairs; housing replacement; and permanent housing construction. IHP funds may also be used for other needs assistance (ONA), including funeral, medical, dental, childcare, personal property, transportation, and other expenses. FEMA provides 100% of the housing assistance costs, but ONA is subject to a 75% federal and 25% state cost share. In addition, there is a limitation on the amount of financial assistance an individual or household may receive, with financial assistance including assistance to reimburse temporary lodging expenses; rent for alternate housing accommodations; home repairs and replacement; as well as ONA. Financial assistance for repairs and replacement may not exceed $34,900 (FY2019). Separately, financial assistance for ONA may not exceed $34,900 (FY2019). Financial assistance to rent alternate housing accommodations under Section 408 (c)(1)(A)(i) of the Stafford Act, however, is excluded from the cap. The maximum amount of financial assistance is adjusted annually to reflect changes in the Consumer Price Index. IHP assistance is intended to be temporary and is generally limited to a period of 18 months from the date of the declaration, but may be extended by FEMA. (Also see " Physical Disaster Loans—Residential SBA Disaster Loans Available to Homeowners and Renters " below for additional assistance for homeowners and renters.) Agency : Federal Emergency Management Agency Authority : 42 U.S.C. §5174 Regulation : 44 C.F.R. §§206.110–206.120 Phone : Office of Congressional Affairs, 202-646-4500 Website : https://www.fema.gov/media-library/assets/documents/24945 CFDA Program Numbers : 97.048 and 97.050 CRS Contact : Elizabeth Webster, 202-707-9197 Disaster Unemployment Assistance (DUA) provides benefits to previously employed or self-employed individuals rendered jobless as a direct result of a major disaster and who are not eligible for regular federal or state unemployment compensation (UC). In certain cases, individuals who have no work history or are unable to work may also be eligible for DUA benefits. DUA is federally funded through FEMA, but is administered by the Department of Labor and state UC agencies. In general, individuals must apply for benefits within 30 days after the date the state announces availability of DUA benefits. When applicants have good cause, they may file claims after the 30-day deadline. This deadline may be extended; however, initial applications filed after the 26 th week following the declaration date will not be considered. When a reasonable comparative earnings history can be constructed, DUA benefits are determined in a similar manner to regular state UC benefit rules. The minimum weekly DUA benefit is required to be half of the average weekly UC benefit for the state where the disaster occurred. DUA assistance is available to eligible individuals as long as the major disaster continues, but no longer than 26 weeks after the disaster declaration. For more information, see CRS Report RS22022, Disaster Unemployment Assistance (DUA) , by Julie M. Whittaker. Agency: Department of Labor, Employment and Training Administration Authority: 42 U.S.C. §5177 Regulation: 20 C.F.R. §625; 44 C.F.R. §206.141 Contact: See listings of resources by state , https://www.careeronestop.org/localhelp/unemploymentbenefits/unemployment-benefits.aspx Website: http://ows.doleta.gov/unemploy/disaster.asp CFDA Program Number : 97.034 CRS Contact: Julie Whittaker, 202-707-2587 The dislocated worker program helps fund training and related assistance to persons who have lost their jobs and are unlikely to return to their current jobs or industries. Of the funds appropriated, 80% are allotted by formula grants to states and local entities and 20% are reserved by the Secretary of Labor to fund a national reserve that supports national dislocated worker grants to states or local ent ities. One type of national emergency grant is Disaster Relief Employment Assistance, under which funds can be made available to states to employ dislocated workers in temporary jobs involving recovery after a national emergency. An individual may be employed for up to 12 months. There are no matching requirements for Workforce Innovation and Opportunity Act (WIOA) programs. Agency: Department of Labor, Employment and Training Administration Authority: 29 U.S.C. §3225 Regulation: 20 C.F.R. §671 Contact: See listings of state Dislocated Worker/Rapid Response Coordinators at http://www.doleta.gov/layoff/rapid_coord.cfm Website: https://www.doleta.gov/DWGs/eta_default.cfm CFDA Program Number : 17.278 CRS Contact: David H. Bradley, 202-707-7352 The majority of disaster loans provided by the Small Business Administration (SBA), approximately 80%, are made available to individuals and households. SBA disaster assistance is provided in the form of loans, not grants, and therefore must be repaid to the federal government. Homeowners, renters, and personal property owners located in a declared disaster area (and in contiguous counties) may apply to the SBA for loans to help recover losses from the disaster. SBA's Home Disaster Loan Program falls into two categories: personal property loans and real property loans. These loans cover only uninsured or underinsured property and primary residences. Loan maturities may be up to 30 years. A personal property loan provides a creditworthy homeowner or renter with up to $40,000 to repair or replace personal property items, such as furniture, clothing, or automobiles, damaged or lost in a disaster. These loans cover only uninsured or underinsured property and primary residences and cannot be used to replace extraordinarily expensive or irreplaceable items, such as antiques, recreational vehicles, or furs. A creditworthy homeowner may apply for a "real property loan" of up to $200,000 to repair or restore the homeowner's primary residence to its predisaster condition. The loans may not be used to upgrade homes or build additions, unless upgrades or changes are required by city or county building codes. A real property loan may be increased by 20% for repairs to protect the damaged property from a similar disaster in the future. Agency: Small Business Administration Authority: 15 U.S.C. §636(b) Regulation: 13 C.F.R. §§123.200–123.204 Contact : Office of Congressional and Legislative Affairs, 202-205-6700 Website : https://disasterloan.sba.gov/ela/Information/TypesOfLoans CFDA Program Number : 59.008 CRS Contact : Bruce R. Lindsay, 202-707-3752 This unique fund directs payments to individuals and groups for disaster-related needs that have not been or will not be met by government agencies or other organizations. A disaster survivor will normally receive no more than $2,000 from this fund in any one declared disaster unless the Assistant Administrator for the Disaster Assistance Directorate determines that a larger amount is in the best interest of the disaster victim and the federal government. There is no matching requirement for this program and no limitation on the time period in which assistance is available. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5121 et seq. Regulation: 44 C.F.R. §206.181 Contact : Office of Congressional Affairs, 202-646-4500 Website : http://www.fema.gov/library/viewRecord.do?id=5037 CRS Contact: Bruce R. Lindsay, 202-707-3752 This program provides grants that enable states to offer crisis counseling services, when required, to victims of a federally declared major disaster for the purpose of relieving mental health problems caused or aggravated by the disaster or its aftermath. Assistance is short-term and community-oriented. Cost-share requirements are not imposed on this assistance. The regulations specify that program funding generally ends after nine months, but time extensions may be approved if requested by the state and approved by federal officials. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5183 Regulation: 44 C.F.R. §206.171 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www.fema.gov/recovery-directorate/crisis-counseling-assistance-training-program CFDA Pr ogram Number : 97.032 CRS Contact: Sarah A. Lister, 202-707-7320 Disaster Legal Services (DLS) are provided for free to low-income individuals who require them as a result of a major disaster, and the provision of services is "confined to the securing of benefits under the [Stafford] Act and claims arising out of a major disaster." Assistance may include help with insurance claims, drawing up new wills and other legal documents lost in the disaster, help with home repair contracts and contractors, and appeals of FEMA decisions. Neither the statute nor the regulations establish cost-share requirements or time limitations for DLS. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5182 Regulation: 44 C.F.R. §206.164 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www.fema.gov/media-library/assets/documents/24413 CFDA Program Number : 97.033 CRS Contact: Elizabeth Webster, 202-707-9197 The Disaster Case Management (DCM) program partners case managers and disaster survivors to develop and implement Disaster Recovery Plans to address unmet needs. The DCM program is authorized under the Stafford Act. Following a presidentially declared major disaster that includes Individual Assistance (IA), the governor or tribal executive may request a grant to use DCM providers to supply services to survivors with long-term, disaster-caused unmet needs. The program is time-limited, and it shall not exceed 24 months from the date of the presidential major disaster declaration. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5189d Contact: Office of Congressional Affairs, 202-646-4500 Website: https://www.fema.gov/media-library/assets/documents/101292 CFDA Program Number : 97.088 CRS Contact: Elizabeth Webster, 202-707-9197 The Internal Revenue Code (IRC) includes tax relief provisions that apply to individuals and businesses affected by federally declared disasters, and the following are some examples. Individuals located in affected areas are allowed extra time (four years instead of the general two) to replace homes due to involuntary conversion (e.g., destruction from wind or floods, theft, or property ordered to be demolished) and still defer any gain. Taxpayers may also be able to deduct personal casualty losses attributable to federally declared disasters, subject to certain limitations. Qualifying disaster relief payments received by affected individuals are not subject to tax. The Internal Revenue Service also has the authority to provide some relief, including the extension of tax filing deadlines. In addition to these and other permanent tax relief provisions, special temporary provisions have been enacted for certain disasters. The 2017 tax revision ( P.L. 115-97 ) provided tax relief related to 2016 and 2017 disasters. These measures were expanded to cover the California wildfires in the Bipartisan Budget Act of 2018 ( P.L. 115-123 ). Agency : Internal Revenue Service Authority : Various provisions throughout the Internal Revenue Code, Title 26 U.S.C., including §§123, 139, 165, 402, 408, 1033, 6654, 7508A Regulation : No specific regulation Contact : Congressional Liaison, 202-317-6985 Website : http://www.irs.gov/uac/Tax-Relief-in-Disaster-Situations CRS Contact s : Molly Sherlock, 202-707-7797 Authorized by multiple sections of the Stafford Act, the Public Assistance (PA) Grant Program is FEMA's primary form of financial assistance for state and local governments. The PA Program provides grant assistance for many eligible purposes, including the following: Emergency work, as authorized by Sections 403, 407, and 502 of the Stafford Act, which provide for the removal of debris and emergency protective measures, such as the establishment of temporary shelters and emergency power generation. Permanent work, as authorized by Section 406, which provides for the repair, replacement, or restoration of disaster-damaged, publicly owned facilities and the facilities of certain private nonprofit organizations (PNPs). At its discretion, FEMA may provide assistance for hazard mitigation measures that are not required by applicable codes and standards. As a condition of PA assistance, applicants must obtain and maintain insurance on their facilities for similar future disasters. Management costs, as authorized by Section 324, which reimburses some of the applicant's administrative expenses incurred managing the totality of the PA Program's projects and grants. PNPs are generally eligible for permanent work assistance if they provide a governmental type of service, though PNPs not providing a "critical" service must first apply to the SBA for loan assistance for facility projects. The federal government provides a minimum of 75% of the cost of eligible assistance, and this cost share can rise if certain criteria are met. Funding for the PA Program comes through discretionary appropriations to the Disaster Relief Fund. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §§5170b, 5172, 5173, 5189f, 5192 Regulation: 44 C.F.R. §206, subparts G, H, I Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www.fema.gov/public-assistance-local-state-tribal-and-non-profit CFDA Program Number : 97.036 CRS Contact: Natalie Keegan, 202-707-9569 The Hazard Mitigation Grant Program (HMGP) provides grants to states for implementing mitigation measures after a disaster and to provide funding for previously identified mitigation measures to lessen future damage and loss of life. The federal government provides up to 75% of the cost share of eligible projects. Historically, the amount available for HMGP awards is established by a scale that authorizes three tiers of awards: 15% of the total of other Stafford Act assistance in a state for a major disaster in which no more than $2 billion is provided; 10% for assistance that ranges from more than $2 billion to $10 billion; and 7.5% for a major disaster that involves Stafford Act assistance from more than $10 billion to $35.3 billion. Funding for HMGP comes through discretionary appropriations to the Disaster Relief Fund. The amount of funding provided can be increased if the state has an approved enhanced mitigation plan. HMGP funding is only awarded with a major disaster declaration, not an emergency declaration. However, during FY2015, FY2017, and FY2018, Congress directed that HMGP grants be made available with fire management assistance grants. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5170c Regulation: 44 C.F.R. §§206.430–206.440 Contact : Office of Congressional Affairs , 202-646-4500 Website : http://www.fema.gov/hazard-mitigation-grant-program CFDA Program Number : 97.039 CRS Contact: Diane P. Horn, 202-707-3472 The Pre-Disaster Mitigation (PDM) Grant Program provides grants and technical assistance to states, territories, and local communities for cost-effective hazard mitigation activities that complement a comprehensive hazard mitigation program and reduce injuries, loss of life, and damage and destruction of property. Through FY2018, a minimum of the lesser of $575,000 or 1.0% of appropriated funds was provided to a state or local government, with assistance capped at 15% of appropriated funds. Federal funds generally comprise 75% of the cost of approved mitigation projects, except for small impoverished communities that may receive up to 90% of the cost. Funding for the PDM Program changed significantly with the passage of the Disaster Recovery Reform Act of 2018 (DRRA). DRRA authorizes the National Public Infrastructure Pre-Disaster Mitigation Fund, for which the President may set aside from the DRF, with respect to each major disaster, an amount equal to 6% of the estimated aggregate amount of the grants to be made pursuant to the following sections of the Stafford Act: 403 (essential assistance), 406 (repair, restoration, and replacement of damaged facilities), 407 (debris removal), 408 (federal assistance to individuals and households), 410 (unemployment assistance), 416 (crisis counseling assistance and training), and 428 (public assistance program alternative program procedures). These changes may increase the focus on funding public infrastructure projects that improve community resilience before a disaster occurs, although FEMA has the discretion to shape the program in many ways. There is potential for significantly increased funding post-DRRA through the new transfer from the DRF, but it is not yet clear how FEMA will implement this new program. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5133 Regulation: 44 C.F.R. §201 Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www.fema.gov/pre-disaster-mitigation-grant-program CFDA Program Number : 97.047 CRS Contact: Diane P. Horn, 202-707-3472 The Community Disaster Loan (CDL) program provides loans to local governments that have suffered substantial loss of tax and other revenue in areas included in a major disaster declaration. Typically, the loan may not exceed 25% of the local government's annual operating budget for the fiscal year of the disaster. The limit is 50% if the local government lost 75% or more of its annual operating budget. A loan may not exceed $5 million, and there is no matching requirement. The statute does not impose time limitations on the assistance, but the normal term of a loan is five years. The statute provides that the repayment requirement is cancelled if local government revenues are not sufficient to meet operations expenses during a three-fiscal-year period after a disaster. The governor's authorized representative must officially approve the application and funds must be available in the Disaster Assistance Direct Loan Program (DADLP) account. In P.L. 115-72 , Congress provided up to $4.9 billion for the CDL program to assist local governments in providing essential services as a result of Hurricanes Harvey, Irma, or Maria. However, this legislation departed from the traditional CDL program framework by giving the Secretary of Homeland Security (in consultation with the Secretary of the Treasury) broad authority over lending terms, eligible uses, and criteria for loan cancelation, among other program elements. As a result, this CDL-type program operates differently from the traditional program. For more information, see CRS Insight IN11106, Community Disaster Loans: Homeland Security Issues in the 116th Congress , by Michael H. Cecire. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5184 Regulation: 44 C.F.R. §§206.360–206.378 Contact : Office of Congressional Affairs, 202-646-4500 CFDA Program Number : 97.030 CRS Contact: Michael H. Cecire, 202-707-7109 This program provides grants to state and local governments to aid states and their communities with the mitigation, management, and control of fires burning on publicly or privately owned forests or grasslands. The federal government provides 75% of the costs associated with fire management projects, but funding is limited to calculations of the "fire cost threshold" for each state. No time limitation is applied to the program. For more information, see CRS Report R43738, Fire Management Assistance Grants: Frequently Asked Questions , by Bruce R. Lindsay and Katie Hoover. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §5187 Regulation: 44 C.F.R. §§204.1–204.64 Contact : Office of Congressional Affairs, 202-646-4500 Website: https://www.fema.gov/fire-management-assistance-grant-program CFDA Program Number : 97.046 CRS Contact: Bruce R. Lindsay, 202-707-3752 Congress created the Oil Spill Liability Trust Fund (OSLTF) in 1986. Subsequent laws authorized the OSLTF taxing authority, appropriations from the fund, and eligible uses for the fund. The OSLTF complements the Oil Pollution Act of 1990 (OPA; P.L. 101-380 ), which established a new federal oil spill liability framework, replaced existing federal liability frameworks, and amended the existing Clean Water Act oil spill response authorities. In addition, OPA transferred monies into the OSLTF from existing liability funds. The OSLTF may be used, among other purposes, to fund oil spill response activities and to compensate individuals, businesses, and governments for applicable economic damages resulting from an oil spill. Potential damages include injury or loss of property and loss of profits or earning capacity. OPA established a claims process for compensating parties affected by an oil spill. In general, claims must be presented first to the party responsible for the spill, but specific circumstances (e.g., the responsible party is unknown) allow persons to present a claim directly to the OSLTF. Agency : National Pollution Funds Center (part of the U.S. Coast Guard) Authority : 26 U.S.C. §9509 and 33 U.S.C. §2712 Regulation : 33 C.F.R. §136 Contact : Office of Legislative Affairs, 202-245-0520 Website : http://www.uscg.mil/npfc/ CRS Contact : Jonathan L. Ramseur, 202-707-7919 This program assists small businesses and nonprofits suffering economic injury as a result of disasters by offering loans and loan guarantees. Businesses must be located in disaster areas declared by the President, the Small Business Administration, or the Secretary of Agriculture. There is no matching requirement in this program. The maximum loan amount is $2 million. Loan terms may extend for up to 30 years. The application period is announced at the time of the disaster declaration. For more information, see CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R. Lindsay. Agency: Small Business Administration Authority: 15 U.S.C. §636(b) Regulation: 13 C.F.R. §§123.300–123.303 Contact : Office of Congressional Affairs, 202-205-6700 Website : https://disasterloan.sba.gov/ela/Information/EIDLLoans CFDA Program Number : 59.008 CRS Contact: Bruce R. Lindsay, 202-707-3752 This program provides loans to businesses and nonprofits in declared disaster areas for uninsured physical damage and losses. The maximum loan amount is $2 million. Loan terms may extend for up to 30 years. There is no matching requirement in this program. For more information, see CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R. Lindsay. Agency: Small Business Administration Authority: 15 U.S.C. §636(b) Regulation: 13 C.F.R. §§123.200–123.204 Contact : Office of Congressional Affairs, 202-205-6700 Website: https://disasterloan.sba.gov/ela/Information/BusinessPhysicalLoans CFDA Program Number : 59.008 CRS Contact: Bruce R. Lindsay, 202-707-3752 When a county has been declared a disaster area by either the President or the Secretary of Agriculture, agricultural producers in that county may become eligible for low-interest emergency disaster (EM) loans available through the U.S. Department of Agriculture's Farm Service Agency. Producers in counties that are contiguous to a county with a disaster designation also become eligible for an EM loan. EM loan funds may be used to help eligible farmers, ranchers, and aquaculture producers recover from production losses (e.g., when the producer suffers a significant loss of an annual crop) or from physical losses (e.g., repairing or replacing damaged or destroyed structures or equipment, or replanting permanent crops, such as orchards). A qualified applicant can then borrow up to 100% of actual production or physical losses (not to exceed $500,000) at a below-market interest rate. For more information see CRS Report RS21212, Agricultural Disaster Assistance , by Megan Stubbs. Agency: Department of Agriculture, Farm Service Agency Authority: 7 U.S.C. §1961 Regulation: 7 C.F.R. §764 Contact : Legislative Liaison Staff, 202-720-7095 Website: https://www.fsa.usda.gov/programs-and-services/farm-loan-programs/emergency-farm-loans/index CFDA Program Number : 10.404 CRS Contact: Megan Stubbs, 202-707-8707 Since 1968, the federal government has pursued a comprehensive flood risk management strategy designed to (1) identify and map flood-prone communities across the country (flood hazard mapping); (2) encourage property