MEDICAID

Opportunities for 

Improving Program 

Oversight

Statement of Carolyn L. Yocom

Director, Health Care

Testimony 

Before the Subcommittee on Government 

Operations and the Subcommittee on 

Intergovernmental Affairs, Committee on 

Oversight and Government Reform, House 

of Representatives

For Release on Delivery 

Expected at 10:00 a.m. ET

Thursday, April 12, 2018

GAO-18-444T

United States Government Accountability Office

This testimony was revised on April 12, 2018 to correct the 

addressees on pages 1 and 16.
United States Government Accountability Office

Highlights of GAO-18-444T, a testimony 

before the Subcommittee on Government 

Operations and the Subcommittee on 

Intergovernmental Affairs, Committee on 

Oversight and Government Reform, House of 

Representatives. 

April 12, 2018

MEDICAID

Opportunities for Improving Program Oversight

What GAO Found

The Centers for Medicare & Medicaid Services (CMS) has taken steps to 

improve Medicaid program integrity and reduce improper payments; however, 

GAO has identified areas where additional, or continued, action could help 

strengthen program integrity and ensure beneficiaries’ access to services. These 

actions include improving data quality, oversight, and federal-state collaboration. 

Need for better data. As GAO has previously reported, a fundamental challenge 

to the oversight of the Medicaid program is the lack of complete, accurate, and 

timely data. This challenge has hindered CMS’s ability to ensure the appropriate 

use of federal and state dollars for beneficiary care. Without reliable data, CMS 

is unable to effectively monitor who is providing services, or the type of services

provided. CMS has taken steps to develop reliable Medicaid data, most notably 

with the Transformed Medicaid Statistical Information System, which will collect 

more information on beneficiaries. This system could improve CMS’s ability to 

identify improper payments and help ensure beneficiaries’ access to services, 

but additional work is needed. In December 2017, GAO made two 

recommendations to CMS to improve the completeness and comparability of the 

data from this system and CMS’s plans for oversight. The agency concurred with 

the recommendations, but has not yet implemented them.

Need for stronger oversight. GAO has previously identified areas where 

stronger CMS oversight will help the agency better manage program risks, and 

improve beneficiaries’ access to needed health care services. 

• Manage program risks. From May 2015 to December 2017, GAO made 11

recommendations that could help CMS better assess the risk of fraud, as 

well as ensure that only eligible providers—particularly those in managed 

care—and beneficiaries are enrolled and participating in the Medicaid 

program. The agency generally concurred with these recommendations, but 

has not yet implemented them.

• Access to services. From August 2017 to January 2018 GAO made eight

recommendations aimed at ensuring that beneficiaries with a limited ability to 

care for themselves—such as those with disabilities, complex health needs, 

or infants with neonatal abstinence syndrome—have access to necessary 

services. The agency concurred with the recommendations, but has not yet 

implemented them. 

Need for greater federal-state collaboration. GAO has previously reported 

that collaborative activities between the federal government and the states—

such as sharing promising program integrity practices—are important to 

improving oversight of the Medicaid program. Recent examples of such activities 

include a national Medicaid training program for state officials and partnerships 

to combat Medicaid fraud. However, in March 2017, GAO also found that 

barriers—such as communication problems between CMS contractors and state 

officials—have limited the use of collaborative audits, which have the potential to 

identify substantial overpayments to providers. GAO recommended that CMS 

identify opportunities to address these barriers. CMS agreed with the 

recommendations, but has not yet implemented them. 

View GAO-18-444T. For more information, 

contact Carolyn Yocom at (202) 512-7114 or 

yocomc@gao.gov.

Why GAO Did This Study

Medicaid, a joint federal-state health 

care program, is a significant 

component of federal and state 

budgets, with total estimated outlays of 

$596 billion in fiscal year 2017. The 

program’s size and diversity make it 

particularly vulnerable to improper 

payments. In fiscal year 2017, 

improper payments were an estimated 

$37 billion of federal Medicaid 

expenditures, an increase from an 

estimated $29.1 billion in fiscal year 

2015. 

The partnership between the federal 

government and states is a central 

tenet of the Medicaid program. 

Medicaid allows significant flexibility for 

states to design and implement their 

programs based on their unique needs. 

These programs are administered at 

the state level and overseen at the 

federal level by CMS. The resulting 

variability of state Medicaid programs 

complicates federal efforts to oversee 

program payments and beneficiaries’ 

access to services.

This testimony focuses on the need for 

(1) better data, (2) improved oversight, 

and (3) greater federal-state 

collaboration to safeguard Medicaid 

program integrity. This testimony is 

based on GAO reports issued between 

May 2015 and January 2018 on the 

Medicaid program. 
Letter

Page 1 GAO-18-444T 

Chairmen Meadows and Palmer, Ranking Members Connolly and Raskin, 

and Members of the Subcommittees:

I am pleased to be here today to discuss oversight efforts intended to 

prevent improper payments in the Medicaid program.1 This federal-state 

program is one of the nation’s largest sources of funding for medical and 

other health-related services, covering acute health care, long-term care, 

and other services for over 73 million low income and medically needy 

individuals in fiscal year 2017. In that same year, estimated federal and 

state Medicaid expenditures were $596 billion. The size and complexity of 

Medicaid make the program particularly vulnerable to improper 

payments—including payments made for people not eligible for Medicaid 

or made for services not actually provided. Due to concerns about the 

adequacy of fiscal oversight, Medicaid has been on our list of high-risk 

programs since 2003.2

Despite efforts to reduce improper payments in the Medicaid program by 

the Centers for Medicare & Medicaid Services (CMS), which oversees the 

program, overall improper payments continue to increase—rising to about 

$37 billion in fiscal year 2017 compared with $29.1 billion in fiscal year 

2015. The Medicaid program alone accounted for 26.1 percent of the 

fiscal year 2017 government-wide improper payment estimate. It is critical 

to take appropriate measures to reduce improper payments, as dollars 

wasted detract from our ability to ensure that the individuals who rely on 

the Medicaid program—including children, and individuals who are elderly 

or disabled—are provided adequate care.

