MEDICAID PERSONAL 

CARE SERVICES

More Harmonized 

Program Requirements 

and Better Data Are 

Needed

Statement of Katherine M. Iritani 

Director, Health Care

Testimony 

Before the Subcommittee on Oversight 

and Investigations, Committee on 

Energy and Commerce, 

House of Representatives

For Release on Delivery 

Expected at 10:15 a.m. ET

Tuesday, May 2, 2017

GAO-17-598T

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-598T, a testimony 

before the Subcommittee on Oversight and 

Investigations, Committee on Energy and 

Commerce, House of Representatives

May 2017

MEDICAID PERSONAL CARE SERVICES

More Harmonized Program Requirements and 

Better Data Are Needed

B

What GAO Found

In its November 2016 report, GAO found a patchwork of federal requirements 

related to how states must protect the safety of beneficiaries in their personal 

care services programs and to how states ensure that billed services are actually 

provided. Personal care services help beneficiaries with basic activities of daily 

living such as bathing and dressing, in a home- or community-based setting. For two 

types of programs under which personal care services can be offered, states 

must describe to the Centers for Medicare & Medicaid Services (CMS) how they 

will ensure the health and welfare of beneficiaries. Similar requirements were not 

in place for several other programs GAO examined. In addition, for some but not 

all personal care services programs that GAO reviewed, states must provide 

evidence to CMS that the state is paying claims for services that have actually

been provided. These differing federal program requirements result in uneven 

beneficiary safeguards and levels of assurances regarding states’ beneficiary 

protections and oversight of billed services. GAO recommended that CMS take 

steps to harmonize and achieve a more consistent application of federal 

requirements across programs. CMS agreed with GAO’s recommendation and 

sought input on how to do so by publishing a request for information.

In its January 2017 report, GAO found limitations in the data that CMS collects to 

monitor the provision of personal care services and to monitor state spending on 

services. For example:

• Data on personal care services provided were often not timely, 

complete or consistent. The most recent data available during GAO’s 

review (2016) were for 2012 and included data for only 35 states. Further, 15

percent of claims lacked provider identification numbers and 34 percent 

lacked information on the quantity of services provided. Data were also 

inconsistent as more than 400 different procedure codes were used by states 

to identify personal care services. Without timely, complete, and consistent

data, CMS is unable to effectively oversee state programs and verify who is 

providing personal care services or the type, amount, and dates of services

provided. 

• Data on states’ spending on CMS’s expenditure reports, the basis for 

states’ receipt of federal matching funds, were not always accurate or 

complete. From 2012 through 2015, 17 percent of expenditure lines were 

not reported correctly by states, according to GAO’s analysis. Nearly twothirds of these errors were due to states not separately identifying personal 

care services expenditures, as required by CMS, from other types of 

expenditures. Inaccurate and incomplete data limit CMS’s ability to, among 

other oversight functions, ensure federal matching funds are appropriate.

GAO made several recommendations to improve the data CMS collects to 

monitor the provision of and expenditures on personal care services. CMS 

agreed with some but not all of these recommendations.

View GAO-17-598T. For more information, 

contact Katherine M. Iritani at (202) 512-7114 

or iritanik@gao.gov.

Why GAO Did This Study

Medicaid, a joint federal-state health 

care program, provides long-term 

services and supports for disabled and 

aged individuals, increasingly in home 

and community settings. Federal and 

state Medicaid spending on home- and 

community-based services was about 

$80 billion in 2014. Personal care 

services are a key component of this 

care. States can offer personal care

services through many different types 

of programs, and each may be subject 

to different federal requirements

established by statute, regulations, and 

guidance. The provision of personal 

care in beneficiaries’ homes can pose 

safety risks, and these services have a 

high and growing rate of improper 

payments, including cases where 

services for which the state was billed 

were not provided. In recent years 

Congress has directed HHS to improve 

coordination of these programs which

could harmonize requirements--that is,

implement a more consistent 

administration of policies and 

procedures--and enhance oversight.

This statement highlights key issues 

regarding (1) the federal program 

requirements to protect beneficiaries’ 

safety and ensure that billed services 

are provided, and (2) the usefulness of 

data collected by CMS for oversight. 

This testimony is based on reports 

GAO issued in 2016 and 2017. For 

these reports, GAO assessed CMS 

data on personal care services

provided to beneficiaries and state 

spending. GAO also reviewed federal 

statutes, regulations, and guidance, 

and interviewed CMS officials.
Letter

Page 1 GAO-17-598T Medicaid Personal Care Services

Chairman Murphy, Ranking Member DeGette, and Members of the 

Subcommittee:

I am pleased to be here today as you examine the personal care services 

benefit available under Medicaid, the federal-state health financing 

program for low-income and medically needy individuals. Medicaid is the 

nation’s primary payer of long-term care services and supports for 

disabled and aged individuals who may need care for an extended period 

of time. Personal care services are a significant and important component 

of Medicaid’s long-term care services and supports. Personal care 

services provide assistance to beneficiaries of all ages who have limited 

ability to care for themselves because of physical, developmental, or 

intellectual disabilities, helping them with activities of daily living such as 

bathing, dressing, and toileting. Such assistance can enable disabled and 

aged beneficiaries to remain in their homes, maintain their independence, 

and participate in community life to the fullest extent possible.

Medicaid spending on long-term care services and supports is significant, 

representing more than one-quarter of Medicaid spending annually. The 

federal cost of Medicaid long-term care spending is expected to increase 

from $75 billion in 2015 to $111 billion in 2026.1 Historically, Medicaid 

spending for long-term care has been largely for services provided in 

institutional settings, such as nursing homes. In recent years, this trend 

has changed and the majority of federal and state spending has shifted 

towards home- and community-based services (HCBS)—that is, services 

and assistance provided to beneficiaries in their homes or other settings 

integrated with their communities.2 As a result of the aging of the nation’s 

population and increased opportunities for aged and disabled individuals 

to live in their homes instead of institutions, the demand for and spending 

on HCBS and personal care services is expected to increase.