owners in NFIP participating communities to purchase insurance as a protection against flood losses (flood insurance); and (3) require communities in designated flood risk zones to adopt and enforce approved floodplain management ordinances to reduce future flood risk to new construction in regulated floodplains (floodplain management). The Federal Insurance and Mitigation Administration (FIMA), a part of FEMA, manages the NFIP. For more information, see CRS Report R44593, Introduction to the National Flood Insurance Program (NFIP) , by Diane P. Horn and Baird Webel, and CRS In Focus IF11023, Selected Issues for National Flood Insurance Program (NFIP) Reauthorization and Reform , by Diane P. Horn. Agency: Federal Emergency Management Agency Authority: 42 U.S.C. §4001 et seq. Regulation: 44 C.F.R. §59.1–§82.21 Contact : Office of Congressional Affairs, 202-646-4500 Website: http://www.fema.gov/national-flood-insurance-program CFDA Program Number : 97.022 CRS Contact : Diane Horn, 202-707-3472 In addition to programs described above that provide targeted assistance to individuals, states, territories, local governments, and businesses specifically affected by disasters, other general assistance programs may be useful to communities in disaster situations. For example, individuals who lose income, employment, or health insurance may become eligible for programs that are not specifically intended as disaster relief, such as cash assistance under the Temporary Assistance for Needy Families (TANF) program, job training under the Workforce Investment Act, Medicaid, or the State Children's Health Insurance Program (S-CHIP). Likewise, state or local officials have the discretion to use funds under programs such as the Social Services Block Grant or Community Development Block Grant to meet disaster-related needs, even though these programs were not established specifically for such purposes. Other agencies may offer assistance to state and local governments, including the Economic Development Administration and the Army Corps of Engineers. For businesses, however, only the disaster programs administered by the Small Business Administration are generally applicable. Numerous other federal programs could offer disaster relief, but specific eligibility criteria or other program rules might make it less likely that they would actually be used. Moreover, available funds might already be obligated for ongoing program activities. To the extent that federal agencies have discretion in the administration of programs, some agencies may choose to adapt these non-targeted programs for use in disaster situations. Also, Congress may choose to provide additional funds through emergency supplemental appropriations for certain general assistance programs, specifically for use after a disaster. CRS analysts and program specialists can help provide information regarding general assistance programs that might be relevant to a given disaster situation. CRS appropriations reports may have information on disaster assistance within particular federal agencies. These reports also list CRS's key policy staff by their program area and agency expertise. CRS Report R41981, Congressional Primer on Responding to Major Disasters and Emergencies , by Bruce R. Lindsay and Elizabeth M. Webster CRS Report R41101, FEMA Disaster Cost-Shares: Evolution and Analysis , by Natalie Keegan and Elizabeth M. Webster CRS Report RL33330, Community Development Block Grant Funds in Disaster Relief and Recovery , by Eugene Boyd CRS Report RL33579, The Public Health and Medical Response to Disasters: Federal Authority and Funding , by Sarah A. Lister CRS Report R44593, Introduction to the National Flood Insurance Program (NFIP) , by Diane P. Horn and Baird Webel CRS Insight IN10450, Private Flood Insurance and the National Flood Insurance Program (NFIP) , by Baird Webel and Diane P. Horn CRS Report R45099, National Flood Insurance Program: Selected Issues and Legislation in the 115th Congress , by Diane P. Horn CRS In Focus IF10730, Tax Policy and Disaster Recovery , by Molly F. Sherlock CRS Report R41884, Considerations for a Catastrophic Declaration: Issues and Analysis , by Bruce R. Lindsay CRS Report R43784, FEMA's Disaster Declaration Process: A Primer , by Bruce R. Lindsay CRS Report R43738, Fire Management Assistance Grants: Frequently Asked Questions , by Bruce R. Lindsay and Katie Hoover CRS Report R45085, FEMA Individual Assistance Programs: In Brief , by Shawn Reese CRS Report R45238, FEMA and SBA Disaster Assistance for Individuals and Households: Application Process, Determinations, and Appeals , by Bruce R. Lindsay and Shawn Reese CRS Report RS22022, Disaster Unemployment Assistance (DUA) , by Julie M. Whittaker CRS Report R41309, The SBA Disaster Loan Program: Overview and Possible Issues for Congress , by Bruce R. Lindsay CRS Report RS21212, Agricultural Disaster Assistance , by Megan Stubbs CRS Report R42854, Emergency Assistance for Agricultural Land Rehabilitation , by Megan Stubbs CRS In Focus IF10565, Federal Disaster Assistance for Agriculture , by Megan Stubbs CRS In Focus IF10730, Tax Policy and Disaster Recovery , by Molly F. Sherlock CRS Report R44808, Federal Disaster Assistance: The National Flood Insurance Program and Other Federal Disaster Assistance Programs Available to Individuals and Households After a Flood , by Diane P. Horn CRS Insight IN11094, The Evolving Use of Disaster Housing Assistance and the Roles of the Disaster Housing Assistance Program (DHAP) and the Individuals and Households Program (IHP) , by Elizabeth M. Webster CRS Insight IN11054, Disaster Housing Assistance: Homeland Security Issues in the 116th Congress , by Elizabeth M. Webster CRS Insight IN11106, Community Disaster Loans: Homeland Security Issues in the 116th Congress , by Michael H. Cecire Note: Because not all agencies have complete, up-to-date information available on the internet, in particular during and immediately after a disaster, congressional users are encouraged to contact the appropriate CRS program analysts or department or agency program officers for more complete, timely information. USA.gov http://www.USA.gov/ Many federal agencies have established websites specifically for responding to disasters. Some agencies maintain websites with comprehensive information about their disaster assistance programs, whereas others supply only limited information; most list contact phone numbers. An A-Z index of U.S. government departments and agencies is available at the website above. FEMA Website http://www.fema.gov From its website, FEMA offers regular updates on recovery efforts in areas under a major disaster declaration. Information on a specific disaster may include a listing of declared counties and contact information for local residents. Disaster Assistance.gov http://www.disasterassistance.gov/ DisasterAssitance.gov provides information on how help might be obtained from the U.S. government before, during, and after a disaster. The website includes tools to find, apply for, and check the status of assistance by category or agency. The website also includes disaster-related news feeds and information on community resources. Assistance Listings at beta.SAM.gov https://beta.SAM.gov/ Official descriptions of more than 2,200 federal assistance programs, including disaster and recovery grants and loans, can be found on beta.SAM.gov. The website is currently in beta, and it houses federal assistance listings previously found on the now-retired Catalog of Federal Domestic Assistance (CFDA). For programs summarized in this report, CFDA program numbers are given (which are searchable at the "Assistance Listings" domain at beta.SAM.gov). Full assistance listing descriptions, updated by departments and agencies, cover authorizing legislation, objectives, and eligibility and compliance requirements. For current appropriations and additional information, users can contact CRS analysts, or departments and agencies.