The partnership between the federal government and states is a central 

tenet of the Medicaid program. Within broad federal requirements, states 

have significant flexibility to design and implement their programs based 

 1

An improper payment is 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 service, any duplicate 

payment, payment for services not received (except where authorized by law), and any 

payment that does not account for credit for applicable discounts. See 31 U.S.C. § 3321 

note. Office of Management and Budget guidance also instructs agencies to report as 

improper payments any payments for which insufficient or no documentation is found.

2

See GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial 

Efforts Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017).

Letter
Page 2 GAO-18-444T 

on their unique needs, resulting in 56 distinct Medicaid programs.3 These 

programs are administered at the state level and overseen at the federal 

level by CMS, an agency within the Department of Health and Human 

Services (HHS). The resulting variability of state Medicaid programs 

complicates federal efforts to oversee program payments and 

beneficiaries’ access to services.

My testimony today will focus on three actions important to improving 

oversight of the Medicaid program:

1. addressing data challenges that limit CMS’s ability to ensure the 

appropriate use of federal Medicaid dollars;

2. strengthening federal oversight to address program risks that can help 

reduce improper payments, as well as ensure appropriate care for 

beneficiaries; and

3. improving federal-state collaboration to strengthen program oversight.

My remarks are based on our large body of work examining the Medicaid 

program, specifically our reports issued and recommendations made from 

May 2015 to January 2018. (See app. I for selected recommendations 

and a list of related GAO reports at the end of this statement.) Those 

reports provide further details on our scope and methodology. We 

conducted all of 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.

Under Medicaid’s federal-state partnership, CMS provides oversight and 

technical assistance for the program, and states are responsible for 

administering their respective Medicaid programs’ day-to-day 

operations—including determining eligibility, enrolling individuals and 

providers, and adjudicating claims—within broad federal requirements. 

Federal oversight includes ensuring that the design and operation of state 

programs meet federal requirements and that Medicaid payments are 

 3

Medicaid programs are administered by the 50 states, the District of Columbia, American

Samoa, Guam, the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the 

U.S. Virgin Islands. 

Background
Page 3 GAO-18-444T 

made appropriately. (See fig. 1 for a diagram of the federal-state 

Medicaid partnership framework.) Financing Medicaid is also a fixture of 

the federal and state partnership, with the federal government matching 

most state Medicaid expenditures using a statutory formula based, in 

part, on each state’s per capita income in relation to the national average 

per capita income.

Figure 1: Federal-State Medicaid Partnership Framework

Note: If a state wishes to make amendments to its state Medicaid plan, it must seek approval from the 

Centers for Medicare & Medicaid Services (CMS). Similarly, a state that desires to change its 

Medicaid program in ways that deviate from certain federal requirements may seek to do so through a 

Medicaid demonstration approved under section 1115 of the Social Security Act, which is outside of 

its state Medicaid plan. States must submit an application describing the proposed demonstration to 

CMS for review. CMS will specify the special terms and conditions that encompass the requirements 

for an approved demonstration.
Page 4 GAO-18-444T 

Medicaid provides coverage to a diverse group of beneficiaries, including 

certain categories of children, parents and other non-elderly adults, 

pregnant women, and individuals who are disabled or aged 65 and older. 

The health care needs and costs of these populations vary. For example, 

in fiscal year 2013—which are the most recent reliable data—children and 

adults constituted the majority—75 percent—of enrollees; however, the 

bulk of Medicaid expenditures—66 percent—were for aged and disabled 

enrollees. (See fig. 2.)

Figure 2: Medicaid Enrollment and Expenditures by Eligibility Group, Fiscal Year 

2013

Note: Enrollees include individuals in 50 states and the District of Columbia who were enrolled in 

Medicaid during fiscal year 2013. Expenditures include both federal and state funds for 48 states and 

the District of Columbia, but exclude spending for administration. Payments from the Centers for 

Medicare & Medicaid Services to cover the costs of providing care to uninsured patients at 

Medicaid Covers a Wide 

Variety of Services for 

Low-Income and Medically 

Needy Populations
Page 5 GAO-18-444T 

disproportionate share hospital are also excluded. Due to anomalies in the expenditure data, 

MACPAC excluded Rhode Island and Vermont from the expenditure data.

The program covers a comprehensive set of services, including 

physician, and inpatient and outpatient hospital care; and is also a 

particularly significant source of health care coverage and financing for 

certain services. For example, Medicaid is the nation’s primary payer of 

long-term services and supports, including nursing home care and homeand community-based services, which allow individuals to live more 

independently and age in their homes. Medicaid is also the nation’s 

largest source of funding for behavioral health services, including 

treatment related to mental health and substance use conditions.

States also have flexibility in determining how their Medicaid benefits are 

delivered. Many states deliver all or some services through contracted 

managed care organizations. For example, states may contract with 

managed care organizations to provide a specific set of Medicaid-covered 

services to beneficiaries and pay them a set amount per beneficiary per 

month; pay health care providers for each service they provide on a feefor-service basis; or rely on a combination of both delivery systems. 

Managed care continues to be a growing component of the Medicaid 

program. In fiscal year 2017, expenditures for managed care represented 

almost 50 percent of total federal program expenditures, compared with 

38 percent in fiscal year 2014.

States also have the flexibility to innovate outside of many of Medicaid’s 

otherwise applicable requirements through Medicaid demonstrations 

approved under section 1115 of the Social Security Act.4 Demonstrations 

allow states to test new approaches to providing coverage and to improve 

quality and access or generate savings or efficiencies. For example, 

under demonstrations, states have

• extended coverage to certain populations,

• provided services not otherwise eligible for Medicaid, and

 4

Under section 1115 of the Social Security Act, the Secretary of Health and Human 

Services may waive certain Medicaid requirements and approve new types of 

expenditures that would not otherwise be eligible for federal Medicaid matching funds for 

experimental, pilot, or demonstration projects that, in the Secretary’s judgment, are likely 

to promote Medicaid objectives. See 42 U.S.C. § 1315(a). The Secretary has delegated 

the approval and administration of Medicaid section 1115 demonstrations to CMS, which 

requires that such demonstrations be budget neutral to the federal government; that is, the 

federal government should spend no more for Medicaid under a state’s demonstration 

than it would have spent without the demonstration. 
Page 6 GAO-18-444T 

• made payments to providers to incentivize delivery system 

improvements.

