Medicaid: Improving Transparency and Accountability of Supplemental Payments and State Financing Methods
Published: 2015-11-03T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid is an over $500 billion dollar jointly financed program for which the federal government matches state Medicaid expenditures. Within certain limits, states can make supplemental payments to providers in addition to their regular claims-based payments and receive federal matching funds. These payments have grown in the past decade. To finance the nonfederal share of Medicaid payments, states can use funds from local governments and providers, within federal parameters. CMS is responsible for overseeing state programs and ensuring that state payments are consistent with Medicaid payment principles—including that they are economical and efficient, and appropriately financed.
States may have incentives to make excessive supplemental payments to certain providers who finance the nonfederal share of the payment. GAO has a body of work from 2004 to 2015 raising concerns with Medicaid supplemental payments and financing methods. Congress and CMS have taken actions to improve accountability for these payments, and GAO has made further suggestions for Congress and CMS.
This statement highlights key issues and opportunities for improving transparency and oversight from GAO's work related to (1) certain supplemental payments states make to providers, and (2) states' financing of the non-federal share of Medicaid. This testimony is based on GAO reports from 2004 to 2015 on state Medicaid financing and supplemental payments, and selected updates from CMS on the status of prior recommendations.
section_title: What GAO Found
paragraphs: GAO has found that complete and reliable data are lacking on the tens of billions in Medicaid supplemental payments states often make, hindering transparency and oversight. In a November 2012 report, GAO found that Congress and the Centers for Medicare & Medicaid Services (CMS) have acted to improve transparency and accountability for one type of Medicaid supplemental payment known as disproportionate share hospital (DSH) payments, made for uncompensated care costs experienced by hospitals serving low-income and Medicaid patients. Since 2010, DSH payments are required to be reported to CMS and are subject to independent audits that assess their appropriateness. States also make other supplemental payments—referred to here as non-DSH payments—to hospitals and other providers that, for example, serve high-cost Medicaid beneficiaries. Gaps in oversight remained for non-DSH supplemental payments, which as of 2011 exceeded DSH in amounts paid. For example, GAO reported that 39 states made non-DSH supplemental payments to 505 hospitals that, along with regular Medicaid payments, exceeded those hospitals' total costs of providing Medicaid care by about $2.7 billion. Medicaid payments are not limited to a provider's costs for services, but GAO concluded in an April 2015 report that payments that greatly exceed costs raise questions about whether they are economical and efficient as required by law, and the extent to which they are ultimately used for Medicaid services. CMS lacks data on supplemental payments made to individual providers. Per federal internal control standards, agencies should have reliable information for decision making and reporting, and reasonable assurance that agency objectives, such as compliance with laws, are being met. In 2012, CMS officials said legislation was needed to implement non-DSH reporting and auditing requirements, and GAO suggested that Congress consider requiring CMS to provide guidance on permissible methods for calculating non-DSH payments and require state reports and audits.
GAO found in a July 2014 report that states are increasingly relying on providers and local governments to finance Medicaid and data needed for oversight are lacking. About $46 billion or 26 percent of the nonfederal share was financed with funds from providers and local governments in 2012—an increase from 21 percent in 2008. GAO found that states' financing arrangements can effectively shift costs from states to the federal government. In one state, a $220 million payment increase for nursing facilities funded by a $115 million tax on nursing facilities yielded a net payment increase to the facilities of $105 million. The state obtained $110 million in federal matching funds for the payments. GAO found that CMS generally does not require or otherwise collect data from states on sources of funds to finance Medicaid, nor ensure that the data it does collect are accurate and complete. GAO identified, for example, incomplete reporting of provider taxes. As a result, CMS cannot fully assess the appropriateness of states' financing or the extent to which the increased reliance on providers and local governments serves to provide fiscal relief to states or improve access. Per federal internal control standards, agencies should collect accurate and complete data for monitoring. GAO recommended in 2014 that CMS improve the data states report on Medicaid financing. The agency disagreed, stating its efforts were adequate. GAO maintains its recommendation is valid.