Although personal care services are an important support for Medicaid 

beneficiaries, provision of these services is not without risk, both for 

beneficiary safety and for improper Medicaid payments. Beneficiaries 

receiving personal care services include aged individuals and individuals 

with physical, developmental, or intellectual disabilities, some of whom 

 1

Congressional Budget Office, Detail of Spending and Enrollment for Medicaid for CBO’s 

March 2016 Baseline (Washington, D.C.: 2016).

2

See Truven Health Analytics, Medicaid Expenditures for Long-Term Services and 

Supports in FY 2013 (June 30, 2015).

Letter
Page 2 GAO-17-598T Medicaid Personal Care Services

can be vulnerable. Also, when personal care services are provided in a 

private home, other providers or community members may not be present 

to help discourage or report on questionable activities. These factors can 

result in some beneficiaries being at risk of unintentional harm and 

potential neglect and exploitation. A beneficiary’s capacity to manage 

finances and secure possessions may decline with age, onset of 

dementia, or other cognitive disabilities, and put them at risk of theft or 

financial exploitation from unscrupulous attendants.3 Moreover, 

depending on the particular state and Medicaid program, personal care 

attendants who provide services may not be required to have a credential 

from an organization that trains workers for certain qualifications. The 

provision of personal care services is also at high risk for Medicaid 

improper payments, including instances where services for which the 

state was billed were not provided. The Centers for Medicare & Medicaid 

Services (CMS), an agency within the U.S. Department of Health and 

Human Services (HHS), estimated that about 12 percent of all states’

payments for personal care services in 2015 were improper—twice the 6 

percent error rate estimated for 2014—and that the projected dollar 

amount of payment errors was over $3.6 billion, up from $2 billion 

estimated for 2014.4

 3

GAO, Elder Justice: National Strategy Needed to Effectively Combat Elder Financial 

Exploitation, GAO-13-110 (Washington, D.C.: Nov. 15, 2012). In addition, the HHS Office 

of Inspector General has issued reports that documented cases of beneficiary neglect. 

See U.S. Department of Health and Human Services Office of Inspector General, 

Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care 

Services, Memo to Vikki Wachino, Deputy Administrator and Director, Center for Medicaid 

and CHIP Services, Centers for Medicare & Medicaid Services (Washington, D.C.: Oct. 3, 

2016).

4

Centers for Medicare & Medicaid Services (CMS), Medicaid and CHIP 2015 Improper 

Payments Report, (Washington, D.C.: 2016). These figures represent spending on a feefor-service basis only and exclude claims paid as part of a managed care arrangement. 

An improper payment is defined by statute as any payment that should not have been 

made or that was made in an incorrect amount (including overpayments and 

underpayments) under statutory, contractual, administrative, or other legally applicable 

requirements. It includes any payment to an ineligible recipient, any payment for an 

ineligible good or service, any duplicate payment, payment for a good or service not 

received (except for such payments where authorized by law), and any payment that does 

not account for credit for applicable discounts. Improper Payments Elimination and 

Recovery Act of 2010, Pub. L. No. 111-204, § 2(e), 124 Stat. 2224, 2227 (2010) (codified 

at 31 U.S.C. § 3321 note). Additionally, Office of Management and Budget guidance 

instructs agencies to report as improper payments any payments for which insufficient or 

no documentation was found.
Page 3 GAO-17-598T Medicaid Personal Care Services

As the agency overseeing Medicaid at the federal level, CMS is 

responsible for overseeing state Medicaid programs, including protecting 

Medicaid fiscally from improper payments, ensuring that all beneficiaries 

are protected, and collecting data from states on Medicaid spending for 

services, and the types and volume of services provided, to carry out its 

oversight responsibilities. CMS also provides states with guidance on 

federal program requirements. Personal care services can be provided 

under many different authorities under Medicaid, and states have 

developed many different types of programs for delivering personal care 

and other home- and community-based services. In recent years, 

Congress has directed HHS to improve coordination of these programs, 

which could harmonize requirements—that is, implement a more 

consistent administration of policies and procedures. Specifically, in 2010 

Congress required HHS to take steps to improve the coordination among, 

and regulation of all, providers of home- and community-based services 

to achieve a more consistent administration of policies and procedures 

across programs.5

We issued a report in each of 2016 and 2017 examining the federal 

oversight of Medicaid personal care services provided by state Medicaid 

programs.6 My remarks today are based primarily on these two reports 

and will focus on our assessment of:

1. federal program requirements to ensure the safety of Medicaid 

beneficiaries receiving personal care services and to ensure that 

billed services are actually provided; and

2. the extent CMS collects data that can be used to monitor the provision 

of and spending on personal care services by state Medicaid 

programs.

My remarks on the federal program requirements to ensure the safety of 

Medicaid beneficiaries and to ensure that billed services are provided are 

based on our 2016 report. For that report, we reviewed applicable federal 

laws, regulations, and guidance, including state reporting requirements 

specific to Medicaid personal care services programs. We also reviewed 

 5

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2402(a), 124 Stat. 

119, 301-302 (2010).

6

See GAO, Medicaid Personal Care Services: CMS Could Do More to Harmonize 

Requirements across Programs, GAO-17-28 (Washington, D.C.: Nov. 23, 2016) and 

GAO, Medicaid: CMS Needs Better Data to Monitor the Provision of and Spending on 

Personal Care Services, GAO-17-169 (Washington, D.C.: Jan. 12, 2017).
Page 4 GAO-17-598T Medicaid Personal Care Services

personal care services programs in four states, selected to include 

variation in the types of such programs. In addition, we reviewed reports 

by CMS and HHS Office of the Inspector General relating to personal 

care services and interviewed CMS officials. My remarks on the data 

CMS collects on Medicaid personal care services are based on our 2017 

report. For that report, we analyzed data collected by CMS on personal 

care services provided to beneficiaries and on state Medicaid spending 

on those services. For services provided, we analyzed Medicaid provider 

claims and managed care encounter data for calendar year 2012—the 

most recent and complete data available at the time of our 2016 

analysis—for 35 states that had finalized 2012 data.7 For spending, we 

also analyzed Medicaid expenditure data for all 50 states and the District 

of Columbia for calendar years 2012 through 2015.8 Additional 

information on our scopes and methodologies are included in the 2016 

and 2017 reports.

