MEDICAID 

MANAGED CARE

CMS Should Improve 

Oversight of Access 

and Quality in States’

Long-Term Services 

and Supports 

Programs 

Report to Congressional Requesters

August 2017

GAO-17-632

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-632, a report to 

congressional requesters

August 2017

MEDICAID MANAGED CARE

CMS Should Improve Oversight of Access and 

Quality in States’ Long-Term Services and 

Supports Programs

What GAO Found

In Medicaid, long-term services and supports are designed to promote the ability 

of beneficiaries with physical, cognitive, or mental disabilities or conditions to live 

or work in the setting of their choice, which can be in home or community 

settings, or in an institution such as a nursing facility. States are increasingly 

delivering such services through managed care, known as managed long-term 

services and supports (MLTSS). In MLTSS, as with most Medicaid managed 

care programs, states contract with managed care organizations (MCO) to 

provide a specific set of covered services to beneficiaries in return for one fixed 

periodic payment per beneficiary. In addition, beneficiaries have the right to 

appeal an MCO decision to reduce, terminate, or deny their benefits, or file a 

grievance with an MCO regarding concerns about their care. 

The six states GAO reviewed—Arizona, Delaware, Kansas, Minnesota, 

Tennessee, and Texas—used a range of methods for monitoring access and 

quality in MLTSS programs. To oversee beneficiaries’ care, GAO found that 

states used—to varying levels—external quality reviews, beneficiary surveys, 

stakeholder meetings, and beneficiary appeals and grievances data. For 

example, while all six states used external quality reviews and beneficiary 

surveys, GAO found that states varied in the extent to which—and how—they 

used appeals and grievances data to monitor beneficiaries’ concerns about 

quality and access in their MLTSS programs.

The Centers for Medicare & Medicaid Services (CMS)—the federal agency 

responsible for overseeing Medicaid—did not always require the six selected 

states to report the information needed to monitor access and quality in MLTSS

programs. CMS primarily relied on its reviews of state-submitted reports to 

monitor MLTSS programs for compliance with federal regulations and statespecific reporting requirements, and what states are required to report to CMS 

can vary by state. Although CMS highlighted certain elements that it deemed 

essential to developing and maintaining high quality MLTSS programs in its 2013 

guidance, GAO found that CMS did not require all selected states to report on 

these elements—namely, provider network adequacy; critical incidents, which 

are events that may cause abuse, neglect or exploitation of beneficiaries; and 

appeals and grievances. CMS did not require three of the six states that GAO 

reviewed to regularly report on network adequacy or provide summaries of 

critical incidents. Further, although CMS requires all selected states to report on 

their quality assurance efforts, GAO found that states often report general 

descriptions of their planned and ongoing quality assurance activities for MLTSS 

or their entire comprehensive managed care programs. Consequently, state 

reporting did not always provide CMS with information needed to assess state 

oversight of key elements. Gaps in reporting requirements may mean that CMS 

does not always have information needed to monitor key aspects of MLTSS 

access and quality among selected states and it may not be able to reliably 

detect state or MCO practices that do not meet CMS’s guidance.

View GAO-17-632. For more information, 

contact Katherine Iritani at (202) 512-7114 or 

iritanik@gao.gov.

Why GAO Did This Study

Twenty-two states use MLTSS 

programs to provide care for Medicaid 

beneficiaries who need long-term 

support. Using managed care to 

deliver long-term services and 

supports can be a strategy for states to 

expand home- and community-based 

care, which many beneficiaries prefer, 

and to lower costs. However, given the 

potential vulnerability and needs of 

beneficiaries in these programs, 

oversight is crucial to ensure their 

access to quality care.

GAO was asked to review states’ 

implementation and CMS’s oversight of 

MLTSS programs. In this report, GAO 

(1) described how selected states 

monitored MLTSS access and quality, 

and (2) examined the extent to which 

CMS oversees MLTSS access and 

quality in selected states.

GAO reviewed federal regulations, 

guidance, and internal control 

standards. For six states selected for 

variation in location, program size and 

duration, and other factors, GAO 

reviewed reporting requirements, 

reports to CMS, and other documents. 

GAO also reviewed data from these 

states on beneficiary appeals and 

grievances from 2013 through 2015—

the most recent data available—and

interviewed state and CMS officials.

What GAO Recommends

GAO recommends that CMS take

steps to identify and obtain information 

to oversee key aspects of MLTSS 

access and quality, including network 

adequacy, critical incidents, and 

appeals and grievances. HHS 

concurred with GAO’s 

recommendation.
Page i GAO-17-632 Medicaid Managed Care

Letter 1

Background 6

Selected States Used Multiple Methods to Oversee MLTSS Care, 

and Varied in the Extent to Which They Used Beneficiary 

Appeals and Grievances to Monitor Access and Quality 16

CMS’s Oversight Relied Primarily on State Reporting, but 

Selected States Were Not Always Required to Report Key 

Information on MLTSS Access and Quality Needed for CMS 

Oversight 26

Conclusions 32

Recommendation 32

Agency Comments and Our Evaluation 33

Appendix I Characteristics of States’ MLTSS Programs 

Selected for Our Review 34

Appendix II Comments from the Department of Health 

and Human Services 36

Appendix III GAO Contact and Staff Acknowledgments 39

Tables

Table 1: Characteristics of Managed Long-Term Services and 

Supports (MLTSS) Programs in Selected States 9

Table 2: Characteristics of Managed Long-Term Services and 

Supports (MLTSS) Programs in Selected States, 2015 35

Figures

Figure 1: States with Current or Planned Managed Long-Term 

Services and Supports (MLTSS) Programs, May 2017 7

Figure 2: Managed Care Organizations’ (MCO) Role in 

Coordinating Services for Beneficiaries in Managed 

Long-Term Services and Supports (MLTSS) Programs 11

Contents
Page ii GAO-17-632 Medicaid Managed Care

Figure 3: Comparison of Grievances and Grievance Rates per 

10,000 Member Months by Managed Care Organizations 

in One Selected State 21

Figure 4: Appeals Outcomes by Proportion of Appeals Upheld, 

Partially Overturned, or Overturned in Selected States, 

2015 24

Abbreviations

CMS Centers for Medicare & Medicaid Services

EQRO external quality review organization

HCBS home- and community-based services

HHS Department of Health and Human Services

MCO managed care organization

MLTSS managed long-term services and supports

SSI Supplemental Security Income

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Page 1 GAO-17-632 Medicaid Managed Care

441 G St. N.W.

Washington, DC 20548

August 14, 2017

The Honorable Orrin G. Hatch

Chairman

The Honorable Ron Wyden

Ranking Member

Committee on Finance

United States Senate

The Honorable Charles E. Grassley

United States Senate

In Medicaid, long-term services and supports are designed to promote the 

ability of beneficiaries with physical, cognitive, or mental disabilities or 

conditions to live or work in the setting of their choice, which can be in 

home or community settings, or in an institution such as a nursing 

facility.1 States are increasingly delivering such services through 

managed care, known as managed long-term services and supports 

(MLTSS). In MLTSS, as with most Medicaid managed care programs, 

states contract with managed care organizations (MCO) to provide a 

specific set of covered services to beneficiaries in return for one fixed 

periodic payment per beneficiary—typically, per member per month.

2 As 

of May 2017, 22 states had enrolled beneficiaries in MLTSS programs 

and 5 additional states planned to implement such programs. In fiscal 

year 2015, the most recent year for which data were available, MLTSS 

 1

Medicaid is a joint federal-state program that finances health insurance coverage for 

certain categories of low-income people or persons with disabilities. States are required to 

cover care provided in an institution as part of Medicaid, but coverage of most care 

provided in the home or community is optional. Home- and community-based care 

includes, for example, personal care services and adult day care, which may allow

beneficiaries to continue living in their homes. Personal care services assist beneficiaries 

with activities of daily living, such as bathing, dressing, and toileting. Adult day care refers 

to a variety of services and activities provided in a group setting within the community.

2

States may have different types of managed care arrangements in Medicaid; in this 

report, we are referring to comprehensive, risk-based managed care, the most common 

type of managed care arrangement. MLTSS programs can also include prepaid inpatient 

health plans and prepaid ambulatory health plans. States have traditionally offered 

Medicaid long-term services and supports in fee-for-service programs. Fee-for-service is 

an approach to reimbursement in which state Medicaid agencies pay participating 

providers for each delivered service (e.g., an office visit, test, or procedure).

Letter
Page 2 GAO-17-632 Medicaid Managed Care

accounted for an estimated $29 billion of the $158 billion in total Medicaid 

spending on long-term services and supports.3

Given the potential vulnerability and significant needs of the Medicaid 

beneficiaries who use long-term services and supports, federal and state 

oversight of MLTSS programs is crucial for ensuring their access to 

quality care—that is, the provision of health care services that promote 

desired health outcomes and are consistent with current professional 

knowledge.4 The types of beneficiaries eligible for MLTSS programs vary 

by state, but can include the elderly; adults with physical, intellectual, or 

developmental disabilities; and children with disabilities. These 

beneficiaries may have limited ability to care for themselves, and may 

need support such as nursing care or assistance with eating or dressing. 