section_title: Letter
paragraphs: I am pleased to be here today as you discuss legislative proposals related  to Medicaid financing and certain payments states often make, known as  supplemental payments. The size, growth, and diversity of Medicaid  create significant challenges for administration and oversight. Medicaid is  the nation’s largest health program as measured by enrollment and the  second largest health program, after Medicare, as measured by  expenditures. Medicaid is administered by states, overseen by the  Centers for Medicare & Medicaid Services (CMS), and financed jointly by  the federal government and states based on a statutory formula. It is a  significant component of federal and state budgets, with estimated  outlays of $529 billion in fiscal year 2015, of which $320 billion was  expected to be financed by the federal government and $209 billion by  the states. By 2020, Medicaid expenditures are projected to total $725  billion, with federal expenditures alone totaling $436 billion.
States generally finance their share of Medicaid—often called the  nonfederal or state share—by using state general funds appropriated by  state legislatures. However, states can, within certain federal parameters,  use other sources of funds to finance Medicaid, such as taxes on health  care providers and funds from local government providers or local  governments on behalf of providers. States’ financing of the nonfederal  share is subject to federal limits and requirements. For example, states  must use state funds to finance at least 40 percent of the nonfederal  share of total Medicaid expenditures each year. This limit is applied in the  aggregate; that is, across each state’s entire Medicaid program, and not  for individual payments. In addition to flexibility in determining sources of  funds to use to finance their nonfederal share, states have flexibility,  within broad federal requirements, in designing and operating their  Medicaid programs, including setting payment rates for providers. Many  states make supplemental payments—payments above regular claims- based payments for Medicaid services—to certain providers, mainly  hospitals. The federal government shares in the costs of these payments.  Supplemental payments are a significant component of Medicaid  spending, totaling at least $43 billion in fiscal year 2011, up from $32  billion in fiscal year 2010 and at least $23 billion in fiscal year 2006.  These amounts were likely understated because reporting of  supplemental payments was incomplete.
As the agency overseeing Medicaid at the federal level, CMS is  responsible for providing guidance to states on federal Medicaid  requirements and for overseeing state programs, including ensuring that  state Medicaid payments are appropriately financed and consistent with  Medicaid payment principles. For example, Medicaid payments generally  must be for Medicaid covered items and services, and consistent with  efficiency, economy, and quality of care.
We have reported over many years on a number of challenges facing  Medicaid and have a significant body of work on states’ supplemental  payments to providers and financing of the non-federal share. Both  Congress and CMS have taken significant steps to improve transparency  and accountability in these areas. We believe there are opportunities for  additional improvements that are important in view of both the significant  spending for supplemental payments and the integrity of the program. My  testimony today will cover our work related to the supplemental payments  states often make to certain institutional providers, and to states’  financing of the nonfederal share of the Medicaid program. My remarks  focus on key issues related to:  1.  certain supplemental payments states make to providers, and  opportunities for improved oversight and transparency, and  2.  states’ financing of the non-federal share of Medicaid, and  opportunities for improved oversight and transparency.
My remarks are based on multiple reports and testimonies we have  produced on these topics since 2004, including our recent report on key  issues facing the Medicaid program; our reports on opportunities to  reduce fragmentation, duplication and overlap in federal programs; and  our most recent high-risk update. My remarks on supplemental  payments states make to providers are based in large part on findings  from our November 2012 report, which examined how information from  newly required reporting facilitated CMS’s oversight of certain types of  supplemental payments, and the extent to which similar information  existed to facilitate CMS’s oversight of other types of supplemental  payments. For that report, we reviewed audits and reports, analyzed  data on supplemental payments, and interviewed CMS officials. My  remarks on states’ financing of the non-federal share of Medicaid are  based in large part on findings from our July 2014 report, which examined  the extent to which states have relied on funds from health care providers  and local governments to finance the nonfederal share of Medicaid; the  extent to which states have changed their reliance on health care  providers and local governments to help finance the nonfederal share of  Medicaid in recent years and the implications, if any, of these changes;  and the extent to which CMS collects data to oversee states’ use of  various sources of funds. For that report, we administered a  questionnaire to all state Medicaid agencies, examined effects of  financing changes in a nongeneralizable sample of three states selected  in part based on Medicaid spending and geographic diversity, and  interviewed CMS officials. The reports cited provide further details on our  scope and methodology. My remarks also draw on information we  obtained from CMS between March 2015 and June 2015 about the status  of our prior recommendations in these areas, as well as current CMS  efforts related to Medicaid.