We conducted the work on which this statement is based 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.

Medicaid is jointly financed by the federal government and the states, with 

the federal government matching most state Medicaid expenditures using 

 7

Each state transmits digital files with the claims and encounter data to CMS using the 

Medicaid Statistical Information System. This system is designed to provide CMS with a 

detailed, national database of Medicaid program information to support a broad range of 

program management functions, including health care research and evaluation, program 

utilization and spending forecasting, and analyses of policy alternatives. CMS developed a 

research-friendly data set called the Medicaid Analytic eXtract (MAX), which is a set of 

beneficiary-level data files derived from state-submitted MSIS claims data on Medicaid 

eligibility, service utilization, and payments. We used MAX data to analyze claims for 

personal care services because they are more reliable and consistent than states’ 

quarterly MSIS reports. For purpose of this report we refer to MAX data as MSIS data 

because MAX is based on state MSIS data submissions.

8

States must submit their Medicaid expenditures quarterly to CMS using the web-based 

Medicaid Budget and Expenditure System.

Background

Medicaid Program
Page 5 GAO-17-598T Medicaid Personal Care Services

a statutory formula that determines a federal matching rate for each state. 

Medicaid is a significant component of federal and state budgets, with 

estimated total outlays of $576 billion in fiscal year 2016, of which $363 

billion is expected to be financed by the federal government and $213 

billion by the states. Medicaid served about 72 million individuals, on 

average, during fiscal year 2016.9

As a federal-state partnership, both the federal government and the 

states play important roles in ensuring that Medicaid is fiscally sustainable 

over time and effective in meeting the needs of the populations it serves. 

States administer their Medicaid programs within broad federal rules and 

according to individual state plans approved by CMS, the federal agency 

that oversees Medicaid.

Federal matching funds are available to states for different types of 

payments that states make, including payments made directly to 

providers for services rendered under a fee-for-service model and 

payments made to managed care organizations:

• Under a fee-for-service delivery model, states make payments directly 

to providers; providers render services to beneficiaries and then 

submit claims to the state to receive payment. States review and 

process fee-for-service claims and pay providers based on stateestablished payment rates for the services provided.

• Under a managed care delivery model, states pay managed care 

organizations a set amount per beneficiary; providers render services 

to beneficiaries and then submit claims to the managed care 

organization to receive payment. Managed care plans are required to 

report to the states information on services utilized by Medicaid 

beneficiaries enrolled in their plans—information typically referred to 

as encounter data.

Most states use both fee-for-service and managed care delivery models, 

although the number of beneficiaries served through managed care has 

grown in recent years.

Federal law requires each state, under both fee-for-service and managed 

care delivery models, to operate a claims processing system to record 

 9

Expenditure and enrollment data are from Department of Health and Human Services, 

Centers for Medicare & Medicaid Services, Office of the Actuary, 2016 Actuarial Report on 

the Financial Outlook for Medicaid (2017).
Page 6 GAO-17-598T Medicaid Personal Care Services

information about the services provided and report this information to 

CMS:

• Provider claims and managed care encounter data are required to 

include information about the service provided, including the general 

type of service; a procedure code that identifies the specific service 

provided; the location of the service; the date the service was 

provided; and information about the provider who rendered the 

service (e.g., provider identification number).

• Fee-for-service claims records must include the payment amount. 

Federal law requires states to collect managed care encounter data, 

but actual payment amounts to individual providers are not required.

Long-term services and supports financed by Medicaid are generally 

provided in two settings: institutional facilities, such as nursing homes and 

intermediate-care facilities for individuals with intellectual disabilities; and 

home and community settings, such as individuals’ homes or assisted 

living facilities. Under Medicaid requirements governing the provision of 

services, states generally must provide institutional care to Medicaid 

beneficiaries, while HCBS coverage is generally an optional service. 

Medicaid spending on long-term services and supports provided in home 

and community settings has increased dramatically over time—to about 

$80 billion in federal and state expenditures in 2014—while the share of 

spending for care in institutions has declined, and HCBS spending now 

exceeds long-term care spending for individuals in institutions (see fig. 

1).10 All 50 states and the District of Columbia provide long-term care 

 10Medicaid HCBS and institutional long-term care spending is roughly equal for services 

provided on a fee-for-service basis. However, when long-term care services provided 

under a managed care arrangement are included, HCBS spending exceeds institutional 

spending. Truven Health Analytics, under contract with CMS, reported that 2013 was the 

first instance of expenditures for HCBS exceeding institutional services as a percentage of 

all long-term care services—51 percent for HCBS compared to 49 percent for institutional 

services. See Truven Health Analytics, Medicaid Expenditures for Long-Term Services 

and Supports.

Long-Term Services and 

Supports, Home and 

Community Based 

Services, and Personal 

Care Services
Page 7 GAO-17-598T Medicaid Personal Care Services

services to some Medicaid beneficiaries in home and community 

settings.11

Figure 1: Percentage of Spending and Total Spending on Medicaid Long-Term Services and Supports for Institutional Care 

and Home- and Community-Based Services, Fiscal Years 1994 through 2014

Personal care services, a key type of HCBS, are typically nonmedical 

services provided by personal care attendants—home-care workers who 

may or may not have specialized training. The demand for personal care 

services is expected to increase as is the number of attendants providing 

 11Changes to federal Medicaid law in the last 35 years have expanded states’ options for 

providing long-term care services and supports, including personal care services, in home 

and community settings. Factors driving these changes may include the desire and 

increased ability of beneficiaries who are aged and disabled to live in their homes and 

communities and the Supreme Court’s 1999 Olmstead decision, which held that states 

must serve individuals with disabilities in community-based settings under certain 

circumstances. Olmstead v. L.C., 527 U.S. 581 (1999).
Page 8 GAO-17-598T Medicaid Personal Care Services

these services in coming years.12 The number of Medicaid beneficiaries 

receiving personal care services at this time is not known, but likely in the 

millions. In calendar year 2012, the most recent and complete available 

data, an estimated 1.5 million beneficiaries in the 35 states reporting at 

the time received personal care services at least once.13 Total Medicaid 

spending for personal care services is also not known, as spending in 

managed care delivery systems is not reported by service. Total Medicaid 

spending for personal care services in fee-for-service delivery systems 

was about $15 billion in FY 2015.