As we have previously reported, nearly three-quarters of states had CMS 

approved demonstrations as of November 2016. In fiscal year 2015, 

federal spending under demonstrations represented a third of all Medicaid 

spending nationwide.

Our previous body of work has shown that underlying data challenges in 

the Medicaid program have persistently hindered CMS’s ability to ensure 

the appropriate use of federal and state dollars for beneficiary care. CMS 

oversight relies in large part on state-reported data on multiple aspects of 

the Medicaid program, including expenditures and utilization of program 

services. We and others have reported that insufficiencies in these data 

have affected CMS’s ability to ensure proper payments and beneficiaries’

access to care. Specifically, we have previously raised concerns about 

the usefulness of state-reported Medicaid data, because of issues with 

completeness, accuracy, and timeliness. Examples of these data issues 

include the following:

• Expenditure data. CMS relies on a dataset known as the CMS-64, 

which is used to collect state-reported data on aggregate 

expenditures. These data are used to reimburse states for the federal 

share of program spending. In our prior work, we concluded that 

available Medicaid expenditure data do not provide CMS with 

sufficient information to consistently ensure that Medicaid payments 

are proper.5 For example, we found in 2015 that CMS does not collect 

accurate state data on Medicaid enrollment by eligibility type in the 

CMS-64, thus complicating the agency’s ability to identify erroneous 

expenditures due to incorrect eligibility determinations.6

• Utilization data. In our prior work, we concluded that utilization data 

in the Medicaid Statistical Information System—which states used to 

provide beneficiary-based data on eligibility and covered health care 

services, among other things—were incomplete and reported late.

These types of data are important to both CMS and the states for 

 5

See GAO, Medicaid: Program Oversight Hampered by Data Challenges, Underscoring 

Need for Continued Improvement, GAO-17-173 (Washington, D.C.: Jan. 6, 2017). 

6

See GAO, Medicaid: Additional Efforts Needed to Ensure that State Spending is 

Appropriately Matched with Federal Funds, GAO-16-53 (Washington, D.C.: Oct. 16, 

2015).

CMS Must Address 

Data Challenges, 

Which Hamper Its 

Oversight of Medicaid
Page 7 GAO-18-444T 

Medicaid program oversight and evaluation. We noted that without 

better data, CMS may not be able to identify patterns that indicate 

inappropriate provider billing, or ensure that beneficiaries have access 

to covered services.

As we have previously reported, the lack of complete and timely data has 

limited CMS’s oversight. Without reliable data, CMS is unable to 

effectively monitor who is providing services, or the type, amount, and 

dates of such services. For example, in January 2017, we found that the 

most recent Medicaid personal care services data were from 2012, and 

only 35 states had finished reporting for that year.7 Further, 15 percent of 

claims lacked provider identification numbers, over 400 different 

procedure codes were used to identify the services, and the quantity and 

time periods varied widely. Without better data, we concluded that CMS is 

unable to effectively monitor who is providing personal care services or 

the type, amount, and dates of services. 

Additionally, our prior work has found that the lack of complete and 

reliable data on services delivered in Medicaid managed care—known as 

encounter data—presents a significant oversight challenge for CMS given 

that over three-quarters of Medicaid beneficiaries were enrolled in 

managed care in 2014.8 In July 2015, HHS’s Office of Inspector General 

reported that states were not complying with federal requirements 

regarding the submission of Medicaid encounter data in the Medicaid 

Statistical Information System. Specifically, it determined that 11 states 

did not report encounter data for all managed care plans operating in their 

states in fiscal year 2011, as required.9

As part of its efforts to address longstanding data concerns, CMS has 

taken steps toward developing a reliable national repository for Medicaid 

data, most notably the Transformed Medicaid Statistical Information 

System (T-MSIS). T-MSIS will collect more information on enrollees than 

 7

See 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). 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. 

Personal care services assist beneficiaries with activities of daily living such as bathing, 

dressing, and toileting.

8

See GAO, Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care, 

GAO-15-481 (Washington, D.C.: May 29, 2015).

9

See HHS-OIG, Not All States Reported Medicaid Managed Care Encounter Data as 

Required, OEI-07-13-00120 (Washington, D.C.: July 2015).
Page 8 GAO-18-444T 

the Medicaid Statistical Information System—such as their citizenship, 

immigration, and disability status—as well as expanded diagnosis and 

procedure codes associated with their treatments. States will report data 

more frequently than they did for the Medicaid Statistical Information 

System and T-MSIS also includes approximately 2,800 automated quality 

checks, which should improve the timeliness and quality of data that 

states report. By providing more standardized data on various aspects of 

Medicaid—such as spending or utilization rates—states could be better 

positioned to compare their programs with other states, thereby improving 

their ability to identify and correct program inefficiencies.

Implementing the T-MSIS initiative has been a significant, multi-year 

effort. CMS has worked closely with states and has reached a point 

where nearly all states are reporting T-MSIS data. The T-MSIS initiative 

has the potential to improve CMS’s ability to identify improper payments, 

help ensure beneficiaries’ access to services, and improve program 

transparency, among other benefits. While recognizing the progress that 

has been made, we recently noted that more work needs to be done 

before CMS or states can use these data for program oversight. Some 

examples of this work include the following:

• Incomplete data. CMS has made progress in the number of states 

reporting T-MSIS data. As we previously reported, from October 2016

to November 2017, the number of states reporting T-MSIS information 

increased from 18 to 49.10 (See fig. 3.) However, the data being 

reported were not always complete. None of the six selected states in 

the sample we reviewed were reporting complete T-MSIS data as of 

August 2017.11 State officials said that certain unreported elements 

were contingent on federal or state actions, while others were not 

applicable to their state’s Medicaid program. However, we found that 

states did not always document the reasons for missing data, such as 

whether they planned to report data elements in the future or when 

they would report complete data.

