Evaluating COVID-19 Response Could Help CMS Prepare for Future Emergencies (GAO-21-104401)
Summary
A GAO report to congressional committees, GAO-21-104401, dated September 2021, on Medicaid home- and community-based services (HCBS), in which providers help beneficiaries with daily activities such as bathing, dressing and eating. It states that COVID-19 presented risks to HCBS programs. To maintain access to services and prevent disease spread, all states received approval from the Centers for Medicare & Medicaid Services (CMS) for temporary changes to their HCBS programs. Its title states that evaluating the COVID-19 response could help CMS prepare for future emergencies.
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United States Government Accountability Office
Report to Congressional Committees
MEDICAID HOME-
September 2021
AND COMMUNITY-
BASED SERVICES
Evaluating COVID-19
Response Could Help
CMS Prepare for
Future Emergencies
GAO-21-104401
September 2021
MEDICAID HOME- AND COMMUNITY-BASED
SERVICES
Evaluating COVID-19 Response Could Help CMS
Highlights of GAO-21-104401, a report to Prepare for Future Emergencies
congressional committees
Why GAO Did This Study What GAO Found
During emergencies, including COVID- COVID-19 presented risks to Medicaid home- and community-based services
19, CMS may approve certain (HCBS) programs, where providers help beneficiaries with daily activities, such
temporary changes to states’ Medicaid as bathing, dressing, and eating. To maintain access to services and prevent
programs to ensure access to care. disease spread, all states received approval for temporary changes to their
These changes are critical to HCBS programs from the Centers for Medicare & Medicaid Services (CMS),
beneficiaries who rely on HCBS to within the Department of Health and Human Services. These changes enabled
perform daily activities, such as eating, selected states to limit in-person contact to reduce the spread of the disease, but
and who may face greater risk of also led to new challenges to ensuring beneficiary health and welfare.
COVID-19.
The CARES Act includes a provision Examples of Temporary Changes to States’ Medicaid Home- and Community-Based Services
Due to COVID-19, as of December 2020
for GAO to report on its ongoing
COVID-19 monitoring and oversight
efforts. In addition, GAO was asked to
examine temporary changes to
Medicaid in response to COVID-19.
This report (1) describes temporary
changes to Medicaid HCBS programs,
including selected states’ experience in
making these changes; and (2)
examines CMS’s monitoring and
evaluation of the effects of those
changes.
GAO reviewed documentation of
temporary changes approved by CMS
and relevant CMS policies, CMS focused on supporting states’ implementation of temporary changes and
procedures, and analyses. GAO also conducted limited oversight of the effects of the changes. CMS’s Pandemic Plan
interviewed Medicaid officials from establishes the need for monitoring to make mid-course corrections and
CMS and six states selected based on conducting evaluations after the pandemic to inform future emergency response.
variation in Medicaid expenditures and
geographic region. GAO assessed • CMS relied on states to monitor during the emergency. CMS has no
CMS’s monitoring and evaluation procedures for monitoring temporary changes during an emergency. Instead,
activities using CMS’s Pandemic Plan states had the primary responsibility to monitor the effects of temporary
and federal internal control standards. changes during the COVID-19 emergency, according to CMS officials. CMS
provided limited guidance to states on monitoring the changes, and did not
What GAO Recommends request that states share any data, such as COVID-19 infections or deaths,
GAO is making two recommendations with CMS. Without developing monitoring procedures in advance of future
to CMS to (1) develop procedures to public health emergencies, CMS is unlikely to conduct necessary monitoring.
monitor temporary changes to HCBS
programs during public health
• CMS’s plan for evaluating after the emergency is unclear. CMS officials
emergencies; and (2) evaluate the told GAO that they intend to evaluate temporary changes made to HCBS
temporary changes after the COVID-19 programs, but had not developed plans to do so. Officials said they will
emergency and address opportunities continue to review regular state reporting on steps taken to ensure the
for improvement. The Department of overall quality of HCBS programs. However, this reporting may not provide
Health and Human Services concurred useful information for evaluating how temporary changes affected access to
with GAO’s recommendations. HCBS or the prevention of disease spread, and some reports are not due for
more than 3 years. Without a full evaluation, CMS may miss opportunities to
View GAO-21-104401. For more information,
contact Carolyn L. Yocom at (202) 512-7114
better prepare for future emergencies.
or yocomc@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 5
States Pursued a Broad Range of Temporary HCBS Changes;
Less In-Person Contact Presented Challenges for Selected
States 10
CMS Focused on Supporting State Implementation of Temporary
HCBS Changes and Conducted Limited Monitoring and
Evaluation 18
Conclusions 25
Recommendation for Executive Action 26
Agency Comments 26
Appendix I Comments from the Department of Health and Human Services 30
Appendix II GAO Contact and Staff Acknowledgments 34
Tables
Table 1: Examples of Temporary Changes to States’ Medicaid
Home- and Community-Based Services Programs in
Response to COVID-19 and the Number of States with
Approvals as of December 3, 2020 11
Table 2: Examples of Differences in Three States’ Temporary
Changes to Medicaid Home- and Community-Based
Services Programs during the COVID-19 Public Health
Emergency 12
Table 3: Six States’ Actions to Implement Certain Temporary
Changes to Medicaid Home- and Community-Based
Services (HCBS) Programs during the COVID-19 Public
Health Emergency 14
Table 4: Examples of CMS Actions to Assist States with
Temporary Changes to Medicaid Home- and Community-
Based Services (HCBS) due to the COVID-19 Public
Health Emergency, March 2020 to May 2021 18
Page i GAO-21-104401 Medicaid Home and Community-Based Services
Figure
Figure 1: COVID-19 Public Health Emergency and Responses
Related to Medicaid Home- and Community-Based
Services (HCBS) 9
Abbreviations
CMS Centers for Medicare & Medicaid Services
HCBS home- and community-based services
HHS Department of Health and Human Services
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Page ii GAO-21-104401 Medicaid Home and Community-Based Services