With approval from CMS, states can choose to provide personal care 

services under one or more types of authorities (referred to in this 

statement as programs) put in place over the past 41 years under 

different sections of the Social Security Act. The various types of 

programs provide states with options for permitting participant direction 

and choices about how to limit services, among other things (see table 1).

Table 1: Types of Programs under Which States Can Provide Medicaid Personal Care Services

Program name

(Year)

Number of states 

administering 

personal care 

services through 

program Authorizing statute and program description

State Plan Personal Care 

Services

(Implemented in 1975)

25 Starting in 1975, states have had the option of offering personal care services 

as a Medicaid State plan benefit. In its present form, section 1905(a)(24) of the 

Social Security Act, enacted in 1993, authorizes states to provide personal care 

services as a covered service in their state Medicaid plans. State Plan personal 

care services can serve beneficiaries who need an institutional level of care or 

those who do not need an institutional level of care. States must provide 

services to all eligible beneficiaries and cannot limit the number covered or use 

waiting lists.

 12Overall, the number of personal care attendants employed is projected to increase by 26 

percent from 2014 to 2024, growing from 1,768,400 in 2014 to 2,226,500 in 2024. The 26 

percent rate of growth is much faster than the projected national average for all

occupations of 7 percent. See U.S. Department of Labor, Bureau of Labor Statistics, 

Occupational Outlook Handbook, 2016-17 Edition (2016).

13See GAO-17-169.

Types of Personal Care 

Services Programs
Page 9 GAO-17-598T Medicaid Personal Care Services

Program name

(Year)

Number of states 

administering 

personal care 

services through 

program Authorizing statute and program description

Home- and CommunityBased Services (HCBS) 

Waiver

(Enacted in 1981)

48 Section 1915(c) of the Social Security Act authorizes states to seek waivers of 

certain traditional Medicaid requirements in order to provide HCBS, including 

personal care services. For example, the Secretary of HHS can waive the 

requirement that the state provide services statewide to eligible beneficiaries. 

States can choose to provide any of a specified range of services to eligible 

beneficiaries including personal care services, case management, habilitation, 

and respite care.a Only beneficiaries who need an institutional level of care are 

eligible. CMS can waive certain federal requirements, allowing states to target 

services to specific groups and limit the number of beneficiaries served.

State Plan HCBS

(Enacted in 2006)

4 Section 1915(i) of the Social Security Act authorizes states to provide any of the 

same range of services as available under HCBS Waivers, including personal 

care services. Unlike HCBS Waiver programs, states have the option to cover 

beneficiaries who need an institutional level of care, but must provide services 

to beneficiaries who do not require an institutional level of care. States can 

target services to specific groups of beneficiaries but may not limit access to 

services based upon the cost of services or the income or location of eligible 

beneficiaries.

Participant-Directed 

Option

(Enacted in 2006)

9 Section 1915(j) of the Social Security Act gives states additional options for the 

delivery of personal care services and other services. The Participant-Directed 

Option is not a stand-alone program but, instead, must be offered in conjunction 

with either State Plan personal care services or HCBS Waiver. States can offer 

beneficiaries the option to receive individual budgets to pay for personal care 

services and other services. Beneficiaries may also be permitted to compensate 

a legally liable relative, such as a spouse or a parent, for personal care 

services. States are permitted to limit the number of beneficiaries served and to 

target services to specific groups. Beneficiaries can be eligible for an 

institutional level of care or not.

Community First Choice

(Enacted in 2010)

8b Section 1915(k) of the Social Security Act authorizes states to provide personal 

care services and a range of services. States must provide services to all 

beneficiaries who are eligible. Only beneficiaries who would otherwise need an 

institutional level of care are eligible. States receive a 6 percentage point 

enhanced federal match for all services provided under Community First Choice 

programs.

Source: Social Security Act, Title XIX and CMS. | GAO-17-598T

a

Case management is a service that assists Medicaid recipients in gaining access to needed medical, social, educational, and other 

services. Habilitation services help beneficiaries to acquire or improve skills to become more independent. Respite care provides a 

range of services to beneficiaries when unpaid caregivers are absent or need relief.

b

The number of states with a Community First Choice program is current as of September 2016.

CMS has implemented the different statutory requirements associated 

with these various program types by issuing regulations, as well as 

guidance to help states implement their Medicaid programs in accordance 

with applicable statutory and regulatory requirements. Guidance can 

include letters to state Medicaid directors, program manuals, and 

templates to help states apply for CMS approval to provide certain 

services like personal care. Together with federal statutes, the regulations 
Page 10 GAO-17-598T Medicaid Personal Care Services

and guidance issued by CMS establish a broad federal framework for the 

provision of personal care services. States are responsible for 

establishing and administering specific policies and programs within the 

federal parameters laid out in this framework.

In our 2016 report examining the federal program requirements for the 

multiple programs under which personal care services are provided, we 

found significant differences in federal requirements related to beneficiary 

safety and ensuring that billed services are provided.14 These differences 

may translate to differences in beneficiary protections across program 

types. Program requirements can include general safeguards for ensuring 

beneficiary health and welfare, quality assurance measures, critical 

incident monitoring, and attendant screening. For example, states 

implementing an HCBS Waiver program or a State Plan HCBS program 

must:

• Describe to CMS how the state Medicaid agency will determine that it 

is assuring the health and welfare of beneficiaries. To do so, states 

must describe: the activities or processes related to assessing or 

evaluating the program; which entity will conduct the activities; the 

entity responsible for reviewing the results of critical incident 

investigations; and the frequency at which activities are conducted.

• Demonstrate to CMS, by providing specific details that an incident 

management system is in place, including incident reporting 

requirements that establish the type of incidents that must be 

reported, who must report incidents, and the timeframe for reporting.