Many beneficiaries prefer to receive support in home- and communitybased settings, and MLTSS programs can be a strategy for states to 

expand access to home- and community-based care, potentially at a 

lower cost than institutional care.5 MLTSS programs can also provide an

opportunity for states to better integrate Medicaid long-term services and 

supports with acute care or other services.6 At the same time, however, 

the use of managed care to meet MLTSS beneficiaries’ needs assumes 

that the provision of appropriate services can be achieved in a costeffective manner for a population that is among the most vulnerable and 

has particularly high health care needs.

 3

This reflects both federal and state spending on Medicaid. See Truven Health Analytics, 

Medicaid Expenditures for Long-Term Services and Supports (LTSS) in FY 2015 (April 14, 

2017). Due to challenges with collecting MLTSS data, Truven Health Analytics reported 

that this is a conservative estimate of overall MLTSS expenditures. 

4

The Institute of Medicine defines quality of care as the “degree to which health services 

for individuals and populations increase the likelihood of desired health outcomes and are 

consistent with current professional knowledge.” See Institute of Medicine, Medicare: A 

Strategy for Quality Assurance, Volume I (Washington, D.C.: 1990). 

5

Increasing the availability of community-based care is also important for states to be able 

to comply with the Supreme Court’s 1999 decision in Olmstead v. L.C., in which the Court 

held that unjustified institutionalization of a person based on disability violates Title II of 

the Americans with Disabilities Act. Olmstead v. L.C., 527 U.S. 581 (1999). In particular, 

the Court held that states must provide community-based care for persons with disabilities 

who are otherwise entitled to institutional services when such services are appropriate, the 

individual does not oppose such treatment, and the community-based care can be 

reasonably accommodated, taking into account the resources available to a state and the 

needs of others with disabilities.

6

States may, for example, choose to have MCOs provide MLTSS as part of a broader, 

comprehensive managed care program that also provides acute care or behavioral health 

care. 
Page 3 GAO-17-632 Medicaid Managed Care

As with Medicaid generally, the states and the Centers for Medicare & 

Medicaid Services (CMS)—within the Department of Health and Human 

Services (HHS)—share responsibility for overseeing MLTSS programs, 

including monitoring beneficiaries’ access to and quality of care. States 

are responsible for the operation of MLTSS programs and for monitoring 

the MCOs that provide the care. CMS is responsible for approving and 

monitoring states’ MLTSS programs to ensure that they comply with all 

applicable federal requirements. For example, among other beneficiary 

protections to help ensure access to care, MLTSS beneficiaries have the 

right, by law, to appeal an MCO’s decision to reduce, terminate, or deny 

payment for services, such as a decision to deny coverage for a specific 

service or reduce the hours of MLTSS services. MLTSS beneficiaries 

may also file a grievance with an MCO about their care, such as to 

express dissatisfaction about difficulty getting an appointment with an 

MLTSS provider or concerns about the quality of MLTSS care. In 

addition, CMS may set state-specific requirements for an individual 

MLTSS program, which are generally known as special terms and 

conditions. For example, in state programs’ special terms and conditions, 

CMS may establish reporting requirements in which states must 

periodically report to CMS on specific aspects of their MLTSS programs, 

such as on measures of access to care or quality.

You asked us to provide information on how states are implementing 

MLTSS and on CMS oversight of MLTSS programs. In January 2017, we 

issued a report that examined how selected states structured financial 

incentives in their MLTSS programs and CMS’s policies and procedures 

for overseeing states’ payment structures.7 In this report, we

1. describe how selected states monitored access and quality in their 

MLTSS programs, including their use of beneficiary appeals and 

grievances; and

2. examine the extent to which CMS oversees MLTSS access and 

quality in selected states.

To describe how states monitored access and quality in their MLTSS 

programs, including their use of beneficiary appeals and grievances, we 

reviewed selected states’ documentation of their MLTSS monitoring 

efforts as well as relevant federal regulations and guidance regarding 

state oversight. Out of the 21 states with established MLTSS programs as 

 7

GAO, Medicaid Managed Care: Improved Oversight Needed of Payment Rates for LongTerm Services and Supports, GAO-17-145 (Washington, D.C.: Jan. 9, 2017).
Page 4 GAO-17-632 Medicaid Managed Care

of calendar year 2013, we selected 6 states—Arizona, Delaware, Kansas, 

Minnesota, Tennessee, and Texas—whose MLTSS programs were 

authorized under a section 1115 demonstration or section 1915 waiver 

and reflected a range of experiences in terms of the length of time they 

had been in place; the number of beneficiaries receiving MLTSS in fiscal 

year 2013; the percentage of MLTSS spending on services provided in 

the home and the community—referred to as home- and communitybased services (HCBS)—in fiscal year 2013; and geographic region.8 The 

fiscal year 2013 data on MLTSS programs and their number of 

beneficiaries and spending were the most recently available state-level 

data at the time we selected states for review. The 6 states represented 

over 30 percent of all Medicaid beneficiaries in MLTSS programs as of 

July 2015. We collected information on the methods these states used to 

monitor access and quality in MLTSS programs, such as quality 

improvement strategies and external reviews, and examined states’ uses 

of beneficiary appeals and grievances. We reviewed documentation, such 

as state contracts with MCOs—which specify what services MCOs are 

required to provide and what information MCOs are required to report to 

the state, among other responsibilities—and state quality strategies. We 

also reviewed state data on beneficiaries’ appeals and grievances and 

states’ compliance actions in calendar years 2013 through 2015, and the 

outcomes of beneficiaries’ appeals for calendar year 2015. We 

interviewed state Medicaid officials about their monitoring efforts, and 

discussed state oversight with CMS officials. Neither the MLTSS 

programs in these six states nor the methods they use to monitor access 

and quality that we examined are generalizable to other states.

To examine the extent to which CMS oversees MLTSS access and 

quality in selected states, we reviewed documents regarding CMS’s 

monitoring efforts, including Medicaid managed care regulations and

CMS guidance on MLTSS programs. In addition, for our 6 selected 

states, we reviewed their MLTSS special terms and conditions, including 

 8

Section 1115 of the Social Security Act authorizes the Secretary of Health and Human 

Services to waive certain federal Medicaid requirements and allow costs that would not 

otherwise be eligible for federal matching funds for experimental, pilot, or demonstration 

projects that, in the Secretary’s judgment, are likely to assist in promoting Medicaid 

objectives. Section 1915(b) provides states with the flexibility to modify their delivery 

systems by allowing CMS to waive statutory requirements for comparability, 

statewideness, and freedom of choice. States that use section 1915(b) waivers to 

implement MLTSS programs may also have a concurrent, separate authority such as 

section 1915(c) waivers. Specifically, states use section 1915(b) waivers to mandate 

enrollment in managed care and use section 1915(c) waivers to target eligibility and 

provide certain community-based care in their MLTSS programs.
Page 5 GAO-17-632 Medicaid Managed Care

CMS’s reporting requirements regarding MLTSS access to and quality of 

care, and examined the variation in those requirements across states. We 

focused on states’ reporting requirements related to the section 1115 and 

1915 demonstrations and waivers, the most commonly used authorities 

for MLTSS programs. We also reviewed the states’ quarterly and annual 

reports to CMS about their MLTSS programs, and assessed whether 

those reports were consistent with CMS’s state-specific reporting 

requirements. We also interviewed CMS and state officials about MLTSS 

monitoring and oversight efforts. We assessed CMS’s monitoring efforts 

using agency guidance that lists key elements of effective MLTSS 

programs, which CMS uses to review state applications for new MLTSS 

programs as well as existing MLTSS programs.9 For our analysis, we 

focused on a subset of key elements that were directly related to access 

and quality of care, and could be reviewed in the context of state 

reporting requirements. We also considered the extent to which CMS’s 

monitoring efforts are consistent with relevant Standards for Internal 

Controls in the Federal Government, specifically, those related to 

monitoring.10 In addition, we interviewed officials with HHS’s 

Administration for Community Living, which is responsible for increasing 

individuals’ access to community supports.

We conducted this performance audit from September 2015 to August 

2017 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

 9

Centers for Medicare & Medicaid Services, Guidance to States Using 1115 

Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports 

Programs (2013).

10GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: Nov. 1999). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved.
Page 6 GAO-17-632 Medicaid Managed Care

States’ increasing use of managed care for Medicaid beneficiaries 

needing long-term services and supports is a significant change from how 

states have historically met the needs of these vulnerable populations. 

While many states have extensive experience with using managed care 

programs to provide physical or behavioral health care services, states 

have not typically included beneficiaries needing long-term care 

services—especially seniors and adults with physical or developmental 

disabilities—in managed care programs. In 2004, only 8 states had 

implemented MLTSS programs. In contrast, as of May 2017, 27 states 

either had implemented MLTSS programs or were planning to implement 

them. (See fig. 1.) The most recent enrollment data available at the time 

of our study, from July 2015, showed that MLTSS programs in 18 states 

collectively served around 1 million Medicaid beneficiaries that year.

11

 11This reflects CMS’s estimate of the total number of MLTSS users, and does not include 

beneficiaries who were enrolled in a MLTSS program but did not actually receive any 

long-term services and supports. See Centers for Medicare & Medicaid Services and 

Mathematica Policy Research, Medicaid Managed Care Enrollment and Program 

Characteristics, 2015 (2016).