Letter
441 G St. N.W.
Washington, DC 20548
September 8, 2021
Congressional Committees
Deadly public health emergencies, such as the Coronavirus Disease
2019 (COVID-19), present Medicaid home- and community-based
services (HCBS) programs with the dual challenge of preventing the
spread of disease while maintaining access to care. These programs
provide Medicaid beneficiaries who are aged or have disabilities with
long-term services and supports, including assistance with daily activities,
such as eating, dressing, and bathing. Beneficiaries rely on HCBS to live
in their homes and communities rather than in institutional settings,
including nursing homes, which have been the site of severe COVID-19
outbreaks. 1 However, delivering HCBS commonly involves close in-
person contact between providers and beneficiaries that can cause the
spread of infectious disease. Further, HCBS beneficiaries may be
particularly vulnerable to these diseases due to age or disability, as
occurred with COVID-19. 2
Medicaid, a federal-state health financing program for certain low-income
and medically needy individuals, provided HCBS to over 3.6 million
beneficiaries in fiscal year 2018. 3 Medicaid spends more than any other
payer—approximately 51 percent of $393 billion in 2019—in the United
1See GAO, COVID-19 in Nursing Homes: Most Homes Had Multiple Outbreaks and
Weeks of Sustained Transmission from May 2020 through January 2021, GAO-21-367
(Washington, D.C.: May 19, 2021). We regularly issue government-wide reports on the
federal response to COVID-19. For the latest report, see GAO, COVID-19: Continued
Attention Needed to Enhance Federal Preparedness, Response, Service Delivery, and
Program Integrity, GAO-21-551 (Washington, D.C.: July 19, 2021). Our next government-
wide report will be issued in October 2021 and will be available on GAO’s website at
https://www.gao.gov/coronavirus.
2See, for example, Scott D. Landes et al., “COVID-19 Outcomes Among People with
Intellectual and Developmental Disability Living in Residential Group Homes in New York
State,” Disability and Health Journal vol. 13, no. 4 (2020): 100969.
3These beneficiaries received at least one non-institutional long-term service or support in
fiscal year 2018 under a fee-for-service arrangement, according to the Centers for
Medicare & Medicaid Services’ Transformed Medicaid Statistical Information System data,
as of April 2020. Approximately 2 million of these beneficiaries received HCBS under a
waiver program authorized by section 1915(c) of the Social Security Act. See Medicaid
and CHIP Payment and Access Commission, MACStats: Medicaid and CHIP Data Book
(December 2020).
Page 1 GAO-21-104401 Medicaid Home and Community-Based Services
States on long-term services and supports, and most of this spending has
gone toward HCBS in recent years. 4
States have considerable flexibility to vary the provision of HCBS. 5 Nearly
all states provide Medicaid HCBS through waivers approved by the
Centers for Medicare & Medicaid Services (CMS)—the federal agency
within the Department of Health and Human Services (HHS) responsible
for overseeing states’ Medicaid programs. 6 Under HCBS waivers, states
can provide HCBS to a specific population, such as individuals with
intellectual or developmental disabilities, or limit the number of
beneficiaries who can receive HCBS. States must ensure the quality of
these waiver programs (referred to in this report as HCBS programs) by,
for example, protecting beneficiaries’ health and welfare, and providing
evidence to CMS that demonstrates quality assurance.
To respond to COVID-19, CMS has approved states’ requests to make
temporary changes to HCBS programs through an expedited process.
With initial guidance from CMS in March 2020, states decided what
temporary changes were needed to maintain beneficiaries’ access to
HCBS and prevent the spread of COVID-19. CMS has described the
number of the changes approved as unprecedented. Although time-
limited in nature, temporary changes made in response to COVID-19
4Information on expenditures on long-term services are derived from Centers for Medicare
& Medicaid Services’ National Health Expenditure Accounts. They exclude Medicare post-
acute care expenditures. Medicaid HCBS expenditures exceeded those for institutional
long-term services and supports from 2013 through 2018, the most recent years for which
data are available. See Caitlin Murray et al., “Medicaid Long Term Services and Supports
Annual Expenditures Report: Federal Fiscal Years 2017 and 2018,” (Chicago, Ill.:
Mathematica, January 7, 2021).
5For purposes of this report, states refers to the 50 states and the District of Columbia.