In contrast, states implementing a State Plan personal care services 

program or a Community First Choice program have fewer requirements 

for beneficiary safeguards. For example, for these programs, states are

not required to do the following:

• Provide CMS with detailed information describing the activities they 

are taking to assure the health and welfare of beneficiaries.

 14For purposes of this analysis, we reviewed regulations specific to personal care 

services, which appear at 42 C.F.R. Parts G, J, K, and M, as well as any personal care 

service-specific guidance issued by CMS. We did not review regulations or guidance of 

general applicability, such as program integrity requirements set forth in 42 C.F.R. part 

455, because changes to these requirements would affect services beyond those provided 

under personal care services programs.

Federal Program 

Requirements for 

Maintaining 

Beneficiary Safety 

and Ensuring That 

Billed Services Are 

Provided Differ 

Significantly
Page 11 GAO-17-598T Medicaid Personal Care Services

• Demonstrate to CMS specific details about their critical incident 

management process and incident reporting system; instead they are

required to describe more generally their “process for the mandatory 

reporting, investigating and resolution of allegations of neglect, abuse, 

or exploitation.”15

Table 2 below illustrates more broadly the differences in federal program 

requirements that establish beneficiary safeguards and protections that 

we identified in our 2016 report.

Table 2: Federal Medicaid Personal Care Services Program Requirements on Safeguarding Beneficiaries, by Program Type, 

as of November 2016

Personal Care Services Program Typea

Requirements for statesb

State Plan 

personal care 

services

State Plan 

Home- and 

CommunityBased Services 

(HCBS) HCBS Waivers

Community 

First Choice

General health and welfare

Assure necessary safeguards have been taken to protect 

the health and welfare of beneficiaries ○ ● ● ●

Describe health and welfare safeguards ○ ● ● ●

Measure and improve performance in meeting assurances ○ ● ● ○c

Submit performance measurement evidence to determine 

whether or not an assurance has been met ○ ○ ● ○c

Annually report on the impact of the program on the health 

and welfare of recipients ○ ○ ● ●d

Assure that interventions and supports will cause no harm 

to the individual ○ ● ● ●e

The beneficiaries’ plan of care must reflect risk factors and 

measures in place to minimize these factors, including 

back-up plans when needed. 

○ ● ● ●

Quality assurance related to health and welfare

Quality assurance (general) ● ● ● ●

Quality assurance system that continuously monitors health 

and well-being ○ ● ● ●

Quality improvement strategy to measure individual 

outcomes ○ ● ● ●

Critical incidents

 15See, for example, 42 C.F.R. § 441.585(a)(2) (2016). 
Page 12 GAO-17-598T Medicaid Personal Care Services

Personal Care Services Program Typea

Requirements for statesb

State Plan 

personal care 

services

State Plan 

Home- and 

CommunityBased Services 

(HCBS) HCBS Waivers

Community 

First Choice

Quality assurance and improvement plan must identify 

critical incidents ○ ● ● ●

Quality assurance system must include a process for the 

mandatory reporting, investigation, and resolution of 

allegations of critical incidents

○ ○ ○ ●

Demonstrate that on an ongoing basis, the state identifies, 

addresses and seeks to prevent instances of abuse, neglect, 

exploitation, and unexplained death

○ ● ● ○f

Demonstrate that an incident management system is in 

place ○ ● ● ○

Attendant Qualifications, Training, Screening, and Monitoring 

Set standards for training ○ ○ ○ ●

Develop provider qualifications or standards ● ● ● ●g

Monitor uncredentialed providers ○ ● ● ○

Legend: ● = Required ○ = Not required

Source: GAO analysis of Section XIX of the Social Security Act; Personal Care Services Regulations; CMS guidance | GAO-17-598T

a

One other type of personal care services program is called the Participant-Directed Option. It is not a 

standalone program; instead, states pair it with either State Plan personal care services or HCBS 

Waivers. The requirements of the underlying paired authority apply to programs offering the 

Participant-Directed Option.

b

For purposes of this analysis, we reviewed regulations specific to personal care services, which 

appear at 42 C.F.R. Parts G, J, K, and M, as well as any personal care services-specific guidance 

issued by CMS. We did not review regulations or guidance of general applicability, such as Medicaid 

program integrity requirements set forth in 42 C.F.R. part 455, because changes to these 

requirements would affect services beyond those provided under personal care services programs.

c

For the Community First Choice program, states describe how they measure individual outcomes in 

their state plan amendments, but there is no requirement to measure and improve program 

performance and submit evidence of such.

d

States must report on beneficiaries’ “physical and emotional health.”

e

For Community First Choice, states must assure that interventions and supports will cause no harm 

when they are provided in a setting that is owned or controlled by the provider. For HCBS Waivers 

and State Plan HCBS, states must provide this assurance regardless of the setting.

f

For Community First Choice, states must have quality assurance plans that include a process for 

reporting critical incidents, but are not required to have prevention programs.

g

This requirement applies to attendants who work for a provider agency that is approved by the state 

to provide personal care services to beneficiaries.

Differences in federal program requirements may also result in significant 

differences in the level of assurance that billed services are actually 

provided to beneficiaries. States implementing HCBS Waiver programs 

and State Plan HCBS programs, for example, are required by CMS to 

provide evidence that the state is only paying claims when services are 
Page 13 GAO-17-598T Medicaid Personal Care Services

actually rendered, while the State Plan personal care services and 

Community First Choice programs are not required to do so.

Table 3 below highlights the federal Medicaid personal care services 

program requirements that we identified in our 2016 report to ensure that 

billed services are provided for each of the different type of HCBS 

program states may administer.