Background

Prevalence and 

Characteristics of 

Medicaid Managed LongTerm Services and 

Supports Programs
Page 7 GAO-17-632 Medicaid Managed Care

Figure 1: States with Current or Planned Managed Long-Term Services and Supports (MLTSS) Programs, May 2017

Long-term services and supports include a broad range of health and 

health-related services and non-medical supports for individuals who may 

have limited ability to care for themselves because of physical, cognitive, 

or mental disabilities or conditions—and who need support over an 

extended period of time. Individuals needing long-term services and 

supports have varying degrees of difficulty performing activities of daily 

living, such as bathing, dressing, toileting, and eating, without assistance. 
Page 8 GAO-17-632 Medicaid Managed Care

They may also have difficulties with preparing meals, housekeeping, 

using the telephone, and managing money. Long-term services and 

supports to address these needs are generally provided in two settings: 

institutional facilities, such as nursing facilities and intermediate care 

facilities for individuals with intellectual disabilities; and home and 

community settings, such as individuals’ homes or assisted living 

facilities. HCBS cover a wide range of services and supports to help 

individuals remain in their homes or a community setting, such as 

personal care services to provide assistance with activities of daily 

living.12

MLTSS programs can vary due in part to the flexibility that Medicaid 

allows states in establishing their programs. For example, states have 

flexibility in determining which populations to include in their MLTSS 

programs and whether to use mandatory or voluntary enrollment.13 States 

also have flexibility in determining what services to include. In addition, 

states may choose to have MLTSS as part of a broader, comprehensive 

managed care program that also provides acute care or behavioral health 

care, or to have MLTSS as a separate managed care program. See table 

1 for characteristics of MLTSS programs in the six states we selected for 

review. (App. I provides more information on the MLTSS programs in our 

selected states.)

 12HCBS can also include adult day care services and activities provided in a group setting 

within the community; certain home modifications that allow the beneficiary to remain in 

the home; and non-medical transportation. 

13For example, states may include older adults, individuals with physical disabilities, and 

individuals with intellectual or developmental disabilities in their MLTSS programs. States 

may limit some of these populations to adults only or may include both children and 

adults. 
Page 9 GAO-17-632 Medicaid Managed Care

Table 1: Characteristics of Managed Long-Term Services and Supports (MLTSS) Programs in Selected States 

State

Number of 

beneficiaries 

receiving 

MLTSS, 2015

Types of beneficiaries receiving MLTSS, 2015

Mandatory or voluntary 

enrollment, 2015 

Number of 

MCOs 

under 

contract, 

2015

SeniorsAdults with physical disabilitiesAdults with intellectual and developmental disabilitiesChildren with disabilities

Arizona 55,475     Mandatory Three MCOs

One state 

agency 

Delaware 6,340    Mandatory Two MCOs

Kansas 33,255     Mandatorya Three MCOs

Minnesota 33,185  

(over age 65)



(over age 65)

Mandatory for some 

beneficiaries, voluntary 

for othersb

Seven 

MCOs

Tennessee 30,166    Mandatory Three MCOs

Texas 97,914    Mandatory for some 

beneficiaries, voluntary 

for othersc

Five MCOs

Key: MCO means managed care organization.

Source: GAO analysis of state-reported data. | GAO-17-632

Notes: Beneficiary data are as of December 2015 for Arizona, Delaware, Kansas, and Tennessee. 

For Minnesota, data represent full-year equivalents based on member months for calendar year 

2015, and for Texas, data represent average monthly enrollment for calendar year 2015 with 

estimated data after August 2015.

a

In Kansas, the population of American Indians could opt out of mandatory enrollment.

b

In Minnesota, enrollment was mandatory for the Minnesota Senior Care Plus program and voluntary 

for the Minnesota Senior Health Options program, which serves beneficiaries who are dually eligible 

for both Medicaid and Medicare. Enrollees who disenroll from the Minnesota Senior Health Options 

program were subject to mandatory enrollment in the Minnesota Senior Care Plus program.

c

In Texas, for example, enrollment was mandatory for adults receiving Supplemental Security Income 

(SSI)—a Social Security Administration program that provides benefits for disabled, blind, or aged 

people who have low income and limited resources—and voluntary for children and young adults 

under age 21 who received SSI and SSI-related Medicaid benefits.

Within MLTSS programs, MCOs are responsible for coordinating the 

delivery of services to beneficiaries. To be eligible for MLTSS, 

beneficiaries must meet income and asset requirements, and also meet 

state-established criteria on the level of care needed, such as needing an 

Delivery of MLTSS and 

State Oversight
Page 10 GAO-17-632 Medicaid Managed Care

institutional level of care.14 Once a person is determined eligible, the 

individual can be enrolled to receive MLTSS from an MCO. The MCO 

then works with the beneficiary to develop a service plan that addresses 

the beneficiary’s needs and preferences, including determining the type 

and amount of services the beneficiary needs. (See fig. 2.) For example, 

for a beneficiary receiving care in the home, the MCO determines if 

personal care services are needed and, if so, the amount of services, 

such as the number of hours needed per week. The MCO is then 

responsible for implementing this service plan and coordinating the 

beneficiary’s care.

 14To determine who meets criteria on level of care, states may use functional criteria (e.g., 

the extent to which a person needs assistance with activities of daily living), clinical 

criteria, or a combination of the two. Eligibility requirements also apply for long-term 

services and supports provided under fee-for-service.
Page 11 GAO-17-632 Medicaid Managed Care

Figure 2: Managed Care Organizations’ (MCO) Role in Coordinating Services for Beneficiaries in Managed Long-Term 

Services and Supports (MLTSS) Programs

Although MCOs are responsible for coordinating MLTSS beneficiaries’

care, states remain responsible for the operation of MLTSS programs and 

must monitor the MCOs. State contracts establish MCO responsibilities 

with respect to the services the MCO is responsible for providing, the 

beneficiary protections that must be in place, and the information the 

MCO must report to the state. States then monitor MCO actions for 

compliance with contractual requirements. States may take compliance 

actions if they find that MCOs are not complying with contractual 

requirements and if they identify issues with MCOs’ provision of care. 

Compliance actions range in severity and can include informing MCOs of 
Page 12 GAO-17-632 Medicaid Managed Care

problems through letters or notices, issuing corrective action plans for the 

MCO to implement, or assessing intermediate sanctions.

States are required to seek CMS approval for their MLTSS programs, 

which they can implement through several different authorities. Among 

the most commonly used authorities are section 1115 demonstrations 

and section 1915(b) waivers. Before approving an MLTSS program, CMS 

works with the state to shape the program design, including how the 

program will align with CMS guidance. In 2013, CMS issued guidance 

that set expectations for states seeking approval of MLTSS programs 

through section 1115 demonstrations or section 1915(b) waivers.15 In 

particular, CMS listed 10 key elements of effective MLTSS programs that 

the agency expects states to incorporate into both new and existing 

MLTSS programs.16 These elements address a range of topics, including 

qualified providers (or network adequacy), participant protections 

(including appeals and grievance processes and a critical incident 

management system with safeguards to prevent abuse, neglect, and 

exploitation), and quality (implementation of a comprehensive quality 

strategy for MLTSS). For example, states must ensure that MCOs 

maintain a network of qualified long-term services and supports providers 

that is sufficient to provide adequate access to covered services; 

establish safeguards to ensure beneficiary health and welfare; and 

develop mandatory MCO reports on MLTSS quality of care performance

measures, analyze those reports, and take corrective actions if needed. 

CMS’s guidance noted that if a state incorporated these 10 elements it 

would increase the likelihood of having high-quality MLTSS programs. 

CMS uses these elements to review and approve states’ MLTSS 

programs.

 15See Centers for Medicare & Medicaid Services, Center for Medicaid & CHIP Services, 

Guidance to States using 1115 Demonstrations or 1915(b) Waivers for Managed Long 

Term Services and Supports Programs (2013). This guidance was intended to share what 

CMS learned from states, stakeholders, and advocates about best practices for 

establishing and implementing MLTSS programs—and to clarify CMS’s expectations for 

states using these authorities in an MLTSS program. According to the guidance, MLTSS 

program designs, written contracts, program operations manuals, and other documents 

governing the relationship between a state and its managed care plans must incorporate 

this guidance, as well as statutory and regulatory requirements.

16The 10 elements are (1) adequate planning, (2) stakeholder engagement, (3) enhanced 

provision of HCBS, (4) alignment of payment structures and goals, (5) support for 

beneficiaries, (6) person-centered processes, (7) comprehensive integrated service 

package, (8) qualified providers, (9) participant protections, and (10) quality.

Federal Role in MLTSS 

Programs
Page 13 GAO-17-632 Medicaid Managed Care

When CMS approves an MLTSS program under a section 1115 

demonstration or section 1915 waiver, it establishes state-specific 

requirements for the program and also specifies how it will oversee the 

program on an ongoing basis.17 For example, CMS may require a state to 

conduct specific MCO monitoring activities. In addition, CMS may require 

a state to submit quarterly and annual performance reports to CMS. 

These reports may address state-specific measures of quality and 

access, including information on appeals and grievances. Within CMS,

oversight of MLTSS programs is a joint responsibility of the agency’s 

central and regional offices.