6Medicaid HCBS can operate under multiple authorities. HCBS waivers are authorized in
section 1915(c) of the Social Security Act, and states may provide HCBS authorized under
additional provisions of the Social Security Act, including sections 1905(a), 1915(i),
1915(j), and 1915(k). States can also administer HCBS programs through demonstrations
authorized by section 1115 of the Social Security Act, which authorizes the Secretary of
HHS to waive certain federal 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. 42 U.S.C. § 1315(a). The terms of these demonstrations
can require states to follow the requirements of 1915(c) waiver programs. In this report,
we refer to programs authorized under 1915(c) waivers and 1115 demonstrations
collectively as HCBS programs.
Page 2 GAO-21-104401 Medicaid Home and Community-Based Services
have been in effect since the first quarter of 2020 and are expected to
influence program operations going forward.
Given the number and duration of temporary changes to Medicaid HCBS
programs in responding to public health emergencies and protecting
vulnerable populations, you asked us to review the temporary changes
HHS used to respond to COVID-19 and the effects of these changes. 7 In
this report, we
1. describe the temporary changes to HCBS programs for which states
obtained approval in response to COVID-19, and selected states’
experiences in making these changes; and
2. examine CMS’s monitoring and evaluation of the effects of the
temporary changes made to HCBS programs.
To describe the temporary changes to HCBS programs that states sought
approval for in response to COVID-19, we reviewed a CMS contractor’s
analysis of requests approved by CMS as of December 3, 2020—the
most recently available analysis as of June 2021. 8 We reviewed both the
counts of states receiving approval for various categories of changes,
such as increasing provider payment rates, and descriptions of states’
requests, such as how much they would increase payment rates. We
determined this information is sufficiently reliable for the purposes of our
report by comparing the contractor analysis with a similar CMS summary
compiled as part of a risk assessment process and with documentation of
the temporary changes requested by a nongeneralizable sample of six
states: Illinois, Massachusetts, North Carolina, Rhode Island,
Washington, and Wyoming. We selected these states to achieve variation
7In addition, the CARES Act includes a provision for GAO to report on its ongoing
monitoring and oversight efforts related to the COVID-19 pandemic. Pub. L. No. 116-136,
§ 19010(b), 134 Stat. 281, 580 (2020).
8This CMS contractor’s analysis includes temporary changes states requested under
various federal authorities, including (1) through state plans approved for each state by
CMS; (2) demonstrations and waivers approved by CMS under sections 1115 and 1915(c)
of the Social Security Act, respectively; and (3) waivers authorized under section 1135 of
the Social Security Act when both a public health emergency and a disaster or emergency
have been declared.
Page 3 GAO-21-104401 Medicaid Home and Community-Based Services
in terms of geographic location and Medicaid program size in terms of
total program expenditures in 2018. 9
To describe selected states’ experiences in making the temporary
changes to their HCBS programs, we interviewed state Medicaid officials
from the six selected states and used a data collection instrument to
obtain relevant information and documentation. This included information,
when available, on the number of service planning activities where the
delivery method was changed and on expenditures for certain payment
changes in 2020. 10 Other information from selected states included
actions states took to implement temporary changes, challenges they
faced, and data or indicators they used to monitor the effects of these
changes on beneficiaries and providers. 11
To examine CMS’s monitoring and evaluation of the effects of the
temporary changes made to HCBS programs, we reviewed relevant CMS
documents and interviewed CMS officials. Specifically, to examine CMS’s
monitoring activities during the COVID-19 emergency, we reviewed
guidance and technical assistance resources CMS provided to states
during the emergency, requirements for state monitoring, and
documentation of initial monitoring efforts and analyses. To examine
evaluation activities, we interviewed CMS officials about the agency’s
plans and past experience in evaluating their response to emergencies.
We compared CMS’s monitoring and evaluation activities against its
Pandemic Plan, which provides a framework for CMS’s response to
pandemics, including monitoring and evaluation activities. 12 In addition,
we determined that the information and communication component and
monitoring component of federal internal control standards were
significant to our objective, including the underlying principles that
9Selected states’ expenditures on Medicaid services ranged from $0.6 billion in Wyoming
to $22.2 billion in Illinois in 2018; collectively, these states made up 12 percent of the $97
billion in national Medicaid HCBS expenditures in fiscal year 2016, the most recent year
these data are available for each state.
10We asked states to describe any limitations to the amounts reported, and we reflect
those in the report where relevant.
11Selected states provided examples of challenges they faced, which were illustrative, but
not necessarily comprehensive. We did not determine the extent specific challenges that
states identified were experienced among all selected states, and so do not identify which
states reported experiencing specific challenges.
12Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Pandemic Plan, V. 3.1. Public Release (updated Jan. 11, 2021).
Page 4 GAO-21-104401 Medicaid Home and Community-Based Services
management should use quality information to achieve the entity’s
objectives and perform monitoring activities. 13
We conducted this performance audit from June 2020 to September 2021
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.
Background
Medicaid HCBS Programs Medicaid HCBS beneficiaries range from young children to older adults
who have physical, cognitive, intellectual, or behavioral health disabilities
or conditions. Based on state Medicaid program design, various entities—
HCBS Programs including state or local government agencies, independent contractors,
States are authorized to cover Medicaid and HCBS providers—assess beneficiaries’ abilities and needs to
home- and community-based services determine whether they are eligible for HCBS programs and to plan for
(HCBS) under multiple authorities. In this
report, when we refer to HCBS programs, we
the services they need. 14
refer to those authorized under sections
1915(c) and 1115 of the Social Security Act. • Functional assessments measure beneficiaries’ abilities and help
Source: GAO. | GAO-21-104401
determine what services they need.