 

 Report 2:
In order to receive federal matching funds, states report expenditures quarterly to CMS on the CMS-64. States are required to report their expenditures to CMS within 30 days of the end of each quarter, but may adjust their past reporting for up to 2 years after the expenditure was made, referred to as the 2-year filing limit. Adjustments can reflect resolved disputes or reclassifications of expenditures. Expenditures reported after the 2-year filing limit are generally not eligible for a federal match, with certain exceptions. The CMS-64 is a series of forms that capture expenditure data for different aspects of states’ Medicaid programs, such as different types of services, populations, and different federal matching rates. (See table 1 for examples of the expenditure types captured by the CMS-64.) States report their expenditures quarterly on the CMS-64 at an aggregate level— such as a state’s total expenditures for such categories of services as inpatient hospital services—and these reported expenditures are not linked to individual enrollees or services. States’ reporting may vary depending on the features of their Medicaid program. Some examples of this variation include the following: States that expanded eligibility under PPACA would need to report expenditures not only by the type of services (e.g., inpatient hospital services), but also by populations receiving different federal matching rates, such as expansion enrollees. States with waivers—that is, where the state received approval from HHS to waive certain Medicaid requirements in order to test and evaluate new approaches for delivering and financing care under a demonstration—would need to report those expenditures associated with these waivers on additional forms. CMS is responsible for assuring that expenditures reported by states are supported and allowable, meaning that the state actually made and recorded the expenditure and that the expenditure is consistent with Medicaid requirements. CMS regional offices perform the ongoing oversight, with enhanced oversight procedures in the 20 states with the highest federal Medicaid expenditures. (See fig.1) CMS is required to review the expenditures reported by states each quarter. (See fig. 2.) Regional office reviewers have 50 days to review the expenditures and compute the federal share of states’ Medicaid expenditures. As part of the quarterly review, regional office reviewers also check that expenditures receive the correct matching rate. In general, the amount of federal funds that states receive for Medicaid services is determined annually by a statutory formula—the Federal Medical Assistance Percentage (FMAP), which results in a specific federal matching rate for each state. However, there are a number of exceptions where higher federal matching rates can apply for certain types of beneficiaries, services, or administrative costs. See table 2 for examples of higher matching rates that apply for expenditures for certain types of enrollees, services, or administrative costs. When CMS identifies questionable expenditures or errors through its reviews, there are several ways that they can be resolved, as summarized below. Deferral of federal funds. CMS can defer federal matching funds if, during the quarterly review, the regional office reviewer needs additional information to determine whether a particular expenditure is allowable. The reviewer may recommend that CMS defer the expenditure until the state provides additional support or corrects the reporting. State reducing reported expenditures. If the state agrees that the questionable expenditure is an error, the state can submit an adjusted report during the quarterly review or make an adjustment in a subsequent quarter. These adjustments prevent federal payments for those expenditures. Disallowance of expenditure. If CMS determines an expenditure is not allowable, CMS can issue a disallowance, and the state returns federal funds through reductions in future federal allocations. States may appeal disallowances. CMS uses a variety of processes to assure that state-reported expenditures are supported during quarterly reviews and performs focused financial management reviews on expenditures considered at risk of not complying with Medicaid requirements. Although we found that CMS was identifying errors and compliance issues using both review methods, we also found weaknesses in how CMS targets its oversight resources to address risks. CMS uses quarterly reviews to assess whether expenditures are supported by the state’s accounting systems; are in accordance with CMS approved methodologies, plans, and spending caps; and whether there are significant unexplained variances—changes in expenditures— from one quarter to the next (referred to as a variance analysis). CMS review procedures include validation measures that check to ensure that expenditures were reported within the 2-year limit, which is a check done on all types of expenditures. Another validation measure compares expenditures to various approval documents. For example, when a state has a waiver in place, expenditures are reviewed against waiver agreements that authorize payment for specified services or populations. Other examples include comparing supplemental payment expenditures to caps set for those expenditures. (See table 3.) Our examination of the quarterly reviews indicated that the reviews involved significant coordination with other CMS staff and the state. In addition to reviewing state documentation, officials from two regional offices told us that they consult other regional office staff who oversee the approval of new expenditures to ensure that expenditures reflect approved program features. For example, officials in region 9 told us that in reviewing managed care expenditures, they consult with their colleagues who review the state’s payment methodologies for capitated payments. In reviewing information technology development expenditures—which are subject to a higher federal matching rate— reviewers for all six selected states examined advanced planning documents, which requires coordination with staff who approve those documents to ensure that the state was receiving the correct matching rates and staying within the approved amounts. With regard to coordination with states, we found that regional reviewers for all six reviews contacted states to follow-up on issues identified during the review. Officials also described being in regular contact with states to stay abreast of program, system, and staffing changes to inform their reviews. For example, according to regional officials, Arkansas experienced some significant and unexpected staffing challenges in 2016 that resulted in delays in the state reporting expenditures and returning federal overpayments, and the reviewer worked closely with state staff to track the state’s progress. We found evidence that reviewers identified errors during their quarterly reviews. In the six quarterly reviews we examined, regional offices identified errors in three of the six states. For example, region 3 reviewers found errors in Maryland’s expenditure reporting—including claims for the wrong matching rate for two enrollees who were not eligible for PPACA’s Medicaid expansion and reporting provider incentive payments on the wrong line—and worked with the state to correct those errors. Additionally, region 9 reviewers found errors in California’s reporting of expenditures. For example, they found that the state reported waiver expenditures for the incorrect time period, which has implications for CMS’s ability to monitor and enforce spending limits for the waiver. Reviewers worked with the state to correct those errors. To supplement the quarterly reviews, CMS generally directs regional offices to conduct a focused financial management review (FMR) each year on an area of high risk within the region, typically within one state. According to regional officials, CMS uses these reviews to investigate expenditures in greater depth and detail than is reasonable within the timeframes of a quarterly review. For example, reviewers can examine individual claims for services from providers or the methodologies developed for certain payment types. Regional reviewers also use these reviews to investigate errors that could not have been detected by the quarterly review. For example, regional office 6 officials told us that they uncovered inappropriate financing arrangements when they used an FMR to examine how Texas financed the state share of its supplemental payments to hospitals in one of its counties. To do so, the regional office reviewed payments from the state to the provider, project plans, and interviewed providers—steps that are not part of the quarterly review process. Rather, in the quarterly review, the reviewer only checks that state-reported payments are supported by state accounting records and are within applicable caps; thus, inappropriate financing of the state share would not have been detected through the quarterly review. In fiscal years 2014 through 2017, CMS used FMRs to review various expenditures considered to be at risk for not complying with Medicaid requirements. Specifically, as outlined in annual work plans, regional offices planned to conduct 31 FMRs and estimated that the total amount of federal funds at risk in expenditure areas covered by their planned reviews was $12 billion. (See app. I.) Planned FMRs targeted a wide range of topics, with the reviews most frequently targeting expenditures for the Medicaid expansion population. (See table 4.) We found that CMS frequently identified compliance issues through FMRs. As of March 2018, CMS reported that reviewers had identified compliance issues with financial impact in 11 of the 31 planned FMRs, though most of those findings were still under review. More findings from the planned FMRs are likely as some of the reviews were still ongoing. We reviewed the draft results for 5 FMRs. Among these, CMS found that four states were reporting expenditures that were not allowable. For example, as noted earlier, a 2014 FMR on supplemental payments in Texas revealed inappropriate funding arrangements, and CMS issued