In addition to state-specific requirements, states with MLTSS programs 

are also subject to broader quality requirements that apply to all Medicaid 

managed care programs. For example, states must have an external 

quality review process to assess the quality of care MCOs provide to all 

managed care beneficiaries, including MLTSS beneficiaries. States may 

use an external quality review organization (EQRO)—an independent 

organization specializing in external quality reviews—to conduct several 

required external quality review activities, and must use an EQRO for an 

annual quality review.

18 States must also have a quality strategy for 

MLTSS programs that includes, for example, a discussion of performance 

measures, performance improvement projects, and state quality oversight 

plans. Changes to requirements for states regarding Medicaid managed 

care quality are slated to take effect in July 2017 or later, under CMS’s 

2016 Medicaid managed care final rule, which was the first major change 

to Medicaid managed care regulations since 2003.

19

 17CMS documents its state-specific oversight process in the special terms and conditions 

that represent the agreement between CMS and the state about the MLTSS program. 

18Specifically, states have the option to use an EQRO for required external quality review 

activities, including (1) a review of MCO compliance with state requirements, (2) validation 

of performance measures, and (3) validation of performance improvement projects. States 

must also ensure that each year an EQRO reports to the state on aspects of the quality of 

care provided by MCOs. According to CMS, states often use their EQRO to conduct 

optional quality activities. CMS’s optional quality activities include, for example, calculating 

additional performance measures, administering or validating surveys, and conducting 

studies of particular aspects of health care quality.

19Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid 

Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party 

Liability, 81 Fed. Reg. 27498 (May 6, 2016).
Page 14 GAO-17-632 Medicaid Managed Care

The beneficiary appeals and grievance processes are important 

beneficiary protections for MLTSS programs. By law, MCOs must have 

an internal appeals process in place so that MLTSS beneficiaries may 

challenge certain MCO actions, such as decisions to terminate services, 

as well as a process for MLTSS beneficiaries to file a grievance with the 

MCO regarding their care.20

Appeals. A beneficiary can file an appeal in response to an MCO’s 

decision to, among other things, reduce services, terminate services, or 

deny payment for services.21 For example, a beneficiary could appeal an 

MCO’s decision to deny coverage for a specific type of MLTSS care, such 

as personal care services, or to reduce the number of personal care 

attendant hours a beneficiary will receive. After the beneficiary submits an 

appeal, the MCO will either approve the appeal (meaning that the MCO, 

through its internal appeals process, overturns its original decision and 

resolves the appeal in favor of the beneficiary), or deny the appeal 

(meaning that the MCO upholds its original decision). If an MCO denies 

the appeal, the beneficiary can request that the state review the MCO’s 

decision through the state’s fair hearing process, in which state officials 

rule on whether the MCO’s decision should be upheld.

Grievances. A beneficiary can file a grievance with an MCO to express 

dissatisfaction about any matter not covered by appeals. For example, a 

beneficiary could file a grievance about difficulty getting an appointment 

with an MLTSS provider, concerns about the quality of MLTSS care, a 

provider or MCO not respecting a beneficiary’s rights, or a provider not 

treating the beneficiary respectfully. Beneficiaries may also submit 

grievances directly to the state, in a manner determined by the state, 

such as to the state Medicaid agency or state long-term care 

ombudsman.22 After receiving information about the beneficiary’s 

grievance, the MCO conducts an independent review and determines 

what, if any, steps are needed to resolve the grievance.

 2042 U.S.C. § 1396u-2(b)(4).

21In the event of such an action, MCOs are required to send beneficiaries a notice 

including information about the beneficiary’s right to file an appeal and how to do so. 42 

C.F.R. § 438.404 (2016).

22Each state has a long-term care ombudsman program that provides assistance for 

residents of nursing homes, assisted living facilities, and other types of facilities by 

working to resolve problems raised by residents or their families. These state programs 

can assist Medicaid beneficiaries as well as individuals who are not covered by Medicaid.

Beneficiary Appeals and 

Grievance Processes
Page 15 GAO-17-632 Medicaid Managed Care

Appeals and grievances processes are slated to change, beginning in 

July 2017, due to changes specified in CMS’s May 2016 Medicaid 

managed care final rule.23 For example, there is a new requirement that 

MCOs maintain records about each grievance or appeal, including a 

general description of the reason for the appeal or grievance, the date 

received and reviewed, and the resolution at each level of the grievance 

or appeal. MCOs must maintain these records in a manner accessible to 

the state and provide them to CMS upon request.24 Previously, states 

have been required to maintain information on appeals and grievances, 

and the final rule specified what those records must include.

 23Managed care appeals and grievances regulations are set forth at 42 C.F.R. pt. 438, 

subpt. F.

24There is also a new requirement for beneficiaries to exhaust the MCO appeals process 

prior to initiating the state’s fair hearing process, which is a change for states that have 

allowed the state fair hearing process to occur concurrently with the MCO appeals.
Page 16 GAO-17-632 Medicaid Managed Care

The six states we reviewed used a range of methods to oversee MLTSS 

beneficiaries’ access to and quality of care. States’ oversight methods 

included implementing external quality reviews, tracking performance 

measures, surveying beneficiaries, and reviewing medical charts, among 

other activities. In some cases, these oversight methods were specific to 

MLTSS programs, while in other cases the methods addressed MLTSS 

as well as other state managed care programs. Examples of state 

oversight methods included the following:

External quality reviews: All six states implemented the external quality 

reviews that CMS requires, which involves assessments of MCOs’ 

compliance with requirements related to quality, and validating MCO 

performance measures and performance improvement projects. In each 

of these states, the state’s EQRO assessed MCO compliance with quality 

requirements and reported to the state on their findings. Examples of 

EQROs’ findings included:

• The Texas EQRO 2014 report found weaknesses in the state’s 

performance measures on effectiveness of care and made 

recommendations to the state to improve the care provided through 

the state program that provides both MLTSS and acute care for 

elderly beneficiaries. These included steps to improve performance on 

measures such as the rates of potentially preventable hospital 

admissions and emergency department visits.

Selected States Used 

Multiple Methods to 

Oversee MLTSS 

Care, and Varied in 

the Extent to Which 

They Used 

Beneficiary Appeals 

and Grievances to 

Monitor Access and 

Quality

Selected States Used a 

Range of Methods, 

Including External 

Reviews, to Oversee 

MLTSS Access and 

Quality
Page 17 GAO-17-632 Medicaid Managed Care

• The Delaware EQRO assessed aspects of quality and access across 

the two MCOs that operated both MLTSS and non-MLTSS services. 

The EQRO’s 2014 report to the state reported, for example, that both 

plans were compliant with Medicaid managed care regulations 

regarding quality assessment and performance improvement, but that 

they could improve in managing the grievance and appeals process, 

and ensuring appropriate resolution and communication with 

beneficiaries and providers.

In addition to required EQRO reviews, five of the six states reported that 

they had their EQROs conduct other quality oversight activities. For 

example, Delaware’s EQRO took part in a task force that provides a 

forum for sharing best practices, and identifies and implements quality 

improvement strategies. Tennessee contracted with its EQRO to prepare 

an annual report on national initiatives that may affect managed care, and 

conduct educational meetings for state quality staff and MCOs.

Use of MCO performance measures and beneficiary surveys: All six 

states tracked performance measures, which varied by state, but included 

measures such as rates of hospitalization, timely MCO response to 

beneficiary grievances, and the proportion of beneficiaries receiving 

certain services. For example, Texas tracked the proportion of grievances 

that were resolved within certain time frames, and Kansas tracked the 

proportion of beneficiaries receiving HCBS care who received a flu 

vaccine. The states also used beneficiary surveys to help monitor MLTSS 

care. For example, one state’s survey asked beneficiaries about their 

satisfaction with and ability to access services. States generally used 

surveys that were designed by the state or by their EQRO.25 The states 

used established surveys, or incorporated questions from established 

surveys, such as the National Core Indicators–Aging and Disability survey 

and the Consumer Assessment of Healthcare Providers & Systems in 

their surveys.

Reviews of beneficiary information such as medical charts or case 

files: Five of the six states reported that they had efforts to review or 

audit MLTSS beneficiary information, such as medical charts, case files, 

or other information, to identify potential issues with MLTSS care. The 

frequency of their efforts ranged from quarterly to once every 3 years. For 

example, Arizona conducted medical chart reviews at least every 3 years, 

 25In some cases, the EQROs conducted and analyzed the surveys as part of their work for 

the state. 
Page 18 GAO-17-632 Medicaid Managed Care

reviewing a sample of charts for MCO compliance with case management 

requirements in areas such as timeliness, assessments of care, and the 

services provided to beneficiaries. Delaware conducted quarterly on-site 

reviews, which included reviews of beneficiaries’ case files, level of care 

assessments, and each MCO’s critical incident management system, to 

ensure that beneficiaries were receiving necessary services and that 

MCOs were complying with requirements regarding MLTSS care.26

Reviews of provider networks: Officials in all six states reported 

conducting their own assessments of MLTSS provider networks or 

requiring MCOs to report on their MLTSS provider networks.27 Kansas, 

for example, conducted provider network adequacy assessments and 

annual audits about access. Minnesota, every 2 years, surveys 

geographic areas to identify provider gaps, and assesses provider 

networks and providers’ ability to deliver services; it shares information on 

any identified provider gaps with its MCOs. Arizona required MCOs to 

submit an annual plan about provider network development, including 

information on any network gaps, and to report any changes in networks 

which would affect more than five percent of beneficiaries within one 

geographic service area.