• Level-of-care evaluations determine how beneficiaries’ service
needs relate to the level of care typically provided in an institutional
setting, such as a nursing home. These evaluations and other criteria
are used to decide if beneficiaries are eligible for certain Medicaid
HCBS.
• Person-centered service plans (referred to as service plans in this
report) should reflect the services and supports important to meeting
beneficiaries’ individual needs. Service plans are developed by
beneficiaries with case managers or other individuals.
13GAO, Standards for Internal Control in the Federal Government, GAO-14-704G
(Washington, D.C.: Sept. 10, 2014). Internal control is a process effected by an entity’s
oversight body, management, and other personnel that provides reasonable assurance
that the objectives of an entity will be achieved.
14See 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), 14-15.
Page 5 GAO-21-104401 Medicaid Home and Community-Based Services
HCBS programs aim to help beneficiaries improve or maintain their
abilities and remain safe and healthy in their homes or communities. Core
elements of HCBS programs include the following:
• Service provision. Generally, HCBS entail assistance with (1)
activities of daily living, such as bathing, dressing, and eating; and (2)
instrumental activities of daily living, such as preparing meals,
housekeeping, and using the telephone. 15 Types of services include,
for example, personal care services, such as assistance with bathing
and dressing; adult day care services, which provide a range of social,
medical, and other services in a group setting; and case management
to plan and coordinate services and supports.
• Providers of care. Direct care workers—such as personal care
aides—are the primary providers of paid HCBS. 16 Family members or
legal guardians provide both paid and unpaid care.
• Settings of care. This includes provider facilities, such as adult day
care facilities, and individual or congregate homes, such as assisted
living facilities that provide a residential alternative to nursing homes
for individuals who prefer to live independently, but need assistance.
• Safeguards for beneficiaries. Safeguards help ensure beneficiaries’
health and welfare by detecting, addressing, and avoiding risks of
abuse, neglect, and exploitation—known as critical incidents.
Safeguards include minimum provider qualification requirements—
such as licensing or education requirements—and incident reporting
requirements to identify incidents that are severe enough to merit
review and follow up.
State and Federal States are responsible for the day-to-day administration and oversight of
Oversight their HCBS programs, including monitoring. For example, states must
conduct program integrity activities to help ensure the appropriate use of
Medicaid funds, including fingerprint-based criminal background checks
15Beneficiaries may be eligible for additional types of HCBS to achieve independence,
such as supported employment services.
16Four occupations often used to categorize direct care workers include (1) home health
aides, (2) psychiatric aides, (3) nursing assistants, and (4) personal care aides. See GAO,
Long-Term Care Workforce: Better Information Needed on Nursing Assistants, Home
Health Aides, and Other Direct Care Workers, GAO-16-718 (Washington, D.C.: Aug. 16,
2016).
Page 6 GAO-21-104401 Medicaid Home and Community-Based Services
for certain HCBS providers and on-site reviews of certain providers. 17
States must also ensure that their HCBS programs meet federal
requirements by monitoring and reporting on certain program areas,
including systems to ensure provider qualifications and beneficiary health
and welfare. For example, states must
• verify that providers meet required standards, such as licensure or
certification; and
• identify, address, and seek to prevent instances of abuse, neglect,
exploitation, and unexplained death.
Federal oversight includes CMS approving and renewing HCBS programs
and ensuring states meet program requirements. CMS typically approves
HCBS programs for 5-year periods. 18 CMS issues program requirements
in the form of regulations and guidance; approves changes states make
to their programs; provides technical assistance to states; collects and
reviews required information and data from states; and, in some cases,
reviews individual state programs to examine states’ compliance with
requirements or activities to address known deficiencies. The agency
collects annual reports from states with information on enrollment and
expenditures. These annual reports also include brief descriptions of
states’ processes for monitoring the program and any findings from this
monitoring. Before renewing HCBS programs, CMS also collects quality
assurance reports from states that describe findings from states’
monitoring and efforts to remediate any issues.
Temporary Changes in During an emergency—such as a public health emergency or a national
Response to Public Health emergency, both of which were declared in response to the COVID-19
pandemic—states can seek CMS approval to make temporary changes to
Emergencies
17CMS requirements for these activities depend on the risk of fraud, waste, and abuse
posed by different provider types, as determined by CMS. Newly enrolling home health
providers are considered a high risk and therefore subject to fingerprint-based criminal
background checks, and all home health providers are considered a moderate risk and
therefore subject to on-site reviews.
18CMS typically renews HCBS programs authorized by sections 1115 and 1915(c) waivers
for a 5-year period, although CMS can renew for shorter periods under section 1115.
When renewal is required for HCBS provided under different authorities, such as 1915(i),
CMS renews for 5-year periods.
Page 7 GAO-21-104401 Medicaid Home and Community-Based Services
their HCBS programs through waivers or other program flexibilities. 19
These changes can enable states to address emergencies through
modifications that are not otherwise allowed or would require a more
extensive review and approval process if made on a permanent basis.