Table 3: Federal Medicaid Personal Care Services Program Requirements on Ensuring Billed Services Are Provided, by 

Program Type, as of November 2016

Personal Care Services Program Typea

Requirements for states on ensuring that billed 

services are providedb

State Plan 

personal care 

services

State Plan 

Home- and 

CommunityBased 

Services 

(HCBS)

HCBS 

Waivers

Community 

First Choice

Assure financial accountability and submit to an 

independent financial audit ○ ● ● ○

Provide evidence that claims are only for services 

rendered ○ ● ● ○

Describe the processes to validate provider billings to 

help ensure that services were provided ○ ● ● ○

Monitor service delivery for participant-directed services ● ● ● ○

Legend: ● = Required ○ = Not required

Source: GAO analysis of Section XIX of the Social Security Act; Personal Care Services Regulations; CMS guidance | GAO-17-598T

a

One other type of personal care services program is called the Participant-Directed Option. It is not a 

standalone program; instead, states pair it with either State Plan personal care services or HCBS 

Waivers. The requirements of the underlying paired authority apply to programs offering the 

Participant-Directed Option.

b

For purposes of this analysis, we reviewed regulations specific to personal care services, which 

appear at 42 C.F.R. Parts G, J, K, and M, as well as any personal care service-specific guidance 

issued by CMS. We did not review regulations or guidance of general applicability, such as Medicaid 

program integrity requirements set forth in 42 C.F.R. part 455, because changes to these 

requirements would affect services beyond those provided under personal care services programs.

The four selected states we examined as part of our 2016 report used 

different methods to ensure attendants provided billed services to 

beneficiaries, according to state officials. For example, for at least some 

personal care services programs, two states required beneficiaries to sign 

timesheets, and two states used electronic visit verification timekeeping 
Page 14 GAO-17-598T Medicaid Personal Care Services

systems.16 All four states performed quality assurance reviews for some 

personal care services programs to ensure billed services are received.17

The differing federal program requirements can create complexities for 

states and others in understanding federal requirements governing 

different types of HCBS programs, including personal care services. 

These different requirements may also result in significant differences in 

beneficiary safeguards and fiscal oversight, as illustrated in the following 

examples:

• Beneficiaries may experience different health and welfare safeguards 

depending on the program in which they are enrolled. For example, in 

one state we reviewed in 2016, the state required quarterly or 

biannual monitoring of beneficiaries for most of its personal care 

services programs. In contrast, for another program, the state 

required only annual monitoring contacts, in part, officials told us, due 

to the differing program requirements.18 Depending on the program 

type, CMS may have fewer assurances that beneficiaries’ with similar 

levels of need are in programs with similar protections. For example, 

three of the four states we reviewed—Maryland, Oregon, and Texas—

have in recent years transitioned coverage of personal care services 

 16Electronic visit verification timekeeping systems are newer, technology-based systems 

that electronically record when attendants begin and end providing services to a 

beneficiary. Such systems may include features to verify the attendant’s location and 

make sure the attendant is in the beneficiary’s home.

17State quality assurance procedures help assure state Medicaid personal care services

programs are meeting quality standards and are to be implemented in compliance with 

federal and state program requirements. States design their own quality assurance

procedures in accordance with federal Medicaid personal care service requirements, 

which vary by Medicaid personal care services program and are subject to approval by 

CMS. In general, quality assurance procedures across the four states we reviewed include 

monitoring such as case file or record reviews and in-home visits to make sure required 

procedures were followed. 

18Federal internal control standards state that agencies should establish control activities 

that appropriately cover the objectives and risks of an entity’s operations. See GAO, 

Standards for Internal Controls in the Federal Government, GAO-14-704G (Washington, 

D.C.: Sept. 2014). 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. In the case of personal care services, a risk-based internal 

control process would suggest that programs protecting Medicaid beneficiaries from harm 

and ensuring that payments are made only made when services are actually provided are 

comparable across programs serving like beneficiaries. A consistent process and 

comprehensive framework for managing risk can help ensure risks are managed 

effectively, efficiently, and coherently.
Page 15 GAO-17-598T Medicaid Personal Care Services

for beneficiaries who need an institutional level of care from personal 

care services programs with relatively more stringent federal 

beneficiary safety requirements to programs with relatively less 

stringent requirements. Although they were not required to do so, 

state officials in the three states reported that the states chose to 

continue using the same quality assurance measures in the new 

programs as the best way to ensure safety for beneficiaries. Without 

more harmonized requirements, we concluded that CMS has no

assurance that states that transition personal care services from 

HCBS Waivers to Community First Choice in the future will make the 

same decisions.

• States can use different processes for each personal care services 

program to ensure that billed services are actually provided, and 

some programs may not be subject to federal personal care services 

requirements explicitly in this regard. For example, in one state we 

reviewed in 2016, steps taken to ensure billed services are provided 

under some types of personal care services programs were not 

required in another of the state’s programs.19

A report we issued in 2012 reviewing states’ implementation of different 

HCBS programs also suggested that states could benefit from more 

harmonization of program requirements. Officials in selected states we 

reviewed in 2012 noted the complexity of operating multiple programs.20

For example, officials from one state reported that the complexity resulted 

in a siloed approach, with different enrollment, oversight, and reporting 

requirements for each program. The administration and understanding of 

the programs available to beneficiaries was difficult for state staff and 

beneficiaries, according to officials in another state. The officials indicated 

that they would prefer CMS issue guidance on how states could operate 

different HCBS program types together, rather than issuing guidance on 

each program separately.

In our 2016 report, we acknowledged certain efforts CMS had taken to 

harmonize requirements and improve oversight of personal care services 

programs. However, despite these efforts, we found that significant 

 19The state reported that in one personal care services program, a supervisor must visit 

the beneficiary and document whether the attendant is delivering the authorized personal 

care services tasks. The state did not apply the same process to another of its personal 

care services programs for which there was no specific requirement in this regard.

20GAO, Medicaid: States’ Plans to Pursue New and Revised Options for Home- and 

Community-Based Services, GAO-12-649 (Washington, D.C.: June 13, 2012).
Page 16 GAO-17-598T Medicaid Personal Care Services

differences in program requirements existed. We recommended that CMS 

take additional steps to better harmonize and achieve a more consistent 

application of program requirements, as appropriate, across the different 

personal care services programs in a way that accounts for common risks 

faced by beneficiaries and to better ensure billed services were provided. 