a disallowance for approximately $27 million. In some cases, FMRs did not have apparent financial findings, but identified significant internal control weaknesses in the state and recommended specific corrective actions— such as better aligning eligibility and expenditures systems to better detect and correct irregularities—that would provide greater assurances that federal funds are appropriately spent. Both the quarterly reviews and the FMRs occur in conjunction with other ongoing CMS financial oversight activities. For example in addition to reviewing expenditures, regional office reviewers assess how states estimate their costs, set payment rates for managed care and home and community based services, and allocate costs among different Medicaid administrative activities under their cost allocation plans. CMS officials told us that issues relating to state compliance with Medicaid requirements for expenditures could be identified during these other oversight activities and could inform follow-up during the quarterly reviews or be the subject of a FMR. Officials also told us that since FMRs were instituted, the agency has built in more front-end procedures for preventing problems with the accuracy and allowability of reported expenditures. As examples, they cited their work on managed care rate reviews, among other things. We identified two weaknesses in how CMS is allocating resources for overseeing state-reported expenditures that limited the agency’s ability to target risk in its efforts to assure that these expenditures are supported and consistent with Medicaid requirements. First, we found that CMS has allocated similar staff resources to states with differing levels of risk. For example, the staff resources dedicated to reviewing California’s expenditures—ranking first nationally in expenditures and constituting 15 percent of all federal Medicaid expenditures—are comparable to significantly smaller states in other regions, despite California’s history of reporting challenges and its inability to provide electronic records, which requires on-site review. (See fig. 3.) CMS has allocated 2.2 staff to review California’s expenditures in contrast to one person to review Arkansas’ expenditures, which constitute 1 percent of federal Medicaid expenditures, and Arkansas does not have a similar history of complex reporting challenges. We also found that California’s reviewers have set a higher threshold for investigating variances in reported expenditures than in the five other selected states. Specifically, reviewers investigated variances in California of plus or minus 10 percent if the variances represented more than 2 percent of medical expenditures, or $450 million in the quarter we reviewed. The state experienced an approximately 24 percent increase in its prescription drug expenditures—roughly $200 million—during that quarter, but the variance was deemed not significant. In contrast, for two of our five other selected states, we found that reviewers generally investigated variances of plus or minus 10 percent regardless of the dollar amount of the variance and in the remaining three states they had significantly lower dollar thresholds than used for California. Second, CMS reported cancelling the FMR requirement for regional offices in 17 out of 51 instances in the last 5 years when faced with resource constraints. In some cases, CMS excused individual regional offices from conducting planned FMRs due to staff shortage as the agency did for regions 3 and 7 in 2014; region 8 in 2016; and regions 3, 7, 8, and 9 in 2018. In 2015, according to CMS officials, all 10 regions were excused from conducting an FMR, because the regional offices needed their staff to focus on implementing new procedures for validating expenditures for the Medicaid expansion population. In addition to cancelling FMRs, CMS was delayed in finalizing FMRs. Among the eight FMRs that were conducted in fiscal year 2014, three have been issued as final reports, CMS decided no report was needed on a fourth, and the four remaining FMRs from 2014 were still under review as of March 2018, delaying important feedback to states on their vulnerabilities. According to CMS officials, resource constraints have contributed to both of these weaknesses. Our analysis of staffing data indicated that, from fiscal years 2014 to 2018, the number of full time equivalent staff dedicated to financial oversight activities declined by approximately 19 percent across all 10 regions. These staff are responsible not only for completing the quarterly reviews and FMRs, but also other financial oversight activities, including resolving audit findings and other on-going oversight activities noted previously. During this period, federal Medicaid expenditures are estimated to have increased by approximately 31 percent, and the reporting of expenditures has grown more complex. In addition to the decline in dedicated staff, officials told us they faced challenges in filling vacancies either because of hiring restrictions or challenges in recruiting qualified candidates. Officials described instances where regional offices shared resources with other offices to address critical gaps in resources. For example region 9 was able to obtain part-time assistance from a region 6 reviewer to help review California’s expenditures. However, CMS officials told us that they had not permanently reallocated resources between regional offices, because all regional offices are under-resourced given their various oversight responsibilities as of May 2018. With regard to cancelling FMRs, CMS officials noted that other oversight responsibilities, including the quarterly reviews, are required under statute or regulation and thus have a higher priority than FMRs. Compounding its resource allocation challenges, CMS has not conducted a comprehensive, national assessment of risk to determine whether resources for financial oversight activities are (1) adequate and (2) allocated—both across regional offices and oversight tools—to focus on the greatest areas of risk. Agency officials told us that they have not conducted a formal risk assessment, because they are assessing risk on an on-going basis, allocating resources within each region accordingly and sharing resources across regions to the extent possible. However, this approach does not make clear whether the level of resources dedicated to financial oversight nationally is adequate given the risk. Federal internal control standards for risk assessment require agencies to identify and analyze risks related to achieving the defined objectives (i.e., assuring that state-reported expenditures are in accordance with Medicaid rules), and respond to risks based on the significance of the risk. Without completing a comprehensive, national assessment of risk and determining whether staff resources dedicated to financial oversight are adequate and allocated commensurate with risk, CMS is missing an opportunity to improve its ability to identify errors in reported expenditures that could result in hundreds of millions of dollars in potential savings to the Medicaid program. CMS reviewers in the selected regional offices we reviewed did not consistently perform variance analyses—which compare changes in expenditures from the quarter under review to the previous quarter—of higher matched expenditures during quarterly reviews. Further, the sampling procedures used to examine Medicaid expansion expenditures did not account for varying risks across states. CMS has multiple procedures in place to review expenditures that receive a higher federal matching rate. As with other expenditures, reviewers are required to complete a variance analysis, comparing reported expenditures in the quarter under review to those reported in the prior quarter and investigating variances above a certain threshold. However, we found that our three selected regional offices were not consistently conducting these analyses across several different types of expenditures with higher matching rates. While CMS’s internal guidance required that regional offices conduct variance analyses on expenditures with higher matching rates, we found that for the quarter we investigated (generally the 1st quarter of fiscal year 2017), our selected regional offices did not consistently do so for three types of expenditures that we reviewed: IHS, family planning, and certain women with breast or cervical cancer. Two of the three regional offices (regions 3 and 9) did not conduct or did not document these required variance analyses, and the remaining regional office (region 6) conducted the analyses but deviated from standard procedures outlined in CMS guidance, as summarized below. CMS region 3. Reviewers did not conduct variance analyses for either Maryland or Pennsylvania. Regional office staff with whom we spoke said that as part of the quarterly review they conduct the standard variance analysis on category of service lines of the CMS-64. Expenditures for IHS, family planning and services for certain women with breast or cervical cancer are not separately identified at that level. Although CMS reviewers said they thought the standard analysis was sufficient, net changes within a broad service category may obscure major changes within these higher matched expenditures. For example, examining changes in total inpatient hospital expenditures would not necessarily reveal a significant variance limited to inpatient expenditures in IHS facilities that receive a higher federal match. CMS region 9. Reviewers told us that they examined higher matched expenditures for California; however, no variance analyses of IHS, family planning, or breast or cervical cancer services were included in the work papers provided to us. In addition, they told us that they do not conduct a variance analysis on IHS, family planning, and services for certain women with breast or cervical cancer for Nevada, noting that expenditures in these areas tend to be quite small. CMS region 6. Reviewers conducted a variance analysis of these higher matched expenditures for Arkansas and Texas and provided us documentation; however, the documentation showed some deviation from the required