 10See GAO, Medicaid: Further Action Needed to Expedite Use of National Data for 

Program Oversight, GAO-18-70 (Washington, D.C.: Dec. 8, 2017).

11See GAO-18-70.
Page 9 GAO-18-444T 

Figure 3: States’ Transformed Medicaid Statistical Information System (T-MSIS) Reporting Status, as of November 2017

• Comparability of data. Officials in selected states noted that a 

national repository of T-MSIS data could allow them to compare their 

Medicaid program data—such as spending or utilization rates—to 

other states, which could potentially improve their oversight.12

 12See GAO-18-70.
Page 10 GAO-18-444T 

However, these same state officials expressed concerns that states 

did not convert their data to the T-MSIS format in the same ways. 

These inconsistencies could make cross-state comparisons difficult.

• Plans for using data for oversight. Although CMS has taken steps 

to begin using T-MSIS data, CMS officials acknowledged in August 

2017 that they had yet to outline how best to use T-MSIS data for 

program monitoring, oversight, and management, because they were 

still largely focused on working with the remaining states to begin 

reporting T-MSIS data, analyzing the quality and usability of the TMSIS data, and preparing the data for research purposes.13 In 

December 2017, we recommended that CMS articulate a specific plan 

and associated time frames for using T-MSIS data for oversight. We 

concluded that absent a specific plan and time frames, CMS’s ability 

to use these data to oversee the program, including ensuring proper 

payments and beneficiaries’ access to services, is limited. The agency 

concurred with the recommendation, but has not yet implemented it.

While recognizing the progress that has been made, more work needs to 

be done before CMS or states can use the T-MSIS data for program 

oversight. It remains unclear when all states will report complete and 

comparable T-MSIS data, and how CMS and states will use them to 

improve oversight. In December 2017, we recommended CMS take 

additional steps to expedite the use of T-MSIS for program oversight, and 

the agency concurred with our recommendation, but has not yet 

implemented it. Further delays in T-MSIS’s use limit the agency’s ability to 

reverse the trend of rising improper payments in the Medicaid program, 

underscoring the need for CMS to take additional steps to expedite the 

use of these data.

CMS has taken steps to improve Medicaid program integrity and reduce 

improper payments. However, our work has identified several key areas 

where CMS should strengthen program oversight to address program 

risks that can result in improper payments, and ensure beneficiaries’

access to needed health care services.

 13See GAO-18-70.

CMS Needs to 

Strengthen Oversight 

to Address Program 

Risks and Ensure 

Access to Care
Page 11 GAO-18-444T 

In federal programs, it is necessary to identify program risks in order to 

design and implement strategies to mitigate these risks. For Medicaid, our 

work has identified program risks associated with provider enrollment and 

beneficiary eligibility. Developing strategies to address these risks and 

monitor progress will improve CMS’s ability to oversee the significant 

amount of funds expended in the Medicaid program and reduce improper 

payments. Below, we identify several examples of the recommendations 

we have made to address program risks, and what, if any, steps CMS has 

taken in response to our recommendations. (See table 1.)

Table 1: Examples of Actions Recommended by GAO to Address Medicaid Program Risks

Program risks GAO findings and recommendations Status and GAO response

Managing fraud risks In December 2017, we assessed the Centers for 

Medicare & Medicaid Services’ (CMS) antifraud 

efforts and found, among other things, that while 

the agency has shown commitment to combating 

fraud and has taken steps to identify fraud risks, it 

has not conducted a fraud risk assessment for 

Medicaid or developed a risk-based antifraud 

strategy.a

CMS concurred with these findings and our

recommendations for the agency to conduct a 

fraud risk assessment and to develop a risk-based 

antifraud strategy for Medicaid, but has not yet 

implemented them. We will monitor CMS’s 

actions.

Ensuring that only eligible 

providers are enrolled in 

Medicaid

In April 2016, based on two states and 16 health 

plans, we identified challenges to screening 

providers in Medicaid managed care for eligibility, 

partially due to fragmented information.

b In turn, we 

made four recommendations aimed at assessing 

the databases used to screen providers, improved 

collaboration and coordination with other federal 

agencies on sharing databases and establishing a 

common identifier across databases, and providing 

guidance to state Medicaid agencies.

CMS has addressed two of the four 

recommendations. One remaining 

recommendation directs CMS to determine 

whether any of the databases used by states and 

health plans to screen providers should be added 

to the list of the databases identified by CMS for 

screening purposes. To implement the 

recommendation, CMS will need to determine 

whether the remaining databases it has studied 

should be added to its list and take the 

appropriate action. For the other remaining 

recommendation, CMS needs to explore the use 

of a common identifier for screening Medicaid 

managed care providers across databases. We 

will continue to monitor CMS’s actions.

Ensuring that only eligible 

beneficiaries are enrolled in 

Medicaid

In October 2015, we identified gaps in CMS’s 

efforts to ensure that only eligible individuals are 

enrolled into Medicaid, and that Medicaid 

expenditures for enrollees—particularly those 

eligible as a result of the Patient Protection and 

Affordable Care Act expansion—are matched 

appropriately by the federal government.c

In response to the Act, CMS established a more 

rigorous approach for verifying financial and 

nonfinancial information needed to determine 

Medicaid beneficiaries’ eligibility. The agency 

stated that it would include reviews of federal 

eligibility determinations in states that have 

delegated that authority as a part of its review of 

states’ eligibility determinations. The results of this 

effort will be reported in 2019. We will continue to 

monitor this effort to determine if the agency is 

ascertaining the accuracy of federal eligibility 

determinations and taking corrective action where 

necessary.