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.
subsections: section_title: Background
paragraphs: Medicaid is an open-ended entitlement; states are generally obligated to  pay for covered services provided to eligible individuals, and the federal  government is obligated to pay its share of a state’s expenditures under a  federally approved state Medicaid plan. The federal share of each state’s  Medicaid expenditures is based on a statutory formula known as the  Federal Medical Assistance Percentage (FMAP). Some states design  their Medicaid programs to have local governments contribute to the  programs’ costs, for example, through intergovernmental transfers of  funds from government-owned or -operated providers to the state  Medicaid program. States may, subject to certain requirements, also  receive funds to finance Medicaid payments from health care providers,  for example, through provider taxes—taxes levied on providers such as  hospitals or nursing facilities. Under federal law, provider taxes must be  broad-based, must be uniformly imposed, and must not hold providers  harmless; that is, they must not provide a direct or indirect guarantee that  providers will receive all or a portion of tax payments back. Taxes that are  at or below 6 percent of the individual provider’s net patient service  revenues are considered not to have provided an indirect guarantee that  providers will receive their tax payments back.
In addition to flexibility in determining sources of funds they use to finance  their nonfederal share, states have flexibility, within broad federal  requirements, in designing and operating their Medicaid programs,  including determining which services to cover and setting payment rates  for providers. In general, federal law provides for federal matching funds  for state Medicaid payments for covered services provided to eligible  beneficiaries up to a ceiling or limit, often called the upper payment limit  (UPL). The UPL is based on what Medicare would pay for the same  services. States often make two general types of Medicaid supplemental  payments:
First, under federal Medicaid law, states are required to make  disproportionate share hospital (DSH) payments to certain hospitals.  These payments are designed to help offset these hospitals’  uncompensated care costs for serving Medicaid and uninsured low- income patients. States’ Medicaid payment rates are not required to  cover the full costs of providing care to Medicaid beneficiaries, and  many providers also provide care to low-income patients without any  insurance or ability to pay. Under federal law, DSH payments are  capped at a facility-specific level and state level.
Second, many states also make another type of Medicaid  supplemental payment, referred to here as non-DSH supplemental  payments, to hospitals and other providers who, for example, serve  high-cost Medicaid beneficiaries. Unlike DSH payments, non-DSH  supplemental payments are not required under federal law, do not  have a specified statutory or regulatory purpose, and are not subject  to firm dollar limits at the facility or state level. Unlike regular Medicaid  payments, which are paid on the basis of covered Medicaid services  provided to Medicaid beneficiaries through an automated claims  process, non-DSH supplemental payments are not necessarily made  on the basis of claims for specific services to particular patients and  can amount to tens or hundreds of millions of dollars to a single  provider, annually. States can generally make non-DSH payments up  to the UPL. Typically, state Medicaid payment rates are lower than  what the Medicare program would pay, and so many states make  supplemental payments under the UPL. Non-DSH supplemental  payments, like regular Medicaid payments, must be consistent with  Medicaid payment principles. Under federal law, to receive federal  matching funds, payments generally must (1) be made for covered  Medicaid items and services, (2) be consistent with economy,  efficiency, and quality of care, and (3) not exceed the UPL.  Supplemental payments may also be made under Medicaid  demonstrations, but may not be subject to these requirements,  depending on the terms of the demonstration.
Historically, DSH payments exceeded Medicaid non-DSH payments. In  recent years the opposite has occurred, and non-DSH payments have  exceeded DSH payments. In fiscal year 2011, Medicaid non-DSH  payments totaled nearly $26 billion compared to over $17 billion for DSH  payments.
section_title: Complete and Reliable Data on Non-DSH Supplemental Payments are Lacking, Hindering Transparency and Oversight
paragraphs: For about two decades, we have raised concerns about supplemental  payments and the adequacy of federal oversight. We have designated  Medicaid a high-risk program due in part to these concerns. For example,  in a February 2004 report, we found that over the years some states had  made relatively large non-DSH supplemental payments to relatively small  numbers of government-owned providers, and that these providers were  then sometimes required to return these payments to the states, resulting  in an inappropriate increase in federal matching funds. We also found that  some states had used widely varying and inaccurate methods for  estimating their non-DSH payment amounts, which may inflate the  amount of non-DSH supplemental payments. CMS is responsible for  ensuring that state Medicaid payments are consistent with federal  requirements, including that payments are consistent with economy and  efficiency and are for Medicaid-covered services. To do so, it is important  for CMS to have relevant, reliable, and timely information for  management decision making and external reporting purposes.