In March 2020, CMS provided states with a list of temporary changes
across a number of HCBS program elements that they could request
through an expedited process. 20 These changes are time limited and are
generally scheduled to terminate based on the conclusion of the COVID-
19 public health emergency (referred to in this report as the COVID-19
emergency). According to statements made in January 2021 by the
Acting Secretary of Health and Human Services at that time, the public
health emergency will likely continue at least through the end of 2021. In
December 2020, CMS issued guidance on returning to normal operations
after the COVID-19 emergency ends. 21 This guidance recommended that
states phase out temporary changes as they are no longer needed to
address COVID-19, and established dates for ending temporary changes,
which ranged from the conclusion of the COVID-19 emergency to 12
months after. 22 (See fig. 1.)
19For certain types of changes, the HHS Secretary must declare a public health
emergency and the President of the United States must declare a national disaster or
emergency. See 42 U.S.C. § 1320b–5.
20Department of Health and Human Services, Centers for Medicare & Medicaid Services,
APPENDIX K: Emergency Preparedness and Response and COVID-19 Addendum (Mar.
22, 2020).
21Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance
Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the
COVID-19 Public Health Emergency, SHO# 20-004 (Baltimore, Md.: Dec. 22, 2020).
22According to this guidance, many temporary changes to HCBS must end by the date
specified by CMS in approval letters, but states have up to 12 months after the end of the
emergency to resume certain HCBS activities, such as annual level-of-care evaluations for
existing beneficiaries, for programs operating under certain federal authorities. In August
2021, CMS updated this guidance. See Department of Health and Human Services,
Centers for Medicare & Medicaid Services, Updated Guidance Related to Planning for the
Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and
Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health
Emergency, SHO# 21-002 (Baltimore, Md.: Aug. 13, 2021).
Page 8 GAO-21-104401 Medicaid Home and Community-Based Services
Figure 1: COVID-19 Public Health Emergency and Responses Related to Medicaid Home- and Community-Based Services
(HCBS)
Page 9 GAO-21-104401 Medicaid Home and Community-Based Services
States pursued a broad range of temporary changes to their HCBS
States Pursued a programs in response to COVID-19. Our six selected states implemented
Broad Range of these changes quickly, beginning in March 2020, and state officials told
us that, in general, only minor adjustments were needed throughout the
Temporary HCBS COVID-19 emergency. While the changes reduced in-person contact to
Changes; Less In- limit the spread of COVID-19, state officials said the changes also led to
new challenges in ensuring beneficiaries’ health and welfare.
Person Contact
Presented
Challenges for
Selected States
States Pursued Temporary Our analysis of CMS documentation shows that all 51 states received
Changes to Core approval from CMS to implement a broad range of temporary changes to
core elements of their HCBS programs—service provision, providers,
Elements of HCBS
settings of care, and beneficiary safeguards—in an effort to limit the
Programs that Directly spread of COVID-19 and maintain access to needed services, including
Affected Beneficiaries and by maintaining provider capacity. For example, to reduce the risk of
Providers spreading COVID-19, states increased payments to providers to cover
the cost of personal protective equipment, such as masks. (See table 1.)
Page 10 GAO-21-104401 Medicaid Home and Community-Based Services
Table 1: Examples of Temporary Changes to States’ Medicaid Home- and Community-Based Services Programs in Response
to COVID-19 and the Number of States with Approvals as of December 3, 2020
Number of
Program element and temporary states
change approved Examples of changes approved by CMS
Service provision
Modify level-of-care evaluations 51 Conducting virtual evaluations (via phone or video) of the level of care a
beneficiary needs—used to determine eligibility—rather than in-person
evaluations, signing evaluations electronically, and extending timelines to
complete annual re-evaluations.
Modify person-centered service 50 Conducting service planning virtually (via phone or video) rather than in person
planning and signing plans electronically.
Exceed service limits 42 Exceeding limits on the amount of care allowed, such as the number of home
delivered meals or number of days of respite care.
Providers
Make retainer payments to 39 Paying providers experiencing service disruptions, such as beneficiary
providers hospitalizations or the need to isolate due to contracting COVID-19.
Increase provider payment rates 38 Increasing payments rates for certain providers, which could cover new costs
such as purchasing personal protective equipment or providing hazard pay.
Service settings
Expand service settings 49 Providing services in an alternative setting, such as delivering adult day care
services in a beneficiary’s home rather than in a provider facility.
Safeguards for beneficiaries
Relax provider qualifications 48 Modifying, delaying, or suspending requirements for licensing, certification, or
requirements screening, such as submitting providers’ fingerprints for criminal background
checks.
Modify incident reporting 26 Modifying or delaying requirements for reporting incidents of risk to beneficiary’s
requirements health and welfare, such as potential abuse or neglect.
Source: GAO analysis of Centers for Medicare & Medicaid Services documentation. | GAO-21-104401
Note: This table includes all 50 states and the District of Columbia.
States varied in which temporary changes they made to their HCBS
programs and in the specifics of the changes. For example, among the 38
states that increased payment rates for HCBS providers, increases
ranged from 5 percent to 50 percent. Also, these states applied increases
to different types of HCBS such as, in-home services (25 states) or case
management (four states). Similarly, states took different approaches to
relaxing provider qualification requirements. For example, one of our
selected states, Massachusetts, loosened requirements by allowing
providers to deliver services while background checks were being
completed. Another selected state, Wyoming, received approval to delay
provider background checks altogether until after the COVID-19
emergency, though state officials told us that as of May 2021 the state
Page 11 GAO-21-104401 Medicaid Home and Community-Based Services
had resumed checks. States also took different approaches to temporary
changes based on differences in their programs. 23 (See table 2.)