Source: GAO | GAO-18-444T

CMS Must Strengthen 

Oversight to Manage 

Program Risks
Page 12 GAO-18-444T 

Note: See appendix I for a more complete description of these recommendations and their 

accompanying reports.

a

See GAO, Medicare and Medicaid: CMS Needs to Fully Align Its Antifraud Efforts with the Fraud 

Risk Framework, GAO-18-88 (Washington, D.C.: Dec. 5, 2017).

b

See GAO, Medicaid Program Integrity: Improved Guidance Needed to Better Support Efforts to 

Screen Managed Care Providers, GAO-16-402 (Washington, D.C.: Apr. 22, 2016).

c

See GAO, Medicaid: Additional Efforts Needed to Ensure that State Spending is Appropriately 

Matched with Federal Funds, GAO-16-53 (Washington, D.C.: Oct. 16, 2015). Under the Patient 

Protection and Affordable Care Act, state Medicaid expenditures for certain Medicaid enrollees are 

subject to higher federal matching percentages.

Our prior work has shown that oversight is needed to ensure that 

Medicaid’s low-income and medically needy population is able to access 

necessary health care services. This is particularly important for 

individuals with disabilities and complex health needs. Beneficiaries who 

have limited ability to care for themselves rely on long-term services and 

supports, including nursing home care and home- and community-based 

services. Others with opioid use disorders often rely on Medicaid to 

receive necessary behavioral health treatment. Oversight to ensure 

access and the quality of these services is particularly critical given that 

Medicaid is the largest payer of services for both of these groups. Below, 

we identify several examples of our concerns about access to and 

provision of Medicaid services, the recommendations we have made, and 

what steps, if any, CMS has taken in response to our recommendations. 

(See table 2.)

Table 2: Examples of Program Areas Requiring Action to Improve Access to and Provision of Medicaid Services

Program area GAO recommendations Status and GAO response

Oversight of access and quality 

in managed long-term services 

and supports

In August 2017, we recommended that the Centers 

for Medicare & Medicaid Services (CMS) take 

steps to better identify and obtain key information—

namely, provider network adequacy; critical 

incidents that may cause abuse, neglect, or 

exploitation of beneficiaries, and appeals and 

grievances—which are necessary to oversee 

states’ efforts to monitor beneficiary access to 

quality managed long-term services and supports.a 

The agency stated that it will consider this 

recommendation as it conducts its review of 

managed care regulations to prioritize 

beneficiary outcomes and state priorities. The 

agency stated that it will continue to assist 

states through technical guidance and other 

means and is in the process of enhancing its 

capacity to measure and monitor care and 

quality for these services and others. We will 

continue to monitor CMS actions in this area.

CMS Should Improve 

Oversight to Ensure 

Access to and Provision of 

Necessary Services
Page 13 GAO-18-444T 

Program area GAO recommendations Status and GAO response

Improving assessments of 

individuals’ needs for home- and 

community-based services 

(HCBS)

In December 2017, we reported that CMS had not 

addressed risks associated with providers 

(individual or managed care plans) conducting 

beneficiary needs assessments.b When providers 

conduct such assessments, they can face potential 

conflicts that could lead to inappropriate levels of 

care for beneficiaries in HCBS programs.c Also, we 

found that CMS had not consistently required 

states to follow its 2013 guidance that managed 

care plans not be involved in assessments used to 

determine eligibility for HCBS. We recommended 

that CMS ensure that all HCBS programs have 

requirements for states to address providers’

potential for conflicts of interest in conducting 

assessments.

CMS agreed with our recommendations, but 

has not yet implemented them. We will 

continue to monitor CMS’s actions.

Assessing the expansion of 

medication-assisted treatment 

(MAT) for opioid abused

In October 2017, we reviewed federal efforts to 

expand access to comprehensive substance use 

services, including MAT. According to CMS, states 

are using the flexibility of demonstrations to cover a 

full continuum of care for individuals with substance 

use disorders, including short-term residential 

treatment. The Department of Health and Human 

Services (HHS) has some needed information for 

evaluating its efforts to expand access to MAT, but 

more information is needed.e In particular, we 

recommended that the agency establish targets 

related to expanding access to MAT, and establish 

timeframes for this evaluation.

HHS concurred with both recommendations, 

but has not yet implemented them. We will 

continue to monitor HHS’s actions.

Implementing HHS’s strategy to 

address neonatal abstinence 

syndrome.

In October 2017, we reviewed HHS’s published 

strategy for addressing neonatal abstinence 

syndrome—a withdrawal condition in newborns 

occurring from the prenatal use of opioids or other 

drugs—most of whom are covered under Medicaid. 

We found that HHS has yet to determine how and 

when the recommendations from its strategy will be 

implemented.fWe recommended that HHS should 

expeditiously develop a plan—including priorities; 

roles and responsibilities of stakeholders; 

timeframes; and methods for assessing progress—

for implementing the recommendations included in 

its strategy to address neonatal abstinence 

syndrome.

HHS concurred that it should expeditiously 

address neonatal abstinence syndrome, but 

noted implementation of the strategy is 

contingent on funding. We will continue to 

monitor HHS’s actions.

Source: GAO | GAO-18-444T

a

See GAO, Medicaid Managed Care: CMS Should Improve Oversight of Access and Quality in 

States’ Long-Term Services and Supports Programs, GAO-17-632 (Washington, D.C.: Aug. 14, 

2017).

b

Needs assessments are a process to collect data on functional needs, health status, and other areas 

that are used to determine individuals’ eligibility for HCBS, and to plan services, such as the amount 

of services needed. Effective needs assessments help states ensure appropriate access to, and 

manage utilization of, services and therefore costs.

c

See GAO, Medicaid: CMS Should Take Additional Steps to Improve Assessments of Individuals’ 

Needs for Home- and Community-Based Services, GAO-18-103 (Washington, D.C.: Dec. 14, 2017).
Page 14 GAO-18-444T 

d

For those who are addicted to or misuse opioids, MAT has been shown to be an effective treatment, 

which combines behavioral therapy and the use of certain medications, such as methadone and 

buprenorphine.

e

See GAO, Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to 

Expand Access to Medication-Assisted Treatment, GAO-18-44 (Washington, D.C.: Oct. 31, 2017).

f

See GAO, Newborn Health: Federal Action Needed to Address Neonatal Abstinence Syndrome, 

GAO-18-32 (Washington, D.C.: Oct. 4, 2017).

