GAO Releases Report on Medicaid Funding in Assisted Living

Background
On Feb. 5, the GAO released a report entitled “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare Is Needed.” The report comes in response to a 2015 request from Sens. Collins (R-ME), McCaskill (D-MO), Warren (D-MA) and Hatch (R-UT) for a review of Medicaid spending, and federal and state oversight of care provided to Medicaid enrollees in assisted living. At that time, and periodically over the past two years, Argentum has provided information to the four senators and the GAO on how assisted living is regulated, profiles of the average resident and provider, and on Medicaid utilization in assisted living.

Rationale for the Study
The GAO report describes the following rationale for executing the study:

• The number of individuals receiving Medicaid-funded home and community-based long term services (including assisted living) is expected to increase.
• State Medicaid programs and CMS have a responsibility for overseeing Medicaid funded programs and ensuring health and welfare of the Medicaid beneficiaries receiving these services.

GAO Recommendations
The GAO surveyed all state Medicaid agencies and interviewed officials in three states: Georgia, Nebraska, and Wisconsin. The GAO also reviewed regulations and interviewed CMS officials.  In response, they made the following three recommendations to CMS:

1.  The Administrator of CMS should provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies that states (state Medicaid agencies) using HCBS waivers are required to report on their annual reports.
2. The Administrator of CMS should establish standard Medicaid reporting requirements for all states (state Medicaid agencies) 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) where critical incidents occur.
3. The Administrator of CMS should ensure that all states (state Medicaid agencies) submit annual reports for HCBS waivers on time as required.

Points of Interest
Additional summary points of the GAO report include:

The report was mainly concerned about the health and safety of Medicaid beneficiaries living in assisted living. The study identified some areas of weakness in defining critical incidents, reporting of this information to Medicaid agencies, and making this information available to the public. Specifically the report noted the following:

• The report is most concerned about the lack of information the state Medicaid agencies had about number of critical incidences that occurred involving Medicaid beneficiaries in assisted living.  The report noted that 26 Medicaid state agencies could not report to GAO the number of critical incidences for this population.
• The report was also concerned with the lack of criteria defining “critical incidents.” While all Medicaid agencies included elder abuse in that definition, not all included medication errors or unexplained deaths.
• The report also looked at whether information on critical incidents was made available to the public and found that 34 states did make this information available on the website, or by phone but 14 states did not have information available.
• CMS oversight of HCBS programs requires that states provide annual reports to CMS and identify program deficiencies. But CMS instructions for completing the HCBS annual report are not specific enough on what to report as a deficiency, and steps that should be taken to ensure deficiency won’t recur. In addition, the report found that 28 states had not provided CMS with the required annual reports.

Next Steps
Argentum is meeting with the four senators who requested the report, as well as other members of the U.S. Senate Committee on Aging to discuss the findings. Of particular note: the GAO report included data on younger disabled residents in their findings on Medicaid funding in assisted living. Argentum has reached out to GAO to try to gain clarity on how much of the report pertains to seniors and how much is relevant to younger disabled populations.