steps specified in CMS’s guidance. For example, for Texas, spending on two of the three categories was beyond the threshold for significance, but the reviewer did not document any follow-up with the state. Although expenditures for IHS, family planning, and certain women with breast or cervical cancer constituted a small share of total federal spending on Medicaid services—roughly 1 percent—combined spending on these categories was approximately $1 billion in the first quarter of fiscal year 2017. Our analysis indicated that variances in spending for these three services ranged widely across our six states, and in four of the states, some of their expenditures were above the thresholds for significance. (See fig. 4.) For example, in regional office 3, Maryland experienced a significant variance in its family planning expenditures—an increase of approximately $8 million dollars or 7,700 percent from the previous quarter—but there was no indication in the documentation provided that the regional office identified or investigated that variance. Similar to the variance analyses for other higher matched expenditure types, we found that the selected regional offices did not consistently conduct variance analyses on expenditures reported for the Medicaid expansion population. First, although five of our six states opted to expand Medicaid under PPACA, two of the five states (Maryland and Pennsylvania) were not subjected to a variance analysis for their expansion populations, a segment that accounted for nearly $7 billion in Medicaid expenditures in fiscal year 2016. Among the remaining three states, CMS regional office staff conducted a variance analysis, but in two of them, the reviewers did not document whether they investigated significant variances, leaving it unclear whether this required step was taken. Specifically, for two of the three remaining states—Arkansas and Nevada—reviewers did not document which variances were deemed significant or that any such variances were discussed with state officials. The guidance specified in CMS’s quarterly review guide is not always clear or consistent. For example: For IHS, family planning, and certain women with breast or cervical cancer, the guidance is explicit that the analysis is required, but the automated variance report used by reviewers for the step does not include these expenditures. For Medicaid expansion expenditures, the review guide is not explicit about whether a variance analysis is required, but CMS has an automated variance report available for these expenditures, which suggests that such an analysis was expected. The guidance suggests that a variance analysis should be conducted for expansion enrollees; however, it does not specify whether the analysis should be conducted in conjunction with—or take the place of—more in-depth examinations. According to federal internal controls standards for information and communication, agencies should communicate the information necessary for staff to achieve the agency’s objectives. CMS’s guidance on conducting variance analyses for types of expenditures with higher federal matching rates has not been sufficiently clear to assure that such analyses are being consistently conducted. By not consistently conducting such checks, errors may be going undetected and CMS may be providing federal funds at a higher matching rate than is allowable. CMS has additional procedures in place to review service expenditures reported for the Medicaid expansion population, a category of expenditures that received a 95 percent federal match in 2017. Specifically, in addition to a variance analysis, CMS guidance specifies that each regional office reviewer is to review claims for a sample. The guide directs the reviewer to obtain a full list of all expansion enrollees from the state and to select 30 to 40 for further review. Next, the reviewer is to obtain supporting documentation from the state listing the eligibility factors for the sampled enrollees, such as age, pregnancy status, Medicare enrollment, and income. The reviewer is to select a single claim for each enrollee and verify that the corresponding expenditures were reported under the correct federal matching rate category—i.e., that the sample claim for each individual was accounted for in the relevant section of the CMS-64. The review guide specifies that the sample review be conducted each quarter unless the state has had four consecutive quarters with three or fewer errors, in which case, the sampling must be performed only annually. We found that regional offices were identifying errors in their sampling reviews. For example, region 3 reviewers found that Pennsylvania had incorrectly categorized an individual in the sample as a Medicaid expansion enrollee, with the selected expenditures initially reported as eligible for the higher matching rate. According to CMS central office officials, the sampling methodology has helped identify systemic issues with state expenditure systems in some states and resulted in corrections, adjustments, and in one case, a disallowance. Under current procedures, among our five selected states that expanded Medicaid under PPACA, all five were determined to have had four consecutive clean quarters according to agency officials; that is, the state had three or fewer errors in each quarter. Nationally, all but one of the 33 states that have implemented Medicaid expansion under PPACA had four consecutive clean quarters as of March 2018, according to CMS officials. We found, however, that CMS’s procedures for sampling reviews had a key weakness in that they did not account for varying risks across states, as illustrated in the following examples. We found that sample size does not account for significant differences in program size. For example, both California and Arkansas have expanded Medicaid under PPACA, and regional office staff told us they reviewed claims for 30 expansion enrollees in each of the two states, despite the fact that California has over 10 times as many expansion enrollees as Arkansas. Region 9 officials told us that for California they had initially sampled 100 enrollees during the first quarter they were required to conduct this analysis, but the review was time consuming given staff resources, and they were advised by CMS’s central office to limit their sample to 30 individuals. CMS officials told us that the sampling procedures are resource intensive and that the sample size they decided upon was what they thought they had the resources to complete. Additionally, the sample size does not account for previously identified risks in a state’s program. Specifically, as we noted in a 2015 report, CMS’s sampling review of expansion expenditures was not linked to or informed by reviews of eligibility determinations conducted by CMS, some of which identified high levels of eligibility determination errors. According to CMS officials, the expenditure review is primarily intended to ensure that states are correctly assigning expenditures for the expanded eligibility groups as initially determined, not whether the eligibility determination is correct. Federal standards for internal control related to risk assessment require that agencies identify, analyze, and respond to risks. However, because CMS’s sampling methodology does not account for risk factors like program size and high levels of eligibility determination errors, the agency’s review of expansion population expenditures may be missing opportunities to detect systemic issues with improperly matched expenditures. Quarterly variance analyses and sampling of Medicaid expansion enrollees can be supplemented by financial management reviews. For fiscal year 2016, CMS recommended regional offices conduct FMRs on expenditure claims for expansion enrollees. As of March 2018, however, regional offices had completed an FMR on Medicaid expansion expenditures in only one state, with no findings, and were in the process of completing FMRs for five other states. According to CMS officials, no additional reviews in this area were planned for fiscal year 2018. Financial Impact of Expenditure Reviews Compared with Program Integrity Recoveries The impact of CMS’s expenditure review activities is greater than the impact from other program integrity efforts. For example, in fiscal year 2015, CMS resolved errors through expenditure reviews that saved over $1.4 billion in federal funds. In the same year, CMS reported that efforts by states and the federal government to identify improper payments to providers—for example, services that were billed by a provider but were not received by a beneficiary—resulted in recoveries that totaled $852.9 million, in both state and federal funds. In fiscal years 2014 through 2017, CMS’s regional offices resolved expenditure errors that reduced federal spending by over $5.1 billion, with at least $1 billion in errors resolved in each of three of those four years. Errors were resolved through states agreeing to reduce their reported expenditures, which prevented federal payments to the state for those expenditures; and through CMS issuing disallowances, under which states are required to return federal funds. Although CMS resolved over $1 billion in expenditure errors in each year of fiscal years 2014 through 2016, CMS resolved less than $600 million in fiscal year 2017. CMS officials explained that this change likely reflects delays in clearance of disallowances due to the transition between presidential administrations. (See fig. 3.) In addition to these resolved errors, as of the end of 2017, CMS had $4.47 billion in outstanding deferrals of federal funds, where CMS was delaying federal funds until additional information was provided. Expenditures flagged for deferrals may or may not represent errors. All 10 CMS regional offices resolved errors from fiscal years 2014 through 2017, though the magnitude varied across regions. (See table 5.) Among the 10 regional offices, 9 reported that they had resolved errors through states agreeing to reduce reported expenditures. Additionally, 9 regional offices issued a total of 49 disallowances across 16 states, with the majority of the disallowances occurring in regional