In recent years, our work examining these payments has identified  several instances of payments that further raise concerns about whether  Medicaid payments that greatly exceeded costs are economical and  efficient. For example, as reported in November 2012, we found that 39  states had made non-DSH supplemental payments to 505 hospitals that,  along with their regular Medicaid payments, exceeded those hospitals’  total costs of providing Medicaid care by $2.7 billion. In some cases,  payments greatly exceeded costs; for example, one hospital received  almost $320 million in non-DSH payments and $331 million in regular  Medicaid payments, which exceeded the $410 million in costs reported  for the hospital for providing Medicaid services by about $241 million.
As we reported in April 2015, our more recent analysis of average daily  payment amounts—which reflect both regular payments and non-DSH  supplemental payments—identified hospitals for which Medicaid  payments received exceeded their Medicaid costs, and we also found a  few cases where states made payments to local government hospitals  that exceeded the hospitals’ total operating costs. CMS’s oversight  mechanisms had not identified large overpayments to two hospitals in  one state that resulted from non-DSH supplemental payments until we  identified them. CMS began reviewing the appropriateness of the two  hospitals’ payments during the course of our review. As we concluded in  our 2012 and 2015 reports, although Medicaid payments are not required  to be limited to a provider’s costs of delivering Medicaid services,  payments that greatly exceed these costs raise questions, including  whether they are consistent with economy and efficiency, whether they  contribute to beneficiaries’ access to quality care, and the extent to which  they are ultimately used for Medicaid purposes. However, CMS lacks  data at the federal level on non-DSH supplemental payments, and the  payments are not subject to audit.
Based on our findings, we have identified opportunities to improve the  oversight, transparency, and accountability of non-DSH supplemental  payments to providers, in particular through improved reporting, auditing,  and guidance. Since 2010, states have been required by federal law to  submit annual facility-specific reports and annual independent certified  audits on DSH payments. In connection with the independent audit  requirement, standard methods were established for calculating DSH  payment amounts. However, similar requirements for reporting, annual  independent audits, and guidance on acceptable methods for calculating  non-DSH supplemental payments are not in place for non-DSH  payments. As we reported in November 2012, we found that the newly  implemented annual reporting and audits for DSH payments improved  CMS oversight—and we concluded that better reporting and audits of  non-DSH supplemental payments could improve CMS’s oversight of  these payments as well.
As our work has shown, states’ non-DSH supplemental payments can be  complex and challenging to assess. Hospital-specific information can be  helpful to CMS and others for understanding, at the provider level, the  relationship of supplemental payments to both regular Medicaid payments  and Medicaid costs. For example, reporting of non-DSH payments that  states make to individual hospitals and other providers relative to the  providers’ Medicaid costs could improve the transparency of these  payments. In addition, audits could improve accountability by providing  information on how these payments are calculated and the extent to  which payments to individual providers are consistent with the Medicaid  payment principles of economy and efficiency. Absent complete and  reliable provider-specific data on the non-DSH supplemental payments  individual providers receive, CMS may not identify potentially excessive  payments to providers, and the federal government could be paying  states hundreds of millions—or billions—of dollars more than what is  appropriate.
CMS has taken some steps to improve oversight of these payments, but  has not established facility-specific reporting requirements, required  annual independent audits of states’ non-DSH payments, or specified  uniform methods for calculating non-DSH supplemental payment  amounts. Steps CMS has taken include issuing a state Medicaid Director  letter in 2013 to obtain more information on non-DSH supplemental  payments and awarding a contract in May 2014 to review Medicaid  supplemental payment information, the outcomes of which were not yet  known as of July 2015. CMS said in 2012 that legislation was necessary  for them to implement reporting and auditing requirements for DSH  payments, and that legislation would be needed for the agency to  implement similar requirements for non-DSH supplemental payments.  Consequently, we have suggested that Congress consider requiring CMS  to take steps to improve the transparency and accountability of non-DSH  supplemental payments, including requirements similar to those in place  for DSH.