The federal government and the states play important roles in reducing 

improper payments in the Medicaid program. CMS is responsible for 

broad oversight of the program, while states have had primary 

responsibility for ensuring the integrity of the Medicaid program by 

preventing, identifying, and correcting improper payments. Collaborative 

activities—such as identifying and sharing promising program integrity 

practices—are important to improving Medicaid oversight and we have 

previously recommended that CMS take steps to collect and share 

promising program integrity practices.14 As we have previously noted, 

because states are the first line of defense against Medicaid improper 

payments, CMS should also take steps to address barriers that limit 

effective collaborations. Some recent examples of collaborative activities 

that promote program integrity include the Medicaid Integrity Institute 

(MII), coordination meetings with state auditors, and partnerships to 

combat Medicaid fraud.

• The Medicaid Integrity Institute. In a 2017 report we noted that 

CMS established the MII, the first national Medicaid training program 

for state program integrity officials in 2007.15 The MII offers 

substantive training and support in a structured learning environment 

at no cost to the states, with almost 3,800 attendees participating in 

on-site courses from fiscal years 2012 through 2015. One of the 

important benefits of the MII reported by state officials and course 

participants is the opportunity to meet with and learn from program 

integrity officials from across the country in formal and informal 

settings. In the classroom, participants learn from state officials who 

serve as faculty for the MII courses, and from each other through inclass discussions. While on-site at the MII, there are also informal 

opportunities for information sharing that can lead to further state-tostate collaboration.

 14See GAO, Medicaid Program Integrity: CMS Should Build on Current Oversight Efforts 

by Further Enhancing Collaboration with States, GAO-17-277 (Washington, D.C.: Mar. 15, 

2017).

15See GAO-17-277. 

Greater Federal-State 

Collaboration Is 

Needed to Strengthen 

Program Oversight
Page 15 GAO-18-444T 

• Coordination with state auditors. Similarly, in another 2017 report 

we noted that CMS and selected state audit officials held meetings in 

November 2016 and May 2017 to discuss specific areas of concern in 

Medicaid and future collaboration.16 We facilitated the November 

2016 meeting, and participated in and presented prior audit results at 

the May 2017 meeting. These meetings served as a platform to 

discuss challenges with Medicaid oversight. For example, at the 

November 2016 meeting, state auditors discussed challenges they 

have had accessing data needed for Medicaid managed care 

oversight. Additionally, the state auditors and CMS officials discussed 

some of the benefits of coordination, with the state auditors noting that 

they can assist CMS’s state program integrity reviews by identifying 

program weaknesses.

• Partnerships to combat Medicaid fraud. In 2012, CMS created the 

Healthcare Fraud Prevention Partnership (HFPP) to share information 

with public and private stakeholders, and to conduct studies related to 

health care fraud, waste, and abuse. According to CMS, as of October 

2017, the HFPP included 89 public and private partners—including 

Medicare- and Medicaid-related federal and state agencies, law 

enforcement agencies, private health insurance plans, and antifraud 

and other health care organizations.17 The HFPP has conducted 

studies that pool and analyze multiple payers’ claims data to identify 

providers with patterns of suspect billing across private health 

insurance plans. In August 2017, we reported that the partnership 

participants separately told us the HFPP’s studies helped them 

identify and take action against potentially fraudulent providers and 

payment vulnerabilities of which they might not otherwise have been 

aware, and fostered both formal and informal information sharing.18

• Collaborative audits. CMS oversees and supports states, in part, by 

hiring contractors to audit Medicaid providers and facilitating state 

practices to improve program integrity. In recent years, CMS made 

changes to its Medicaid program integrity efforts, including a shift to 

collaborative audits—in which CMS contractors and states work in 

partnership to audit Medicaid providers. In March 2017, we reported 

that collaborative audits have identified substantial potential 

 16See GAO, Medicare and Medicaid: CMS Needs to Fully Align Its Antifraud Efforts with 

the Fraud Risk Framework, GAO-18-88 (Washington, D.C.: Dec. 5, 2017).

17See GAO-18-88.

18See GAO, Medicare: CMS Fraud Prevention System Uses Claims Analysis to Address 

Fraud, GAO-17-710 (Washington, D.C.: Aug. 30, 2017). 
Page 16 GAO-18-444T 

overpayments to providers, but barriers—such as staff burden or 

problems communicating with contractors—have limited their use and 

prevented states from seeking audits or hindered the success of 

audits.19 We recommended that CMS address the barriers that limit 

state participation in collaborative audits. CMS concurred with this 

recommendation and has taken steps to address them for a number 

of states, but has not yet made such changes accessible to a majority 

of states.

Chairmen Meadows and Palmer, Ranking Members Connolly and Raskin, 

and Members of the Subcommittees, this concludes my prepared 

statement. I would be pleased to respond to any questions you may have.

If you or your staff members have any questions concerning this 

testimony, please contact me at (202) 512-7114 or yocomc@gao.gov. 

Contact points for our Office of Congressional Relations and Public 

Affairs may be found on the last page of this statement. Other individuals 

who made key contributions to this testimony include Leslie V. Gordon 

(Assistant Director), Summar Corley (Analyst-in-Charge), Daniel 

Klabunde, Drew Long, Vikki Porter, and Jennifer Whitworth.

 19See GAO-17-277.

GAO Contacts and 

Staff 

Acknowledgments
Appendix I: Selected GAO Recommendations 

to Improve the Oversight of the Medicaid 

Program

Page 17 GAO-18-444T 

The following table lists selected recommendations we have made to the 

Department of Health and Human Services, the Centers for Medicare &

Medicaid Services, and the Office of Management and Budget regarding 

oversight of the Medicaid program, as well as a matter for congressional 

consideration. These recommendations remain unimplemented, as of 

March 2018.

Table 3: Selected GAO Recommendations to Improve the Oversight of the Medicaid Program

GAO Report Recommendation

Medicaid Assisted Living Services: 

Improved Federal Oversight of 

Beneficiary Health and Welfare is 

Needed. GAO-18-179. January 5, 2018. 