CMS agreed with these recommendations, and has sought input by 

publishing a request for information on numerous topics related to 

Medicaid home and community-based services, including input on how to 

ensure beneficiary health and safety and program integrity across 

different types of personal care services programs.

In our 2017 report examining the data CMS uses to monitor the provision 

of personal care services, we found that claims and encounter data 

collected by CMS were not timely. Data are typically not available for 

analysis and reporting by CMS or others for several years after services 

are provided. We found that this happens for two reasons. First, although 

states have 6 weeks following the completion of a quarter to report their 

claims data, their reporting could be delayed as a result of providers and 

managed care plans not submitting data in a timely manner, according to 

the CMS contractor responsible for compiling data files of Medicaid 

claims and encounters. For example, providers may submit claims for

fee-for-service payments to the state late and providers may need to 

resubmit claims to make adjustments or corrections before they can be 

paid by the state. Second, once complete MSIS data are submitted by the 

states, the data must be compiled into annual person-level claims files 

that are in an accessible format, checked to identify and correct data 

errors, and consolidated for any claims with multiple records. This 

process, for one year of data, can take several years and, as a result, 

when information from claims and encounters becomes available for use 

Data on Personal 

Care Services 

Collected by CMS 

were Often Not 

Timely, Complete, 

Consistent, or 

Accurate

Claims and Encounter 

Data Were Not Timely, 

Complete, or Consistent
Page 17 GAO-17-598T Medicaid Personal Care Services

by CMS for purposes of program management and oversight it could be 

several years old.

We also found that Medicaid personal care services claims and encounter 

data that CMS collects were incomplete in two ways. First, specific data 

on beneficiaries’ personal care services were not included in the calendar 

year 2012 MSIS data for 16 states, as of 2016, when we conducted our 

analysis. Nevertheless, these 16 states received federal matching funds 

for the $4.2 billion in total fee-for-service payments for personal care 

services that year—about 33 percent of total expenditures for personal 

care services reported by all states (see figure 2).21

Figure 2: Percentage of Calendar Year 2012 Personal Care Services Fee-For-Service 

Expenditures for States That Were and Were Not Included in the Medicaid 

Statistical Information System Data

 21To estimate the Medicaid personal care services expenditures associated with the 16 

missing states, we analyzed aggregate fee-for-service expenditures for these services as 

reported by these states through the Medicaid Budget and Expenditure System.
Page 18 GAO-17-598T Medicaid Personal Care Services

Second, even for the 35 states for which 2012 MSIS claims and 

encounter data were available, certain data elements collected by CMS

were incomplete. For example, for the records we analyzed, 20 percent 

included no payment information, 15 percent included no provider 

identification number to identify the provider of service, and 34 percent 

did not identify the quantity of services provided (see figure 3).22

Figure 3: Percentage of 2012 Medicaid Claims and Encounters for Personal Care 

Services in 35 States That Had Complete Information on Payment, Provider 

Information, and the Quantity of Services Provided

a

Payment amounts are available for claims made under a fee-for-service deliver model; payments 

made to providers under managed care are not included in the data.

 22We previously reported that managed care encounter data submitted by states to CMS 

have been relatively incomplete and unreliable. See GAO, Medicaid: Service Utilization 

Patterns for Beneficiaries in Managed Care. GAO-15-481 (Washington, D.C.: May 29, 

2016).
Page 19 GAO-17-598T Medicaid Personal Care Services

Incomplete data limit CMS’s ability to track spending changes and 

corroborate spending with reported expenditures because the agency 

lacked important information on a significant amount of Medicaid 

payments for personal care services. For example, among the 2012 

claims we reviewed for personal care services under a fee-for-service 

delivery model, claims without a provider identification number accounted 

for about $4.9 billion in total payments. Similarly, payments for fee-forservice claims with missing information on the quantity of personal care 

services provided totaled about $5.1 billion. These data gaps represented 

a significant share of total personal care services spending, which totaled 

about $15 billion in fee-for-service expenditures in 2015.

Even when states’ claims and encounter data collected by CMS was 

complete, we found that it was often inconsistent, which limits the 

effectiveness of the data to identify questionable claims and encounters. 

For purposes of oversight, a complete record (claims or encounters) 

should include data for each visit with a provider or caregiver, with dates 

of when services were provided, the amount of services provided using a 

clearly specified unit of service (e.g., 15 minutes), and the type of 

services provided using a standard definition. Such a complete record 

would allow CMS and states to analyze claims to identify potential fraud 

and abuse. The following examples illustrate inconsistencies in data 

regarding when services were provided and the types of services that 

were provided from the 35 states whose data we reviewed:

• When services were provided. State-reported dates of service were 

overly broad. In the 35 states, some claims for personal care services 

had dates of services (i.e., start and end dates) that spanned multiple 

days, weeks, and in some cases months. For 12 of the 35 states, 95 

percent of their claims were billed for a single day of service. 

However, in other states, a number of claims were billed over longer 

time periods. For example, for 10 of the states, 5 percent of claims 

covered a period of at least 1 month, and 9 states submitted claims 

that covered 100 or more days. When states report dates of service 

that are imprecise, it is difficult to determine the specific date for which 

services were provided and identify whether services were claimed 

during a period when the beneficiary is not eligible to receive personal 

care services—for example, when hospitalized for acute care 

services.

• Type of services provided. States used hundreds of different 

procedure codes for personal care services. Procedure codes on 

submitted claims and encounters were inconsistent in three ways: the 

number of codes used by states; the use of both national and state-
Page 20 GAO-17-598T Medicaid Personal Care Services

specific codes; and the varying definitions of different codes across 

states. More than 400 unique procedure codes were used by the 35 

states. CMS does not require that states use standard procedure 

codes for personal care services; instead, states have the discretion 

to use state-based procedure codes of their own choosing or national 

procedure codes. As a result, the procedure codes used for similar

services differed from state to state, which limits CMS’s ability to use 

this data as a tool to compare and track changes in the use of specific 

personal care services provided to beneficiaries because CMS cannot

easily compare similar procedures by comparing service procedure 

codes.