section_title: States are Increasingly Relying on Providers and Local Governments to Finance Medicaid, and Data Needed for Oversight is Lacking
paragraphs: Our work has found that states are increasingly relying on providers and  local governments to finance Medicaid, and has also pointed to the need  for better data and improved oversight to ensure that Medicaid payments  are financed consistent with federal requirements, to understand  financing trends, and to ensure federal matching funds are used  efficiently. Further, our work has shown that state flexibility to seek  contributions from local governments or impose taxes on health care  providers to finance Medicaid may create incentives for states to overpay  providers in order to reduce states’ financial obligations. Such financing  arrangements can have the effect of shifting costs of Medicaid from states  to the federal government. Benefits to providers, which may be financing  a large share of any new payments, and to the beneficiaries whom they  may serve, may be less apparent. CMS is responsible for ensuring that  state Medicaid payments made under financing arrangements are  consistent with Medicaid payment principles, including that they are  economical and efficient, and that the federal government and states  share in the financing of the Medicaid program as established by law. To  oversee the Medicaid program, it is important for CMS to have accurate  and complete information on the amount of funds supplied by health care  providers and local governments to states to finance the nonfederal share  of Medicaid.
As we reported in July 2014, our survey of all state Medicaid programs  found that states are increasingly relying on providers and local  governments to help fund Medicaid. For example, in state fiscal year  2012, funds from providers and local governments accounted for 26  percent (or over $46 billion) of the approximately $180 billion in the total  nonfederal share of Medicaid payments that year—an increase from 21  percent ($31 billion) in state fiscal year 2008. (See fig. 1.) These  sources were used to fund Medicaid supplemental payments—both DSH  and non-DSH—to a greater extent than other types of payments, and we  found this reliance was growing. For Medicaid DSH and non-DSH  supplemental payments, the percentage of the nonfederal share financed  with funds from providers and local governments increased from 57  percent (or $8.1 billion) in state fiscal year 2008 to 70 percent (or $13.6  billion) in state fiscal year 2012. Several states relied on health care  providers and local governments for the entire nonfederal share of  supplemental payments in 2012.
Our reports have illustrated how this increased reliance on non-state  sources of funds can shift costs from states to the federal government,  changing the nature of the federal-state partnership. For example, in our  July 2014 report, our analysis of arrangements involving financing of the  nonfederal share of Medicaid payments with funds from provider taxes or  local governments in three selected states illustrated how Medicaid costs  can be shifted from the state to the federal government and, to a lesser  extent, to health care providers and local governments. The use of  funds from providers and local governments is, as previously described,  allowable under federal rules, but it can also have implications for federal  costs. By increasing providers’ Medicaid payments, and requiring  providers receiving the payments to supply all or most of the nonfederal  share, we found that states claimed an increase in federal matching funds  without a commensurate increase in state general funds. For example, in  our 2014 report, we found that in one state a $220 million payment  increase for nursing facilities in 2012 (which was funded by a tax on  nursing facilities) resulted in an estimated $110 million increase in federal  matching funds; no increase in state general funds; and a net payment  increase to the facilities, after paying the taxes, of $105 million. (See fig.  2.)
As we found in our 2014 report, due to data limitations, CMS is not well- positioned to either identify states’ Medicaid financing sources or assess  their impact. Apart from data on provider taxes, CMS generally does not  require (or otherwise collect) information from states on the funds they  use to finance Medicaid, nor ensure that the data that it does collect are  accurate and complete. The lack of transparency in states’ sources of  funds and financing arrangements hinders CMS’s and federal  policymakers’ efforts to oversee Medicaid. Further, it is difficult to  determine whether a state’s increased reliance on funds from providers  and local governments primarily serves to (1) provide fiscal relief to the  state by increasing federal funding, or (2) increase payments to providers  that in turn help improve beneficiary access.
CMS has recognized the need for better data from states on how they  finance their share of Medicaid and has taken steps to collect some data,  but additional steps are needed. We recommended in July 2014 that  CMS take steps to ensure that states report accurate and complete  information on all sources of funds used to finance the nonfederal share  of Medicaid, and offered suggestions for doing so. The Department of  Health and Human Services (HHS) did not concur with our  recommendation, stating that its current efforts were adequate; however,  HHS acknowledged that additional data were needed to ensure that  states comply with federal requirements regarding how much local  governments may contribute to the nonfederal share, and stated that it  would examine efforts to improve data collection for oversight. As of  June 2015, HHS reported that its position continued to be that no further  action is needed. Given states’ increased reliance on non-state sources  to fund the nonfederal share of Medicaid, which can result in costs  shifting to the federal government, we continue to believe that improved  data are needed to improve transparency and oversight, such as to  understand how increased federal costs may affect beneficiaries and the  providers who serve them.