The Centers for Medicare & Medicaid Services (CMS) should:

• provide guidance and clarify requirements regarding the monitoring and reporting of 

deficiencies that states using home and community-based services (HCBS) waivers 

are required to report on their annual reports;

• establish standard Medicaid reporting requirements for all states to annually report 

key information on critical incidents, considering, at a minimum, the type of critical 

incidents involving Medicaid beneficiaries, and the type of residential facilities, 

including assisted living facilities, where critical incidents occurred; and

• ensure that all states submit annual reports for HCBS waivers on time as required. 

Medicaid: CMS Should Take Additional 

Steps to Improve Assessments of 

Individuals’ Needs for Home- and 

Community-Based Services. 

GAO-18-103. December 14, 2017.

CMS should:

• ensure that all types of Medicaid HCBS programs have requirements for states to 

avoid or mitigate potential conflicts of interest on the part of entities that conduct 

needs assessments that are used to determine eligibility for HCBS and to develop 

HCBS plans of service. These requirements should address both service providers 

and managed care plans conducting such assessments. 

Medicare and Medicaid: CMS Needs to 

Fully Align Its Antifraud Efforts with the 

Fraud Risk Framework. GAO-18-88. 

December 5, 2017.

CMS should:

• provide fraud-awareness training relevant to risks facing CMS programs and require 

new hires to undergo such training and all employees to undergo training on a 

recurring basis;

• conduct fraud risk assessments for Medicare and Medicaid that include respective 

fraud risk profiles and plans for regularly updating the assessments and profiles; and

• create, document, implement, and communicate an antifraud strategy that is aligned 

with and responsive to regularly assessed fraud risks. This strategy should include an 

approach for monitoring and evaluation. 

Medicaid: Further Action Needed to 

Expedite Use of National Data for 

Program Oversight. GAO-18-70. 

December 8, 2017.

CMS should:

• take additional steps to expedite the use of the Transformed Medicaid Information 

System (T-MSIS) data for program oversight. Such steps should include, but are not 

limited to, efforts to (1) obtain complete information from all states on unreported TMSIS data elements and their plans to report applicable data elements; (2) identify 

and share information across states on known T-MSIS data limitations to improve 

data comparability; and (3) implement mechanisms, such as the Learning 

Collaborative, by which states can collaborate on an ongoing basis to improve the 

completeness, comparability, and utility of T-MSIS data; and

• articulate a specific plan and associated time frames for using T-MSIS data for 

oversight.

Appendix I: Selected GAO 

Recommendations to Improve the Oversight 

of the Medicaid Program
Appendix I: Selected GAO Recommendations 

to Improve the Oversight of the Medicaid 

Program

Page 18 GAO-18-444T 

GAO Report Recommendation

Opioid Use Disorders: HHS Needs 

Measures to Assess the Effectiveness of 

Efforts to Expand Access to MedicationAssisted Treatment. GAO-18-44. October 

31, 2017.

The Department of Health and Human Services (HHS) should:

• establish performance measures with targets related to expanding access to 

medication assisted treatment (MAT) for opioid use disorders; and

• establish timeframes in its evaluation approach that specify when its evaluation of 

efforts to expand access to MAT will be implemented and completed. 

Newborn Health: Federal Action Needed 

to Address Neonatal Abstinence 

Syndrome. GAO-18-32. October 4, 2017.

HHS should:

• develop a plan—which includes priorities, timeframes, clear roles and responsibilities, 

and methods for assessing progress—to effectively implement the recommendations 

related to neonatal abstinence syndrome identified in the Protecting Our Infants Act: 

Final Strategy. 

Medicaid Managed Care: CMS Should 

Improve Oversight of Access and Quality 

in States’ Long-Term Services and 

Supports Programs. GAO-17-632. August 

14, 2017.

CMS should:

• 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 specific to network adequacy, critical incidents, and appeals and 

grievances.

Medicaid Program Integrity: CMS Should 

Build on Current Oversight Efforts by 

Further Enhancing Collaboration with 

States. GAO-17-277. March 15, 2017.

CMS should:

• identify opportunities to address barriers that limit states’ participation in collaborative 

audits;

• collaborate with states to develop a systematic approach to collect promising state 

program integrity practices; and

• collaborate with states to create and implement a communication strategy for sharing 

promising program integrity practices with states in an efficient and timely manner. 

Medicaid: CMS Needs Better Data to 

Monitor the Provision of and Spending on 

Personal Care Services. GAO-17-169. 

January 12, 2017.

CMS should:

• establish standard reporting guidance for personal care services collected through TMSIS to ensure that key data reported by states, such as procedure codes, provider 

identification numbers, units of service, and dates of service, are complete and 

consistent;

• better ensure, for all types of personal care services programs, that data on provision 

of personal care services and other HCBS collected through T-MSIS claims can be 

specifically linked to the expenditure lines on the CMS-64 that correspond with those 

particular types of HCBS services;

• better ensure that personal care services data collected from states through T-MSIS 

and the Medicaid Budget and Expenditure System comply with CMS reporting 

requirements; and

• develop plans for analyzing and using personal care services data for program 

management and oversight.

Medicaid Managed Care: Improved 

Oversight Needed of Payment Rates for 

Long-Term Services and Supports.

GAO-17-145. January 9, 2017.

CMS should:

• require all states to collect and report on progress toward achieving managed longterm services and supports program goals, such as whether the program enhances

the provision of community-based care;

• establish criteria for what situations would warrant exceptions to the federal standards 

that the data used to set rates be no older than the three most recent and complete 

years; and

• provide states with guidance that includes minimum standards for encounter data 

validation procedures. 
Appendix I: Selected GAO Recommendations 

to Improve the Oversight of the Medicaid

Program

Page 19 GAO-18-444T 

GAO Report Recommendation

Medicaid: Program Oversight Hampered 

by Data Challenges, Underscoring Need 

for Continued Improvement.

GAO-17-173. January 6, 2017.

CMS should:

• take immediate steps to assess and improve the data available for Medicaid program 

oversight, including, but not limited to, T-MSIS. Such steps could include (1) refining 

the overall data priority areas in T-MSIS to better identify those variables that are most 

critical for reducing improper payments, and (2) expediting efforts to assess and 

ensure the quality of these T-MSIS data.