Stakeholder meetings: Officials in all six states told us that they met with 

stakeholders, such as state long-term care ombudsmen, beneficiary 

advocates, or providers, on a regular basis to discuss beneficiaries’

experiences with MLTSS care.

 26Critical incidents are events or situations that cause or may cause harm to a 

beneficiary’s health or welfare, such as abuse, neglect, or exploitation.

27Some states reported that their efforts were part of broader efforts to assess MCO 

provider networks, including MLTSS and non-MLTSS providers. 
Page 19 GAO-17-632 Medicaid Managed Care

The six states we reviewed varied in the extent to which—and how—they 

used appeals and grievance data to monitor beneficiaries’ concerns about 

quality and access in their MLTSS programs. We found variation, for 

example, in the extent to which states were collecting and using data on 

appeals and grievances specifically related to MLTSS care, calculating 

appeals and grievance rates, and monitoring the outcomes of 

beneficiaries’ appeals.

Collecting and using MLTSS-specific data: Two of the six states–

Arizona and Texas—did not separate MLTSS appeals and grievances 

from those related to other managed care services or beneficiaries. In 

these two states, MCOs that provide MLTSS also provide non-MLTSS 

services, such as acute care.28 While both states collected and used data 

on managed care appeals and grievances, they did not require MCOs to 

report MLTSS appeals and grievances separately from those for other 

managed care services and beneficiaries, or in a way that allowed the 

states to identify all MLTSS-specific appeals and grievances.29 In the 

other four states—Delaware, Kansas, Minnesota, and Tennessee—the 

MCOs reported MLTSS appeals and grievances separately from appeals 

and grievances related to other managed care services and 

beneficiaries.30 Within these four states, monitoring practices varied. 

Officials in one of these four states, for example, reviewed monthly 

reports on MLTSS appeals. They said appeals data helped them 

understand what was happening with beneficiaries on a regular basis, 

identify any systemic patterns in appeals, and take action if needed. They 

 28In Arizona, several MCOs provide MLTSS as a part of comprehensive managed care 

services that also include covered non-MLTSS services, such as acute care and 

behavioral health. In this state, MCOs reported appeals and grievances filed by 

beneficiaries receiving MLTSS care, but the data did not distinguish which appeals and 

grievances were specifically related to MLTSS and which were related to non-MLTSS 

care. In Texas, MCOs that provide comprehensive managed care services inclusive of 

MLTSS also serve beneficiaries who receive only acute care services. In this state, MCOs 

reported appeals in a manner that did not distinguish MLTSS beneficiaries from 

beneficiaries who did not receive MLTSS care—or distinguish MLTSS services from nonMLTSS services.

29According to CMS officials, these two states were fulfilling related regulatory 

requirements even though they were not able to separate MLTSS appeals and grievances 

from other appeals and grievances.

30For example, Minnesota used service categories for nursing facility and home- and 

community-based services to distinguish MLTSS appeals and grievances from those for 

other populations.

Selected States Varied in 

the Extent to Which They 

Used Appeals and 

Grievances to Monitor 

Beneficiaries’ Concerns 

about MLTSS Access and 

Quality

Example of One State’s Use of Managed 

Long-Term Services and Supports 

Program-Specific Appeals and Grievance 

Data

Officials in one state learned through 

beneficiary appeals, complaints to the state, 

and threats of legal action that a managed 

care organization had reduced the hours of 

private duty nursing services provided to 

some beneficiaries without first conducting 

face-to-face meetings between the care 

coordinator and individual beneficiaries about 

the beneficiaries’ coordination of care. The 

state took action in response to these 

findings.

Source: GAO summary of state information. | GAO-17-632
Page 20 GAO-17-632 Medicaid Managed Care

also noted that, as one way of measuring access to care, they review 

appeals and grievance data for any beneficiary complaints about not 

having access to providers. In Kansas, officials said that they regularly 

reviewed appeals and grievances separately for all beneficiaries receiving 

HCBS; they reviewed appeals and grievances for beneficiaries receiving 

MLTSS care in a nursing facility as part of their review of the state’s 

broader managed care population.31

Calculating appeals and grievances rates: Three states—Kansas, 

Minnesota, and Tennessee—calculated rates of MLTSS appeals and 

grievances as a proportion of beneficiary enrollment, so that they could 

track patterns or changes in appeals and grievances independent of 

changes in enrollment, while one state, Delaware, calculated a rate of 

grievances as a proportion of beneficiary enrollment but did not calculate 

a rate of appeals. Officials in one of these states told us that calculating 

rates—rather than by looking only at the numbers of appeals and 

grievances—allowed more meaningful comparisons of appeals and 

grievances across MCOs. Officials in this state provided an example of 

when the state took an action based on appeals rates. The state identified 

that one MCO had a significantly higher appeals rate than other MCOs, 

and as a result, put a temporary moratorium on the MCO’s 

implementation of reductions in or terminations of certain services. The 

state examined the reasons for the high appeals rate—which involved the 

MCO’s process for managing beneficiaries’ use of services—and lifted 

the moratorium after the MCO addressed the issues. After the state lifted 

the moratorium, the MCO’s appeal rate dropped to a rate similar to that of 

the other two MCOs. The remaining two states, Arizona and Texas, did 

not calculate rates of appeals and grievances based on beneficiary 

enrollment.

We analyzed grievance rates in one state and found that one MCO—

identified as MCO B in figure 3—consistently had a lower number of 

grievances than other MCOs in the state. However, when grievances 

were calculated as a proportion of enrollees, MCO B—which had fewer 

enrollees than other MCOs—had a higher grievance rate than most other 

MCOs. See figure 3 for an illustration of the difference in grievance 

numbers and grievance rates for two of the MCOs in this state.

 31Kansas officials noted that there were low numbers of appeals and grievances related to 

nursing facility care, and that in 2017 the state was moving to monitor grievance and 

appeals of HCBS and nursing facility populations in a more detailed way.
Page 21 GAO-17-632 Medicaid Managed Care

Figure 3: Comparison of Grievances and Grievance Rates per 10,000 Member Months by Managed Care Organizations in One 

Selected State

Using categories of appeals and grievances: The six states varied in 

the extent to which—and how—they used categories of appeals or 

grievances to identify beneficiary concerns about specific types of 

services or access to care issues. States can request that MCOs report 

beneficiary appeals and grievances in categories based on the type of 

beneficiary concern. For example, a beneficiary appeal about a reduction 

in private duty nursing service hours could be categorized as being 

related to that particular type of service, and a grievance about late 

transportation services that caused the beneficiary to miss an 

appointment could be categorized as being related to transportation 

services. State officials told us that using categories can help them 

identify patterns or changes in appeals and grievances, and highlight 

areas where the state could take action to address beneficiary concerns. 

All states required MCOs to report categories of grievances and four 

states—Arizona, Kansas, Minnesota, and Texas—required MCOs to 

report categories of appeals. In the two remaining states, each state was
Page 22 GAO-17-632 Medicaid Managed Care

able to review appeals decisions directly and so did not rely on MCOs to 

categorize appeals.32

• Minnesota, for example, asked MCOs to categorize appeals and 

grievances by setting of care, such as nursing facility, and by type of 

services, such as companion services or home-delivered meals. The 

state also asked MCOs to categorize appeals and grievances by the 

type of issue the beneficiary raised.

• Delaware had MCOs use several categories of grievances, including 

quality of care, quality of service, and case management. State 

officials said they regularly review MCOs’ grievance data and evaluate 

the grievance categories, working to refine the categories to make 

them as useful as possible. For example, they evaluate MCOs’

explanations for grievances they categorized as an “other” type of 

grievance (as opposed to a specific category), in order to identify new 

types of beneficiary concerns.

• Arizona used several categories of grievances, such as access to 

care, medical services provision, and transportation. State officials 

provided an example of how they adjusted categories to reflect 

emerging areas of concern. They explained that transportation 

services, which enable MLTSS beneficiaries and other beneficiaries to 

access care, had the highest number of grievances. As a result, the 

state required MCOs to work more closely with transportation 

providers. In addition, the state refined its grievance categories to 

better track specific types of transportation concerns, such as the 

timeliness of pick up, unsafe driving, and missed or late appointments.

Monitoring appeals outcomes: The six states varied in the extent to 

which they monitored whether the appeals that MLTSS beneficiaries filed 

were ultimately approved or denied by MCOs—that is, whether MCOs 

reversed their initial decisions to reduce or terminate services or to deny 

coverage for MLTSS care.33 Officials from one state said that data on 

appeals outcomes, particularly decisions where the MCO reversed its 

 32Two of the four states that used categories of appeals—Arizona and Texas—were 

unable to separate MLTSS appeals and grievances from those related to other managed 

care services or beneficiaries. For the two states that did not use categories of appeals, 

Tennessee officials told us that the state does not require MCOs to specifically categorize 

appeals because the state receives information directly on all appeals through its 

involvement in reviewing and determining outcomes on all appeals, and Delaware officials 

also told us that the state was involved with determining appeals outcomes. 