Table 2: Examples of Differences in Three States’ Temporary Changes to Medicaid Home- and Community-Based Services
Programs during the COVID-19 Public Health Emergency
Temporary change Massachusetts Washington Wyoming
Modify level-of-care Can be delayed until after the Can be delayed for a year. Can be delayed for a year.
evaluations used to emergency. Abbreviated assessments of
renew eligibility beneficiaries can be used for re-
evaluations.
Increase payment Ranges from 10 to 50 percent. Ranges up to 50 percent. Ranges from 12.5 to 15 percent.
rates for providers Increases range from 10 to 25 Providers of certain services can Increases of 12.5 percent applied
percent depending on the type of receive a payment increase up to to adult day and personal care,
service. Increases up to 50 percent 25 percent. Providers, such as while 15 percent increases applied
can apply to providers of in-home residential habilitation providers, to skilled nursing, assisted living,
services to certain beneficiaries can receive an increased and home health.
who have COVID-19. payment rate up to 50 percent.
Offer retainer Available for 30 days for providers Available for 30 days for direct Wyoming did not implement this
payments to of habilitation services that closed care workers or 90 days for change.
providers due to COVID-19. adult day care providers if
beneficiary is either diagnosed
with COVID-19 or quarantined.
Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) documentation. | GAO-21-104401
Notes: The table reflects changes approved by CMS as of December 2020 and reflects differences
across three temporary changes selected for illustrative purposes. The table does not reflect all of the
temporary changes that each state implemented.
Together, the temporary changes significantly altered how beneficiaries
received and engaged in HCBS. For example, Medicaid HCBS must be
documented in a service plan, which beneficiaries develop with case
managers, typically in person. Meeting in person allows the case
manager to observe the beneficiary at home when determining service
needs. 24 To avoid spreading COVID-19, 50 states sought to transition to
managing beneficiaries’ services virtually—over the phone or video—
rather than in person. Of the five selected states that moved to virtual
service planning, the three that had available data reported that they
23Some states also pursued different changes among the various HCBS programs within
their state, such as varying changes to programs providing services in residential facilities
from programs serving beneficiaries in their homes.
24For more information on care management in long-term services and supports, see
GAO, Medicaid Long-Term Services and Supports: Access and Quality Problems in
Managed Care Demand Improved Oversight, GAO 21-49 (Washington, D.C.: Nov. 16,
2020).
Page 12 GAO-21-104401 Medicaid Home and Community-Based Services
collectively completed more than 250,000 service plans virtually in 2020,
most of which would have been conducted in person, according to state
officials. 25
The temporary changes also directly affected providers by allowing states
to make payment changes to address increased provider costs and
disruptions to provider revenues.
• Changes to address increased provider costs. Adapting to COVID-
19 could lead to HCBS providers paying for additional overtime,
personal protective equipment, hazard pay, and additional training.
For example, Washington state officials reported that providers
needed to offer hazard pay to retain staff who were reluctant to
provide services in beneficiaries’ homes due to fears of contracting
COVID-19. Payment rate increases allowed states to address these
increased costs. All six selected states implemented payment
increases. The four that had available data reported payment
increases in 2020 totaling at least $450 million, ranging from $3
million in Rhode Island to $360 million in Washington. 26
• Changes to address provider revenue disruptions. Some
providers—particularly those providing care in congregate settings,
such as adult day care providers—faced a complete shutdown of care
as a result of public health orders. Others faced disruptions from
beneficiary hospitalizations or isolation due to contracting COVID-19
that reduced revenue. Thirty-nine states used retainer payments,
which were time limited, to help providers stay in business through
those disruptions. The five of our six selected states that implemented
retainer payments reported total payments of at least $98 million in
2020, ranging from $2 million in Washington to $59 million in Illinois. 27
25Data on the number of service plans conducted virtually were not available from two
states—Wyoming and Massachusetts—but officials in Massachusetts told us that such
information is documented in individual case files.
26One state that provided data noted its amounts did not include data for all of the state’s
HCBS programs. In the two remaining states that did not report data—Massachusetts and
North Carolina—officials reported that the state did not have data on the amount of
spending under the payment rate increases.
27Although these additional payments were made due to the COVID-19 emergency, the
emergency also likely decreased other HCBS expenditures, such as payments for
services that were suspended. The five states that implemented retainer payments are
Illinois, Massachusetts, North Carolina, Rhode Island, and Washington.
Page 13 GAO-21-104401 Medicaid Home and Community-Based Services
Selected States As the extent of the COVID-19 emergency became clear, selected states
Implemented Temporary acted quickly to adapt their HCBS programs. Each of our six selected
states obtained approval and began implementing temporary changes in
Changes Quickly and
March 2020, the same month that CMS issued guidance to states on the
Made Minor Adjustments various changes available. 28 To implement the changes, these states
over Time reported taking various actions including providing communication,
conducting training, and leveraging technology. (See table 3.)
Table 3: Six States’ Actions to Implement Certain Temporary Changes to Medicaid Home- and Community-Based Services
(HCBS) Programs during the COVID-19 Public Health Emergency
Action to implement temporary Number of states
changes that took action Examples of actions
Issuing guidance to providers 6 of 6 Massachusetts provided written guidance on documentation requirements
for retainer payments.