offices 2 and 3. Finally, all 10 regional offices had taken deferrals for questionable expenditures, with 22 states having outstanding “active” deferrals that had not been resolved as of the fourth quarter of fiscal year 2017, which ranged in amount from $178 to $444 million. CMS officials told us that the range of resolved errors and deferred funds across regional offices may reflect differences in the proportion of high-expenditure states. For example, regional office 4 oversees four states ranking in the top 20 in terms of Medicaid expenditures, while regional office 8 does not oversee any top- 20 states. The variation may also reflect large actions taken in specific states. For example, the majority of the disallowed funds in regional office 2 from fiscal years 2014 to 2017 were due to a single disallowance of $1.26 billion in one state. The financial significance of individual errors resolved by CMS’s regional offices varied significantly. We found that regional offices resolved errors that ranged from reporting errors that had no federal financial impact— such as expenditures that were allowable, but were reported on the incorrect line—to hundreds of millions of dollars in expenditures that were found to be unallowable under Medicaid requirements. Over the fiscal years we reviewed, more than half of the disallowances CMS issued were less than $15 million; however, in four states CMS issued disallowances of over $100 million, including a disallowance of over $1 billion in New York. (See fig. 5.) In some cases, actions taken by CMS to resolve errors were the culmination of years of work. For example, over several years the California Medicaid program reported a large volume of expenditures for which it did not yet have sufficient supporting documentation. The regional office officials told us that the state reported these expenditures in order to comply with the 2-year filing limit, and had reported these as “placeholder claims,” with the intention of providing additional support at a later time. Over the course of at least 6 years, CMS deferred hundreds of millions of dollars in federal funds related to these placeholder claims. Of the active deferrals as of the end of fiscal year 2017, most of the total amount of deferred funds was taken for expenditures in California, which represented $3.4 billion of the $4.5 billion in total active deferrals. According to CMS officials, in 2015, CMS prohibited California from reporting additional placeholder claims. Region 9 officials told us that they continue to work with the state to clear the deferrals related to this issue. They were able to resolve 9 related deferrals in fiscal year 2017; however, another over 60 deferrals were still unresolved. The growth of federal Medicaid expenditures, estimated at about $370 billion in fiscal year 2017, makes it critically important to assure expenditures are consistent with Medicaid requirements. CMS has a variety of processes in place to review state-reported expenditures, and those reviews have resulted in CMS resolving errors that have saved the federal government a considerable amount of money; over $5 billion in the last 4 years. However, the increasing complexity of expenditure reporting is occurring as resources to review these expenditures are decreasing, hindering CMS’s ability to target risk and potentially allowing for hundreds of millions of federal dollars in errors to go undetected. In the absence of a comprehensive risk assessment, which CMS has not conducted, CMS may be missing opportunities to better target resources to higher risk expenditures and increase the savings from these oversight activities. The variety of different matching rates has contributed to the increased complexity of CMS’s expenditure reviews. Although CMS has review procedures in place to assure that the correct matching rate is applied for services and populations receiving a higher federal matching rate, unclear guidance has contributed to inconsistency in the extent to which these reviews are conducted. In addition, we found weaknesses in the sampling methodology CMS requires its regional offices to use to help ensure that expenditures for Medicaid expansion enrollees—expenditures that receive a higher matching rate and that represented almost 20 percent of total federal Medicaid spending in 2016—are consistent with Medicaid requirements. In particular, the methodology does not account for risk factors like program size or vulnerabilities in state eligibility-determination processes and systems. As a result of the inconsistency in reviews and a sampling methodology that does not consider program risk, errors may be going undetected, resulting in CMS providing federal funds at higher federal matching rates than is allowable. In addition, CMS could be missing opportunities to identify any systemic issues that may contribute to such errors. We are making the following three recommendations to CMS: 1. The Administrator of CMS should complete a comprehensive, national risk assessment and take steps, as needed, to assure that resources to oversee expenditures reported by states are adequate and allocated based on areas of highest risk. (Recommendation 1) 2. The Administrator of CMS should clarify in internal guidance when a variance analysis on expenditures with higher match rates is required. (Recommendation 2) 3. The Administrator of CMS should revise the sampling methodology for reviewing expenditures for the Medicaid expansion population to better target reviews to areas of high risk. (Recommendation 3) We provided a draft of this report to HHS for review and comment. HHS concurred with all three recommendations, noting that it takes seriously its responsibilities to protect taxpayer funds by conducting thorough oversight of states’ claims for federal Medicaid expenditures. Regarding our first recommendation—that CMS complete a comprehensive, national risk assessment and take steps to assure that resources are adequate and allocated based on risk—HHS noted that CMS will complete such an assessment, and, based on this review, will determine the appropriate allocation of resources based on expenditures, program risk, and historical financial issues. CMS will also identify opportunities to increase resources. Regarding our second recommendation—clarifying internal guidance on when a variance analysis on higher matched expenditures is required—HHS noted that CMS will issue such internal guidance. Regarding our third recommendation—that CMS revise the sampling methodology for reviewing expenditures for the Medicaid expansion population to better target reviews to areas of high risk—HHS noted CMS is considering ways to revise its methodology. HHS’s comments are reproduced in appendix II. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of Health and Human Services, appropriate congressional committees, and other interested parties. The correspondence is also available at no charge on the GAO website at http://www.gao.gov. If you or your staff members have any questions about this report, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Public psychiatric residential treatment facilities Medicare Part B premium buy-ins Outpatient hospital reimbursement for mental health services Review of comprehensive psychiatric emergency program rates Provider taxes implemented to avoid program reductions Health homes data and expenditures reporting Provider incentive payments for health information technology 1115 demonstration provider incentive payments Public psychiatric residential treatment facilities Managed care organizations’ provider payments Provider incentive payments for health information technology Federally qualified health center reimbursement payments Eligibility and enrollment maintenance and operations Managed care organizations’ reporting of drug rebates 3 CMS cancelled these 2014 FMRs due to a staffing shortage. Region 8 was excused from the requirement to conduct an FMR in 2016 due to staffing constraints. In addition to the contact named above, Susan Barnidge (Assistant Director), Jasleen Modi (Analyst-in-Charge), Caroline Hale, Perry Parsons, and Sierra Gaffney made key contributions to this report. Also contributing were Giselle Hicks, Drew Long, and Jennifer Whitworth.

Question: Write a one-page summary of the report 1.

Answer: This report is designed to assist Members of Congress and their staff as they address the needs of their states, communities, and constituents after a disaster. It includes a summary of federal programs that provide federal disaster assistance to individual survivors, states, territories, local governments, and nongovernmental entities following a natural or man-made disaster. A number of federal agencies provide financial assistance through grants, loans, and loan guarantees to assist in the provision of critical services, such as temporary housing, counseling, and infrastructure repair. The programs summarized in this report fall into two broad categories. First, there are programs specifically authorized for use during situations occurring because of a disaster. Most of these programs are administered by the Federal Emergency Management Agency (FEMA). Second are general assistance programs that in some instances may be used either in disaster situations or to meet other needs unrelated to a disaster. Many federal agencies, including the Departments of Health and Human Services (HHS) and Housing and Urban Development (HUD), administer programs that may be included in the second category. The programs in the report are primarily organized by recipient: individuals, state and local governments, nongovernmental entities, or businesses. These programs address a variety of short-term needs, such as food and shelter, and long-term needs, such as the repair of public utilities and public infrastructure. The report also includes a list of Congressional Research Service (CRS) reports on disaster assistance as well as relevant federal agency websites that provide information on disaster responses, updates on recovery efforts, and resources on federal assistance programs. This report will be updated as significant legislative or administrative changes occur.