33Appeals can also be partially overturned, withdrawn, or denied due to exceeding the 

time frame for appeal.

Examples of Appeals and Grievances 

Categories

Minnesota had managed care organizations 

(MCO) categorize appeals and grievances by 

setting of care, type of service, and the type of 

issue the beneficiary raised. For example, 

regarding the types of issues MCOs could 

report:

• Appeals categories included services and 

benefits; failure to provide services within 

contractual timelines; and billing and 

financial issues, among others.

• Grievance categories included access; 

coordination of care; and technical 

competence and appropriateness, among 

others.

Source: GAO summary of state information. | GAO-17-632.
Page 23 GAO-17-632 Medicaid Managed Care

initial decision, are as important as the data on the appeals themselves. 

They noted that if MCOs often reverse their decisions, it indicates a 

problem with beneficiaries being put through appeals unnecessarily. Four

states—Delaware, Kansas, Minnesota, and Tennessee—monitored the

outcomes of MLTSS appeals. Arizona monitored the outcomes of appeals 

for its managed care programs generally, though its appeals outcome 

data did not distinguish all MLTSS-related appeals from other types of 

appeals. Finally, one state—Texas—had not previously required MCOs to 

report information about appeals outcomes, but began requiring MCOs to 

do so during the course of this study, starting in September 2016.

Two of the six states’ Medicaid agencies—in Delaware and Tennessee—

were actively involved in determining appeals outcomes. In Delaware, 

nursing staff with the state Medicaid agency reviewed each appeal and 

represented the state as a voting member on MCO panels for appeals 

decisions. In Tennessee, the state directly receives and processes all 

appeals and shares them with the MCO, which then reconsiders its 

original decision. If the MCO upholds its decision, the state completes its 

own review and determines whether to uphold or overturn the MCO’s 

decision. Officials from both states said state involvement helped the 

state identify trends in appeals and address issues, and Delaware 

officials believed that their involvement was facilitated by the relatively 

small size of the state. In the remaining four states—Arizona, Kansas, 

Minnesota, and Texas—appeals outcomes were decided by MCOs 

without state involvement, though beneficiaries in all states had the right

to request a state fair hearing, which could overturn the MCO’s decision.

States varied in the extent to which appeals resulted in MCOs’ decisions 

being upheld or reversed. In the two states where the state Medicaid 

agency was actively involved in the appeals process, a greater share of 

beneficiary appeals were resolved in favor of the beneficiary—in other 

words, a greater share of MCOs’ initial decisions were overturned—than 

in the other states. Other factors, such as the type of services being 

appealed, or the beneficiary populations included in the appeals data, 

may also affect the rate of appeals approved. (See fig. 4.)
Page 24 GAO-17-632 Medicaid Managed Care

Figure 4: Appeals Outcomes by Proportion of Appeals Upheld, Partially Overturned, 

or Overturned in Selected States, 2015

Note: This only includes appeals that were resolved, and excludes appeals that were withdrawn, 

resolved informally, or unresolved. Texas did not receive data on appeals outcomes from MCOs in 

2015. Arizona’s appeals data are not specific to MLTSS services, but include MLTSS and nonMLTSS services. Kansas’s appeals data reflect beneficiaries receiving HCBS care and do not include 

beneficiaries receiving care in institutions.
Page 25 GAO-17-632 Medicaid Managed Care

All six states reported taking compliance actions against MCOs in 

response to issues they identified that affected MLTSS beneficiaries, 

though to varying degrees.34 States identified issues through their MCO 

monitoring efforts and other means. States took various actions to resolve 

those issues, ranging from warning letters or notices to MCOs to financial 

penalties. For example, in Delaware, the state Medicaid agency issued a 

formal notice to an MCO about deficiencies the state identified in its 

quarterly reviews of beneficiaries’ medical charts. Delaware found 

deficiencies with respect to beneficiary contact with behavioral health 

providers, and difficulty in scheduling timely coordination of care 

meetings. Arizona assessed financial penalties in response to an MCO’s 

failure to coordinate medically necessary transportation. The state 

identified the issue through hundreds of beneficiary grievances related to 

transportation services, which the state tracked to a transportation 

provider that served MLTSS and other beneficiaries. The prevalence of 

compliance actions varied across our selected states; some states, for 

example, reported over 20 instances in which they required MCOs to 

submit corrective action plans to address issues that affected MLTSS 

beneficiaries, while other states reported using few corrective action plans 

from 2013 through 2015.

 34We requested that states provide the number of compliance actions—specifically 

including warning letters or notices to MCOs, corrective action plans, or intermediate 

sanctions—issued from 2013 through 2015 for issues that affected MLTSS beneficiaries. 

These issues may not be specific to MLTSS beneficiaries, and may not have always 

included issues that affected access and quality of care. We did not assess the 

circumstances under which selected states took compliance actions, and did not assess 

whether the actions taken were appropriate.

Selected States Reported 

Using Different Types of 

Compliance Actions to 

Resolve Issues Affecting 

MLTSS Beneficiaries
Page 26 GAO-17-632 Medicaid Managed Care

CMS generally depends on quarterly and annual reporting requirements 

as stipulated in states’ special terms and conditions as a framework to 

monitor access and quality in their MLTSS programs.

35 CMS’s reporting 

requirements are customized for each state, and as such, the content and 

specificity of reports can vary by state. CMS officials told us that as state 

reports are received, the central and regional office staff reviews them for 

compliance with federal regulations and the state’s particular reporting 

requirements. Agency officials explained that after reviewing the state 

reports, regional office staff can contact state Medicaid officials as 

necessary with questions or concerns. CMS officials indicated that all six 

of our selected states were compliant with their reporting requirements, 

and that the agency did not request additional reports from the states 

from 2013 through 2015. Also, all of our selected states were required to 

have meetings with CMS at varying intervals, depending on the state. The 

frequency of these meetings was determined when CMS approved the 

states’ special terms and conditions, and ranged from bimonthly to 

quarterly.

While CMS has specified certain parameters for state oversight of 

MLTSS, the agency did not always require the six selected states to 

report the information needed to monitor this oversight. CMS’s 2013 

guidance for MLTSS programs highlights the 10 elements that it deems 

essential for developing and maintaining high-quality programs, which 

CMS uses when reviewing or approving state MLTSS programs. In 

particular, this guidance establishes key elements to ensure access and 

quality, including qualified providers (which includes an adequate network 

of qualified providers), participant protections (which includes appeals

 35This report focuses on the reporting requirements related to the section 1115 and 1915 

demonstrations and waivers, the most commonly used authorities for MLTSS programs. In 

addition to the reporting requirements stipulated in states’ special terms and conditions 

governing demonstration and wavier programs, CMS also depends on the managed care 

quality measurement and reporting framework that is specified in regulation and 

applicable to managed care programs across all authorities. The quality provisions in 42 

C.F.R. Subpart E provide the general framework across all of managed care for 

monitoring quality, and are reported separately from the quarterly and annual reporting 

that is outlined in each state’s special terms and conditions for their section 1115 and 

1915 demonstrations and waivers.

CMS’s Oversight 

Relied Primarily on 

State Reporting, but 

Selected States Were 

Not Always Required 

to Report Key 

Information on 

MLTSS Access and 

Quality Needed for 

CMS Oversight
Page 27 GAO-17-632 Medicaid Managed Care

and grievance processes and reporting of critical incidents), and quality.36

Further, CMS’s guidance says that states should provide reports to CMS 

to demonstrate their oversight of these elements. In addition, federal 

internal control standards stipulate that agencies conduct monitoring and 

evaluation activities. In our review of the reporting required of our 

selected states, however, we found that CMS did not require all states to 

report on certain areas related to those key elements—namely network 

adequacy, that is, the sufficiency in the number and types of long-term 

care providers serving beneficiaries in the managed care plans; critical 

incidents, which are events or situations that cause or may cause harm to 

a beneficiary’s health or welfare, such as abuse, neglect, or exploitation; 

and appeals and grievances.37 As a result, we found cases where state 

reporting did not allow CMS to assess state adherence with federal 

guidance and oversight of MLTSS access and quality.

Network adequacy. CMS did not require three of our six selected 

states—Arizona, Minnesota, and Tennessee—to regularly report 

information on network adequacy, but it did require Delaware, 

Kansas, and Texas to report such information.38 As part of states’

oversight responsibilities of MCOs, CMS requires states to ensure 

that MCOs maintain a network of providers that is sufficient to provide 

adequate access to all covered services, and includes network 

adequacy as 1 of the 10 elements it uses to review, approve and 

renew MLTSS waivers. CMS regulations direct MCOs to submit 

assurances of network adequacy to the state. However, CMS 

currently does not require that states report this information to the 

agency unless it is stipulated in the state’s reporting requirements, or 

 36Centers for Medicare & Medicaid Services, Guidance to States using 1115 

Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports 

Programs (2013). We focused our attention on these elements because, in part, they were 

directly related to access to and quality of care, and could be reviewed in the context of 

state reporting requirements.

37Centers for Medicare & Medicaid Services, Guidance to States using 1115 

Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports 

Programs (2013). Appeals and grievance processes and reporting of critical incidents are 

important to assuring participant protections.