Improper Payments: Strategy and 

Additional Actions Needed to Help 

Ensure Agencies Use the Do Not Pay 

Working System as Intended.

GAO-17-15. October 14, 2016.

Congress should:

• consider amending the Social Security Act to explicitly allow the Social Security 

Administration to share its full death file with Treasury for use through the Do Not Pay 

(DNP) working system.

The Office of Management and Budget (OMB) should:

• develop guidance that clarifies whether the use of DNP’s payment integration 

functionality is required and—if required—the circumstances and process in which 

agencies may obtain an exemption from this requirement;

• develop a strategy—and communicate its strategy through guidance—for how 

agencies should use the DNP working system to complement existing data matching 

processes and whether and how agencies should consider using the DNP working 

system to streamline existing data matching;

• develop and implement monitoring mechanisms—such as goals, benchmarks, and 

performance measures—to evaluate agency use of the DNP working system;

• develop a process for comparing agency reporting on the use of the DNP working 

system to available sources, such as OMB guidance and DNP working system 

adjudication reports; and

• revise its guidance to clarify whether agencies should report on their uses of all of the 

functionalities of the DNP working system in their agency financial reports. 

Medicaid Program Integrity: Improved 

Guidance Needed to Better Support 

Efforts to Screen Managed Care 

Providers. GAO-16-402. April 22, 2016.

CMS should:

• consider which additional databases that states and Medicaid managed care plans 

use to screen providers could be helpful in improving the effectiveness of these efforts 

and determine whether any of these databases should be added to the list of 

databases identified by CMS for screening purposes; and

• coordinate with other federal agencies, as necessary, to explore the use of an 

identifier that is relevant for the screening of Medicaid managed care plan providers 

and common across databases used to screen Medicaid managed care plan 

providers.

Medicaid: Additional Efforts Needed to 

Ensure that State Spending is 

Appropriately Matched with Federal 

Funds. GAO-16-53. October 23, 2015.

CMS should:

• conduct reviews of federal Medicaid eligibility determinations to ascertain the 

accuracy of these determinations and institute corrective action plans where 

necessary; and

• use information obtained from state and federal eligibility reviews to inform the 

agency’s review of expenditures for different eligibility groups in order to ensure that 

expenditures are reported correctly and matched appropriately. 

Medicaid: Additional Actions Needed to 

Help Improve Provider and Beneficiary 

Fraud Controls. GAO-15-313. May 14, 

2015.

CMS should:

• provide guidance to states on the availability of automated information through 

Medicare’s enrollment database—the Provider Enrollment, Chain and Ownership 

System—and full access to all pertinent system information, such as ownership 

information, to help screen Medicaid providers more efficiently and effectively.

Source: GAO. | GAO-18-444T
Related GAO Reports

Page 20 GAO-18-444T 

Medicaid Assisted Living Services: Improved Federal Oversight of 

Beneficiary Health and Welfare is Needed. GAO-18-179. Washington, 

D.C.: January 5, 2018.

Medicaid: CMS Should Take Additional Steps to Improve Assessments of 

Individuals’ Needs for Home-and Community-Based Services.

GAO-18-103. Washington, D.C.: December 14, 2017.

Medicaid: Further Action Needed to Expedite Use of National Data for 

Program Oversight. GAO-18-70. Washington, D.C.: December 8, 2017.

Medicare and Medicaid: CMS Needs to Fully Align Its Antifraud Efforts 

with the Fraud Risk Framework. GAO-18-88. Washington, D.C.: 

December 5, 2017.

Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness 

of Efforts to Expand Access to Medication-Assisted Treatment.

GAO-18-44. Washington, D.C.: October 31, 2017.

Newborn Health: Federal Action Needed to Address Neonatal Abstinence 

Syndrome. GAO-18-32. Washington, D.C.: October 4, 2017.

Medicare: CMS Fraud Prevention System Uses Claims Analysis to 

Address Fraud. GAO-17-710. Washington, D.C.: August 30, 2017.

Medicaid Managed Care: CMS Should Improve Oversight of Access and 

Quality in States’ Long-Term Services and Supports Programs.

GAO-17-632. Washington, D.C.: August 14, 2017.

Medicaid Program Integrity: CMS Should Build on Current Oversight 

Efforts by Further Enhancing Collaboration with States. GAO-17-277. 

Washington, D.C.: March 15, 2017.

High-Risk Series: Progress on Many High-Risk Areas, While Substantial 

Efforts Needed on Others. GAO-17-317. Washington, D.C.: February 15, 

2017.

Medicaid: CMS Needs Better Data to Monitor the Provision of and 

Spending on Personal Care Services. GAO-17-169. Washington, D.C.: 

January 12, 2017.

Related GAO Reports
Related GAO Reports

Page 21 GAO-18-444T 

Medicaid Managed Care: Improved Oversight Needed of Payment Rates 

for Long-Term Services and Supports. GAO-17-145. Washington, D.C.: 

January 9, 2017.

Medicaid: Program Oversight Hampered by Data Challenges, 

Underscoring Need for Continued Improvement. GAO-17-173. 

Washington, D.C.: January 6, 2017.

Improper Payments: Strategy and Additional Actions Needed to Help 

Ensure Agencies Use the Do Not Pay Working System as Intended. 

GAO-17-15. Washington, D.C.: October 14, 2016.

Medicaid Program Integrity: Improved Guidance Needed to Better 

Support Efforts to Screen Managed Care Providers. GAO-16-402. 

Washington, D.C.: April 22, 2016.

Medicaid: Additional Efforts Needed to Ensure that State Spending is 

Appropriately Matched with Federal Funds. GAO-16-53. Washington, 

D.C.: October 16, 2015.

Medicaid: Service Utilization Patterns for Beneficiaries in Managed Care.

GAO-15-481. Washington, D.C.: May 29, 2015.

Medicaid: Additional Actions Needed to Help Improve Provider and 

Beneficiary Fraud Controls. GAO-15-313. Washington, D.C.: May 14, 

2015.

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