In conclusion, the flexibility states have in how they pay providers and  finance the nonfederal share has enabled states to make excessive  payments to certain providers and allowed states to shift costs to the  federal government. While Congress and CMS have taken important  steps to improve the integrity of the Medicaid program through improved  oversight of some Medicaid supplemental payments and financing  arrangements, Congress and CMS need better information and more  tools to understand who receives non-DSH supplemental payments and  in what amounts, to ensure they are economical and efficient as required  by law, and to determine the extent to which they are ultimately used for  Medicaid purposes.
Chairman Pitts, Ranking Member Green, and Members of the  Subcommittee, this concludes my prepared statement. I would be  pleased to respond to any questions that you might have at this time.
section_title: GAO Contacts and Staff Acknowledgments
paragraphs: If you or your staff 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; Robin Burke;  Sandra George; Jessica Morris; Laurie Pachter; Said Sariolghalam; and  Emily Wilson.
section_title: Appendix I: GAO’s Matters for Congressional Consideration and Agency Recommendations
paragraphs: The following table lists matters for congressional consideration regarding  actions to improve the transparency of and accountability for the Medicaid  non-disproportionate share hospital (DSH) supplemental payments states  make to providers. It also includes recommendations we have made to  the Department of Health and Human Services (HHS) regarding actions  to improve data and oversight of the sources of funds states use to  finance the nonfederal share of Medicaid.
section_title: Related GAO Products
paragraphs: Medicaid: Key Issues Facing the Program. GAO-15-677. Washington,  D.C.: July 30, 2015.  2015 Annual Report: Additional Opportunities to Reduce Fragmentation,  Overlap, and Duplication and Achieve Other Financial Benefits.  GAO-15-404SP. Washington, D.C.: April 14, 2015.
Medicaid: CMS Oversight of Provider Payments Is Hampered by Limited  Data and Unclear Policy. GAO-15-322. Washington, D.C.: April 10, 2015.
Medicaid Financing: Questionnaire Data on States’ Methods for Financing  Medicaid Payments from 2008 through 2012. GAO-15-227SP.  Washington, D.C.: March 13, 2015, an e-supplement to GAO-14-627.
High-Risk Series: An Update. GAO-15-290. Washington, D.C.: February  11, 2015.
Medicaid Financing: States’ Increased Reliance on Funds from Health  Care Providers and Local Governments Warrants Improved CMS Data  Collection. GAO-14-627. Washington, D.C.: July 29, 2014.
Medicaid: Completed and Preliminary Work Indicate that Transparency  around State Financing Methods and Payments to Providers Is Still  Needed for Oversight. GAO-14-817T. Washington, D.C.: July 29, 2014.  2013 Annual Report: Actions Needed to Reduce Fragmentation, Overlap,  and Duplication and Achieve Other Financial Benefits. GAO-13-279SP.  Washington, D.C.: April 9, 2013.
Medicaid: More Transparency of and Accountability for Supplemental  Payments Are Needed. GAO-13-48. Washington, D.C.: November 26,  2012.
Medicaid: States Reported Billions More in Supplemental Payments in  Recent Years. GAO-12-694. Washington, D.C.: July 20, 2012.
Medicaid: Ongoing Federal Oversight of Payments to Offset  Uncompensated Hospital Care Costs is Warranted. GAO-10-69.  Washington, D.C.: November 20, 2009.
Medicaid: CMS Needs More Information on the Billions of Dollars Spent  on Supplemental Payments. GAO-08-614. Washington, D.C.: May 30,  2008.
Medicaid Financing: Federal Oversight Initiative Is Consistent with  Medicaid Payment Principles but Needs Greater Transparency.  GAO-07- 214. Washington, D.C.: March 30, 2007.
Medicaid: Improved Federal Oversight of State Financing Schemes Is  Needed. GAO-04-228. Washington, D.C.: February 13, 2004.
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