38CMS required all six states to report that they review beneficiary access generally, but 

did not specifically require all six states to report on network adequacy. CMS officials 

noted that, under federal regulations, they have the right to request network adequacy 

information; therefore, CMS may not include it in state reporting requirements.
Page 28 GAO-17-632 Medicaid Managed Care

if CMS requests it.39 CMS officials said that the agency can request 

network adequacy information from the states, even though it may not 

be part of the reporting requirements in the states’ special terms and 

conditions. Given that in recent years CMS has not requested that any 

of our selected states provide additional information, including 

network adequacy assurances, the agency may miss potential 

network adequacy issues in states where there are no specific 

reporting requirements. Without ongoing monitoring of network 

adequacy, CMS may not be able identify when enrollment or other 

trends begin to erode beneficiary access to MLTSS.

Critical incidents reports. CMS required three of our six states—

Delaware, Kansas, and Minnesota—to submit analyses or summaries 

of their MCOs’ critical incidents reports, but did not require the other 

three states—Arizona, Tennessee, and Texas—to do so. Even though 

Delaware was required to submit information on critical incidents, in 

our review of two of the state’s 2015 quarterly reports, we did not find 

summaries or data on critical incidents. In addition, Delaware’s annual 

report did not provide any information on critical incidents in the state, 

but described how the state collects and tracks critical incidents and 

their outcomes on a monthly basis. This gap in Delaware’s reporting, 

and the lack of a requirement to report in Arizona, Tennessee, and 

Texas, means that CMS cannot directly monitor the degree to which 

critical incidents are occurring in these states or how the states are 

tracking and resolving incidents that involve reports of abuse, neglect, 

or exploitation of vulnerable beneficiaries.

Appeals and grievances. CMS required all states to report 

information on complaints or problems reported by consumers, of 

which appeals and grievances are an important part. However, the 

level of detail CMS required from each state varied. For example, 

CMS’s reporting requirements for Delaware, Kansas, and Minnesota 

specifically included a request for MCO appeals and grievance reports 

with outcomes or overturn rates, which represent the extent that 

MCOs reverse their decisions to deny certain services, and which can 

indicate potential access problems. However, for the other states, 

Arizona, Texas, and Tennessee, CMS only requires that they report a 

 39Starting in 2018, states will be required to provide assurance to CMS at least annually 

that the state has reviewed network adequacy data and performed an analysis to validate 

that the network is sufficient. To foster alignment of state’s managed care activities related 

to network adequacy, CMS has also incorporated the state’s adequacy and availability of 

services standards as a required element of the state’s managed care quality strategy.
Page 29 GAO-17-632 Medicaid Managed Care

summary of the types of complaints or grievances that consumers 

identified about the program in a quarter, including any trends, 

resolutions of complaints or grievances, and any actions taken or 

planned to prevent other occurrences. In addition, CMS included 

language in Texas that required the state to report on appeals, but not 

necessarily appeals outcomes. A lack of specificity in the reporting 

requirements may result in CMS not receiving necessary information 

on beneficiary appeals and grievances. For example, CMS’s use of 

such a broad reporting requirement yielded the following reporting 

responses from the three states:

• Arizona provided appeals and grievance summaries for two 

specific programs, but not for the MLTSS population as whole.40

CMS officials acknowledged that the grievance and appeals data 

included in Arizona’s quarterly and annual reports were only for 

those two programs, which aligned with reporting requirements in 

the state’s special terms and conditions. CMS officials told us that 

they can request additional reports from states at any time, but 

they had not done so.41

• Texas did not require its MCOs to report appeals outcomes as of 

April 2016. However, Texas officials indicated that as of 

September 2016, they began to require MCOs to report appeals 

outcomes.

• Tennessee provided appeals data including appeals outcomes in 

its quarterly report.

As noted earlier, a number of selected states examined MLTSSrelated appeals and grievance data—including the rates and 

categories of appeals and grievances by managed care plans, as well 

as appeals outcomes—to identify potential areas for greater MCO 

oversight. Even though the rates of appeals or grievances were 

available in four of our selected states, CMS did not require any of the 

states to report them. Furthermore, without requiring states to report 

readily available information on the rates of appeals and grievances 

 40Arizona is required to report appeals and grievances for two programs—Child 

Rehabilitative Services and Individuals with Serious Mental Illness; individuals in these 

programs may or may not also receive MLTSS.

41CMS officials also said that Arizona’s EQRO should be reviewing policies and 

procedures for appeals and grievances, including potentially reviewing a sample of 

appeals and grievances as part of their recurring annual review. As the state must submit 

a summary of the EQRO report to CMS, this could be a mechanism though which they 

obtain appeals and grievance data.
Page 30 GAO-17-632 Medicaid Managed Care

and appeals outcomes, CMS may not be able to identify trends in 

consumer complaints and denied appeals in a timely manner, and 

may not be able to identify MCOs that may be inappropriately 

reducing or denying services. 

We also found cases where CMS’s reporting requirements lacked detail, 

which may have limited the usefulness of the information states provided 

in certain sections of their reports. Although CMS required all of our 

selected states to report on “events that may affect access to care” (see 

sidebar), as well as quality assurance efforts, the requirements were 

broadly written, and as such, they may not garner the information needed 

for CMS to monitor access and quality. For example, CMS used the 

same, or similar, statement to indicate that all states should report on 

quality assurance efforts: “Identify any quality assurance and monitoring 

activities in the quarter.” In response to this, we found that four states 

reported general descriptions of their planned and ongoing quality 

assurance activities for MLTSS or their comprehensive managed care 

programs as a whole, and often repeated the same or similar information 

in subsequent quarterly reports.42 For example, in Minnesota’s quarterly 

reports, the state provided little information about its quality assurance 

efforts other than a description of how the state has a team that meets 

twice a year to review and analyze performance measure and

remediation data. Furthermore, the same information is repeated in 

multiple quarterly reports.

In discussions with CMS about the differences in reporting requirements 

stipulated in the special terms and conditions for states’ MLTSS programs 

in our review, and about the broad language used for certain elements 

that are key to monitor MLTSS access and quality, agency officials told us 

that, apart from annual requirements related to quality strategies and 

 42Also, as part of the required external quality review process in which states assess the 

quality of care MCOs provided to MLTSS and other beneficiaries in managed care, states 

contract with an EQRO to produce an annual external quality review technical report. 

According to CMS, these reports could provide significant insight about changes in the 

quality of care for MLTSS. CMS may request the EQRO reports from the states if it needs

them. CMS officials commented that since 2014 the agency has requested states submit 

all EQRO technical reports for data abstraction and inclusion in CMS’s annual quality 

reporting obligations. Starting on July 1, 2018, states will be required to post the EQRO 

reports on their websites. See Medicaid and Children’s Health Insurance Program (CHIP) 

Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions 

Related to Third Party Liability, 81 Fed. Reg. 27498 (May 6, 2016).

Example of One State’s Reporting 

Requirements on Events That May Affect 

Access to Care 

Events occurring during the quarter or 

anticipated to occur in the near future that 

affect health care delivery, including but not 

limited to: systems and reporting issues, 

approval and contracting with new plans; 

benefits; enrollment; grievances; proposed or 

implemented [level of care] changes; quality 

of care; changes in provider qualification 

standards; access; proposed changes to 

payment rates; health plan financial 

performance and the implementation of 

managed long-term services and supports, 

that is relevant to the demonstration; pertinent 

legislative activity; and other operational 

issues. 

Source: Excerpt from the special terms and conditions 

associated with one state’s MLTSS authority. | GAO-17-632
Page 31 GAO-17-632 Medicaid Managed Care

external quality review, CMS does not have one consistent approach for 

monitoring MLTSS programs. Instead, CMS customizes its monitoring of 

MLTSS to each state’s program to accommodate the variability among 

MLTSS programs.43 The customized approach to monitoring is reflected 

in the quarterly and annual reporting requirements in the program’s 

special terms and conditions. When asked about differences in content 

and specificity in reporting requirements for the same elements across 

states, agency officials said that these differences could be partly due to 

changes in the staff who write the reporting requirements. They also said 

that terminology of requirements may evolve as state programs age with 

later versions, reflecting more refined language. Also, states with more 

recently approved programs may have requirements that reflect lessons 

CMS staff has learned about the programs. However, any gaps in 

reporting requirements, and gaps in state reporting from what CMS has 

required, may mean that CMS does not always have the data to monitor 

key aspects of MLTSS access and quality among selected states and 

may be unable to reliably detect state or MCO practices that do not meet 

CMS’s guidance. See sidebar for an example of how oversight of access 

and quality is diminished when CMS does not obtain necessary 

information.

The new 2016 managed care final rule will require states to report 

annually on their managed care programs, beginning one year following 

the release of new CMS guidance. The managed care rule specifies that 

annual reports must include, among other things: appeals, grievances, 

and state fair hearings; access and availability of services; MCO 

performance on quality measures; and results of any corrective action 

plans, sanctions, or other actions taken by the states.44 At the time of our 

review, the specific requirements were not yet known, including whether 

states would need to address MLTSS programs separately from 

managed care programs for acute care services, which have different 

 43As discussed previously, CMS has consistent annual reporting requirements for quality 

strategies and external quality review as specified in regulation for all managed care 

programs, including those not specifically for MLTSS. CMS regulations and guidance 

include reporting requirements for MCO performance on quality measures for states’ 

quality strategies and EQROs. For example, CMS has provided guidance on a quality 

strategy checklist for states, which will remain in effect until the quality strategy provisions 

of the 2016 managed care rule become effective.