Holding information sessions 6 of 6 Illinois communicated with other state agencies and managed care
organizations on implementing the temporary changes.
Providing training to providers and 6 of 6 Wyoming trained public health nurses on using open-ended questions to
state staff better assess beneficiaries over the phone or video.
Communicating to beneficiaries 4 of 6 North Carolina hosted phone calls with beneficiaries about the
about the change implementation of temporary changes for the various HCBS programs.
Making changes to information 4 of 6 North Carolina modified its billing and claims systems to avoid duplicate
technology systems payments to providers receiving retainer payments.
Providing technology to 3 of 6 Washington distributed pre-paid mobile phones to beneficiaries to conduct
beneficiaries assessments or service planning over the phone.
Source: GAO analysis of information provided by state officials. | GAO-21-104401
Officials from selected states told us they generally only needed to make
minor adjustments to the temporary changes over the course of the
emergency. For example, Illinois implemented temporary changes to its
HCBS programs in March 2020 and state officials said they subsequently
made only minor adjustments to these changes, such as resuming in-
person service delivery in some cases, or extending the changes. Also,
officials from Washington told us their initial approval allowed the
temporary changes they wanted, although they made substantive
changes to retainer payment policies by requiring participating providers
to meet new federal requirements. Officials from the five selected states
that implemented retainer payments made substantial updates to their
28Three states implemented these changes based on approvals received after March
2020 that gave retroactive authorization for temporary changes extending back through
March 2020.
Page 14 GAO-21-104401 Medicaid Home and Community-Based Services
retainer payment policies after CMS issued its guidance in June 2020
(see text box). 29
Evolving Guidance on the Use of Retainer Payments during COVID-19
Federal Guidance
In March 2020, the Centers for Medicare & Medicaid Services (CMS) responded to COVID-19 by updating a template for
applying for temporary changes to certain Medicaid home- and community-based services programs in response to
emergencies. The template included the option to make retainer payments to replace the revenue of certain providers whose
services were disrupted.
In June 2020, CMS issued guidance placing new requirements on providers receiving retainer payments for more than 30 days.
For example, the guidance required providers to attest that they would not lay off staff.
Implications of June 2020 Guidance on Implementing Retainer Payments
In the five of our six selected states that implemented retainer payments, officials indicated that the timing of the guidance
created challenges. In particular, states that began implementing retainer payments prior to June 2020 needed to alter their
approaches to meet the new guidance.
Officials from one state told us that the June 2020 guidance was challenging to implement in the middle of the pandemic, but
they issued new state guidance to providers to ensure compliance. In contrast, in another state, officials told us that as a result of
this new guidance, the state decided not to extend retainer payments beyond 30 days.
Source: GAO analysis of Centers for Medicare & Medicaid Services documentation and information provided by selected states. | GAO-21-104401
Selected states maintained approval for temporary changes even as
COVID-19 vaccinations increased and cases fell, but state officials
reported relying less on these changes over time. As of May 2021,
temporary changes remained approved in all of our six selected states.
Officials in four of these states said they had begun scaling back their use
of the changes. For example, officials from North Carolina said that while
they are still maintaining the flexibility for beneficiaries to receive services
virtually—such as adult day care—some beneficiaries had begun to
return to receiving those services in person.
To monitor the effects of COVID-19 and temporary changes made to
HCBS programs, selected states reported using a range of data and input
29One state opted to not continue retainer payments beyond 30 days. CMS made an
additional update to its policy, authorizing states to offer retainer payments for three more
30-day periods in 2021 due to the duration of the COVID-19 emergency. Department of
Health and Human Services, Centers for Medicare & Medicaid Services, Implementation
of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid
Home and Community-Based Services during the COVID-19 Emergency, SMD# 21-003
(Baltimore, Md.: May 13, 2021).
Page 15 GAO-21-104401 Medicaid Home and Community-Based Services
from stakeholders, including managed care organizations, providers, and
beneficiary groups. For example, selected states monitored:
• COVID-19 infections among HCBS beneficiaries. Three of our six
selected states reported monitoring COVID-19 infections or services
related to COVID-19. For example, North Carolina tracked COVID-19
cases and deaths among Medicaid beneficiaries state-wide and by
county; and Wyoming tracked the number of COVID-19 cases,
hospitalizations, and deaths among beneficiaries of each of its HCBS
programs.
• HCBS program enrollment and utilization data. Each of our six
selected states monitored data on HCBS program enrollment and
utilization, according to state officials. For instance, Rhode Island
compared utilization of HCBS services before and during the COVID-
19 emergency to monitor access to HCBS.
• Stakeholder experience. All six selected states reported regularly
communicating with stakeholders to monitor HCBS and the effects of
COVID-19 on those services. For example, Rhode Island met
regularly with HCBS providers and monitored provider data on staffing
levels, according to state officials. Communications with stakeholders
were as frequent as every week in three of our selected states
(Illinois, Washington, and Wyoming), according to state officials.