In our 2017 report we found that Medicaid personal care services 

expenditure data collected were not always accurate or complete, 

according to our analysis of expenditure data collected by CMS from 

states for calendar years 2012 through 2015. When submitting 

expenditure data, CMS requires states to report expenditures for personal 

care services on specific reporting lines. These reporting lines correspond 

with the specific types of programs under which states have received 

authority to cover personal care services, and can affect the federal 

matching payment amounts states receive when seeking federal 

reimbursement. For example, a 6 percent increase in federal matching is 

available for services provided through the Community First Choice 

program.23 For three other types of HCBS programs, CMS also requires 

states to report their expenditures for personal care services separately 

from other types of services provided under each program on what CMS 

refers to as feeder forms—that is, individual expenditure lines for different 

types of services that feed into the total HCBS spending amount for each 

program.

We found that not all states were reporting their personal care services 

expenditures accurately, and, as result, personal care services 

expenditures may have been underreported or reported in an incorrect 

category. We compared personal care services expenditures for all states 

for calendar years 2012 through 2015 with each state’s approved 

programs during this time period and found that about 17 percent of 

personal care services expenditure lines were not reported correctly. As 

 23In addition to the 6 percent enhanced federal matching rate, states operating a

Community First Choice program are subject to a maintenance of expenditures 

requirement—that is, states operating such a program are required in their first year to 

maintain or exceed the level of spending from the prior year.

Medicaid Expenditure 

Data Collected by CMS 

Were Not Always Accurate 

or Complete
Page 21 GAO-17-598T Medicaid Personal Care Services

illustrated in figure 4, nearly two-thirds of the reporting errors were a 

result of states not separately identifying and reporting personal care 

services expenditures using the correct reporting lines, as required by 

CMS. Without separate reporting of personal care expenditures as 

required, CMS is unable to ensure appropriate federal payment, monitor 

how spending changes over time across the different program types and 

have an accurate estimate of the magnitude of potential improper 

payments for personal care services. The other types of errors involved 

states erroneously reporting expenditures that did not correspond with 

approved programs. As a result, CMS is not able to efficiently and 

effectively identify and prevent states from receiving federal matching 

funds inappropriately, in part because it does not have accurate fee-forservice claims data that track payments by personal care program type 

that is linked with expenditures reported for purpose of federal 

reimbursement.

Figure 4: Percentage of Personal Care Services Expenditure Lines in 2012 to 2015 

with State Reporting Errors

a

Errors include states reporting personal care services expenditures for programs that they did not 

administer and states not reporting personal care services expenditures for programs that they did 

administer.
Page 22 GAO-17-598T Medicaid Personal Care Services

These errors demonstrated that CMS was not effectively ensuring its 

reporting requirements for personal care expenditures were met. We 

concluded that by not ensuring that states are accurately reporting 

expenditures for personal care services, CMS is unable to accurately 

identify total expenditures for personal care services, expenditures by 

program, and changes over time. According to CMS, expenditures that 

states reported through MBES are subject to a variance analysis, which 

identifies significant changes in reported expenditures from year to year. 

However, CMS’s variance analysis did not identify any of the reporting 

errors that we found. CMS officials told us that they would continue to 

review states’ quarterly expenditure reports for significant variances and 

follow up on such variances.

In our 2017 report, we acknowledged certain efforts CMS had taken to 

improve the data it collects. However, these efforts had not addressed 

data issues we identified that limited the usefulness of the data for 

oversight. We recommended that CMS take steps to improve the 

collection of complete and consistent personal care services data and 

better monitor the states’ provision of and spending on Medicaid personal 

care services. Specifically, CMS agreed with recommendations to better 

ensure states comply with data reporting requirements and to develop 

plans for analyzing and using the data. The agency neither agreed nor 

disagreed with recommendations to issue guidance to ensure key data 

regarding claims and encounter data are complete and consistent, or with 

a recommendation to ensure claims data can be accurately linked with 

aggregate expenditure data. In light of our findings of inconsistent and 

incomplete reporting of claims and encounters, errors in reporting 

expenditures, and the high-risk of improper payments, we believe action 

in response to these recommendations is needed.

In conclusion, Medicaid personal care services are an important benefit 

for a significant number of Medicaid beneficiaries and amount to billions 

of dollars in spending to the federal government and states. The demand 

and spending for personal care services continues to grow. However, the 

services are not without risk. Personal care services are at high risk for 

improper payments and beneficiaries may be vulnerable and at risk of 

unintentional harm and potential neglect and exploitation. Over the years, 

federal laws have given states a number of different options to provide 

home- and community- based services. Having various options for 

providing personal care services provides flexibilities for states in how 

they administer their programs and provide services to different groups of 

beneficiaries. At the same time, our work has also found a patchwork of 
Page 23 GAO-17-598T Medicaid Personal Care Services

federal requirements, resulting in varying levels of beneficiary safeguards 

and requirements to ensure that billed services are actually provided. As 

a result, beneficiaries with similar needs could be receiving services in 

programs with significantly different safeguards in place, depending on 

the program. Similarly, the level of assurance that billed services are 

actually provided could vary based on the type of program. Further, our 

work showed that the data CMS collects for oversight of these programs 

is not always timely, complete, accurate, and consistent. Without better 

data, CMS is hindered in effectively performing key management 

functions related to personal care services, such as ensuring state claims 

for enhanced federal matching funds are accurate. CMS has taken steps 

to improve the data it collects from states, and to establish more 

consistent administration of policies and procedures across the programs 

under which personal care services are provided. However, we found 

additional steps are warranted.

Chairman Murphy, Ranking Member DeGette, and Members of the 

Subcommittee this concludes my prepared statement. I would be pleased 

to respond to any question that you might have at this time.

If you or your staffs have any questions about this testimony, please 

contact Katherine M. Iritani at (202) 512-7114. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this statement. Individuals making key contributions to 

this testimony include Tim Bushfield, Assistant Director; Anna Bonelli; 

Christine Davis; Barbara Hansen; Laurie Pachter; Perry Parsons; and 

Jennifer Whitworth.

GAO Contact and 

Staff 

Acknowledgments

(102019)
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