44States will also be required to post the annual reports publicly on their websites. 

The Centers for Medicare & Medicaid 

Services’ (CMS) Onsite Review of 

KanCare.

In response to hundreds of complaints from 

beneficiaries, providers, and advocates voiced 

directly to CMS between late 2015 and mid2016, in October 2016, the agency conducted 

a detailed, on-site review of KanCare, 

Kansas’s comprehensive managed care 

program that includes managed long-term 

services and supports (MLTSS). For this 

review, CMS requested documentation from 

the state beyond what the state is required to 

report—such as managed care organization 

(MCO) oversight policies and procedures. The 

agency also reviewed information on specific 

complaints, and met with state officials in 

multiple state agencies to discuss overarching 

concerns and to remediate individual 

complaints.

As a result of this review, CMS found 

systemic, longstanding program deficiencies 

in Kansas’s state oversight that it had not 

previously identified from the information 

obtained through the state’s required 

reporting. Specifically, CMS found that the 

Kansas state agency was substantively out of 

compliance with federal statutes and 

regulations as well as with its approved state 

plan, and that this noncompliance “placed the 

health, welfare, and safety of KanCare 

beneficiaries at risk and required immediate 

action.” CMS also found that Kansas’s state 

agency’s oversight of its MCOs had 

diminished since the beginning of its 

operation, that it did not seem to be analyzing 

access to care reports, and that it did not have 

a comprehensive system for reporting and 

tracking critical incidents, among other issues.

As of July 2017, Kansas was implementing a 

corrective action plan to address these issues.

Source: January 13, 2017 letter from CMS to Kansas 

Department of Health and Environment, and GAO interview

with CMS officials. | GAO-17-632
Page 32 GAO-17-632 Medicaid Managed Care

networks of providers. As of July 2017, HHS had not yet issued guidance

clarifying the format of the annual reports.

45

Using managed care to deliver long-term services and supports offers 

states an opportunity to allow Medicaid beneficiaries with significant 

health needs to live and receive care in the setting of their choice, expand

access to home and community-based care, and provide such care at a 

potentially lower cost than institutional care. Although states’ increasing 

use of MLTSS can yield benefits for improved access to quality care, it 

also heightens the importance of federal and state oversight, which is 

critical to ensure that the potentially vulnerable populations served by 

these programs—such as the elderly and adults with physical or 

developmental disabilities—are able to obtain the care they need, when 

they need it. States rely on MCOs to coordinate MLTSS care, but remain 

responsible for monitoring beneficiaries’ access to and quality of care. 

Along with the states, CMS plays an important role in establishing 

requirements for MLTSS programs and overseeing states’ programs. To 

monitor MLTSS programs, CMS relies in large part on states’ reports on 

different aspects of their programs. CMS’s reporting requirements are 

critical to CMS’s oversight because they establish the foundation for the 

information CMS will receive about MLTSS programs and the 

beneficiaries they serve. However, on the basis of our review, CMS’s 

requirements for state reporting do not always include key elements 

necessary for the agency to monitor certain key aspects of MLTSS 

beneficiaries’ access and quality of care, including data related to appeals 

and grievances, network adequacy, and critical incident tracking. As a 

result, these requirements do not ensure CMS has information for all of 

the key areas identified in its 2013 guidance for MLTSS. Without state 

reporting requirements that provide CMS with necessary information on 

MLTSS programs, CMS’s ability to monitor programs, identify potential 

problems, and take action as needed, may be limited.

To improve CMS’s oversight of states’ MLTSS programs, we recommend 

that the Administrator of CMS take steps to identify and obtain key 

information needed to oversee states’ efforts to monitor beneficiary 

access to quality services, including, at a minimum, obtaining information 

 45In December 2016, in commenting on a draft of our report examining MLTSS ratesetting, HHS said that it intended to release guidance clarifying the format of the annual 

reports. See GAO-17-145.

Conclusions

Recommendation
Page 33 GAO-17-632 Medicaid Managed Care

specific to network adequacy, critical incidents, and appeals and 

grievances.

We provided a draft of this report to HHS for comment. In its comments, 

which are reprinted in appendix II, HHS concurred with our 

recommendation and described certain of its efforts to address it. HHS 

also stated that it is in the process of reviewing its May 2016 Medicaid 

managed care regulations in order to prioritize beneficiary outcomes and 

state priorities, and will take our recommendation into consideration as 

part of that review. HHS stated that it takes seriously its effort to oversee 

access and quality in MLTSS programs and that it shares responsibility 

with states to protect beneficiaries. HHS also provided technical 

comments, which we incorporated as appropriate. 

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 to the Secretary of Health 

and Human Services, the Administrator of CMS, the Administrator of the 

Administration for Community Living, appropriate congressional 

committees, and other interested parties. In addition, the report will be 

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 at iritanik@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 that made key contributions to 

this report are listed in appendix III.

Katherine M. Iritani

Director, Health Care

Agency Comments 

and Our Evaluation
Appendix I: Characteristics of States’ MLTSS 

Programs Selected for Our Review

Page 34 GAO-17-632 Medicaid Managed Care

Our six selected states—Arizona, Delaware, Kansas, Minnesota, 

Tennessee, and Texas—have managed long-term services and supports 

(MLTSS) programs that varied across a number of characteristics, such 

as program start year, cost, and enrollment. For example, the MLTSS 

programs in Delaware and Kansas both began within the last five years, 

while the MLTSS program in Arizona began over 25 years ago. In 

addition, in 2015, total capitated payments to managed care 

organizations (MCO) for MLTSS, as reported by the six states, ranged 

from $438.9 million in Delaware to $3.6 billion in Texas. Also, the number 

of MLTSS beneficiaries reported by the states ranged from 6,340 

beneficiaries in Delaware to almost 98,000 beneficiaries in Texas. (See 

table 2.) The number of beneficiaries in some programs has changed in 

recent years. For example, between 2013 and 2015, Texas increased the 

number of MLTSS beneficiaries by over 145 percent, after the state 

expanded its community-based MLTSS program to rural areas in 2014 

and began including beneficiaries receiving nursing facility care in the 

program in 2015.

Appendix I: Characteristics of States’ MLTSS 

Programs Selected for Our Review
Appendix I: Characteristics of States’ MLTSS 

Programs Selected for Our Review

Page 35 GAO-17-632 Medicaid Managed Care

Table 2: Characteristics of Managed Long-Term Services and Supports (MLTSS) Programs in Selected States, 2015

State

Program 

start year

Current program 

authority

Total capitated 

payments to managed 

care organizations 

(MCO) for 

beneficiaries receiving 

MLTSS 

(dollars in millions)

Number of 

beneficiaries 

receiving MLTSS

Number of MCOs 

under contract

Contract 

period

Arizona 1989 Section 1115 

demonstration

1,570.3 55,475 Three MCOs

One state agency

5 years

1 year with state 

agency

Delaware 2012 Section 1115 

demonstration

438.9 6,340 Two MCOs 3 years, plus 2 

option years

Kansas 2013 Section 1115 

demonstration with 

section 1915(c) 

waivers

1,272.6 33,255 Three MCOs 3 years, plus 2

option years

Minnesota 1997 and 

2005 (two 

programs)

Section 1915(a)/(c) 

and section 

1915(b)/(c) waivers

636.0 33,185 Seven MCOs 1 year

Tennessee 2010 Section 1115 

demonstration

1,488.1 30,166 Three MCOs 3 years, plus 5 

option years

Texas 1998 Section 1115 

demonstration

3,591.0 97,914 Five MCOs 3 years, plus 5 

option years

Source: GAO analysis of state-reported data, and Centers for Medicare & Medicaid Services data. | GAO-17-632

Note: Data on payments are for calendar year 2015 for all states except for Arizona, which uses the 

federal fiscal year for one program and the state fiscal year for its other program. Data on 

beneficiaries for Arizona, Delaware, Kansas, and Tennessee are as of December 2015. Data on 

beneficiaries for Minnesota represent full-year equivalents based on member months for calendar

year 2015. Data on beneficiaries for Texas represent average monthly enrollment for calendar year 

2015.
Appendix II: Comments from the Department 

of Health and Human Services

Page 36 GAO-17-632 Medicaid Managed Care

Appendix II: Comments from the Department 

of Health and Human Services
Appendix II: Comments from the Department 

of Health and Human Services

Page 37 GAO-17-632 Medicaid Managed Care
Appendix II: Comments from the Department 

of Health and Human Services

Page 38 GAO-17-632 Medicaid Managed Care
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 39 GAO-17-632 Medicaid Managed Care

Katherine M. Iritani, (202) 512-7114 or iritanik@gao.gov

In addition to the contact named above, Susan Barnidge and Leslie V. 

Gordon (Assistant Directors), Shamonda Braithwaite, Robin Burke, 

Caroline Hale, Corissa Kiyan-Fukumoto, and Laurie Pachter made key 

contributions to this report. Also contributing were Vikki Porter and Emily 

Wilson.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100347)
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