Temporary Changes Made The temporary changes to HCBS programs enabled selected states to
by Selected States to limit in-person contact with beneficiaries to avoid spreading COVID-19
while maintaining services, but these changes created new challenges to
Protect from COVID-19
ensuring beneficiaries’ health and welfare. Officials from selected states
Led to New Challenges in provided the following examples of these challenges and the actions
Ensuring Beneficiaries’ taken to address them: 30
Health and Welfare
• Assessing beneficiaries’ needs over the phone or video rather than in
person hindered the ability of providers or case managers to observe
beneficiaries’ living conditions and capabilities, such as whether
beneficiaries can access their bathroom, enter and exit their home,
and take medications as prescribed. State officials directed those
completing the assessments to ask beneficiaries additional questions
during the virtual assessments to gain a better understanding of their
living conditions. Officials in one state said that after resuming in-
30Selected states provided examples of challenges they faced, which were illustrative, but
not necessarily comprehensive. We did not determine the extent specific challenges that
states identified were experienced among all selected states, and so do not identify which
states reported experiencing specific challenges.
Page 16 GAO-21-104401 Medicaid Home and Community-Based Services
person visits, case managers have observed problems with
beneficiaries’ quality of life or living conditions that could have been
caught earlier through in-person assessments. For example, case
managers observed the need for additional durable medical
equipment, home modifications, and assistive technology.
• Reports of abuse or neglect fell in the absence of more routine in-
person contact with beneficiaries, creating concerns that incidents of
potential or actual harm to beneficiaries were going unreported.
Officials from one of our selected states told us the state has used
algorithms to target in-person visits to beneficiaries who are
particularly vulnerable to lapses in appropriate care, such as being
prone to isolation or pressure ulcers, also known as bed sores or
pressure sores. 31
• Some investigations of reported incidents of potential or actual harm
to beneficiaries have been delayed or postponed. For example, in one
state, reports of more severe types of incidents—such as abuse and
neglect—had priority for investigation over others, such as financial
exploitation, which have been postponed.
• Conducting virtual reviews of provider facilities limited the ability of
reviewers to conduct a complete, visual assessment, because
reviewers only see what providers show them over video. Also, the
virtual environment does not allow for reviewers to conduct
unannounced visits of provider facilities. Conducting unannounced
visits of provider facilities can reveal conditions that may require
further inspection.
• Re-establishing some quality assurance activities—such as timely
inspections of provider facilities—after the COVID-19 emergency ends
will take time. 32 Officials in one selected state sought additional state
appropriations to reduce the backlog of inspections of provider
facilities and resume timely inspections.
31Pressure ulcers are wounds caused by unrelieved pressure on the skin. They may occur
because of a lack of effective care management.
32For additional information on challenges states will face in resuming normal Medicaid
activities after the COVID-19 emergency ends, see GAO-21-387.
Page 17 GAO-21-104401 Medicaid Home and Community-Based Services
CMS Focused on
Supporting State
Implementation of
Temporary HCBS
Changes and
Conducted Limited
Monitoring and
Evaluation
CMS Helped States During the COVID-19 emergency, CMS’s priority was to support states in
Implement Temporary implementing temporary HCBS changes. CMS officials told us that the
national scope of the COVID-19 emergency resulted in an unprecedented
Changes and Relied on
number of temporary changes being approved. To support states, CMS
States to Monitor the officials said they issued a substantial volume of guidance and technical
Changes during COVID- assistance to states throughout the emergency. (See table 4.)
19 Emergency
Table 4: Examples of CMS Actions to Assist States with Temporary Changes to Medicaid Home- and Community-Based
Services (HCBS) due to the COVID-19 Public Health Emergency, March 2020 to May 2021
Type of assistance Assistance descriptions and examples
HCBS program In March 2020, CMS issued templates and instructions to outline state options for temporary changes to
templates and HCBS programs. For example, these included at least four sets of options to make changes under different
instructions HCBS program authorities.
Responses to Beginning in April 2020, CMS issued responses to frequently asked questions to describe how states could
frequently asked make temporary changes, including delivering HCBS in alternative settings. CMS periodically updated
questions these responses through January 2021.
Disaster Response In March 2020, CMS updated its online Disaster Response Toolkit for states with new COVID-19 guidance.
Toolkit CMS continued to add resources to the online toolkit throughout the emergency, including information on
public health guidelines.
Regular calls with state Beginning in March 2020, CMS held weekly calls with states to assist them in responding to COVID-19,
Medicaid officials including, for example, informing states on options to maintain the provider workforce, avoid unnecessary
in-person contact, and continue delivering HCBS.
Source: GAO analysis of documents from the Centers for Medicare & Medicaid Services (CMS). | GAO-21-104401
Officials from several selected states said that CMS’s guidance and
technical assistance early in the pandemic helped them identify which
changes to make to their programs and how to navigate the approval
process. For example, officials in one state told us that the Disaster
Response Toolkit that CMS updated during the early months of the
pandemic helped them decide which changes to employ for their different
Page 18 GAO-21-104401 Medicaid Home and Community-Based Services
HCBS populations, and to ensure these changes worked for beneficiaries
in a variety of care settings. Officials from another state said CMS’s
HCBS waiver template, which included a list of changes that CMS could
approve, helped the state consider options they had not initially
considered in responding to COVID-19.
Monitoring and Evaluation While CMS helped states to implement temporary changes, the agency’s
Monitoring occurs during an event and is an efforts to monitor the effectiveness of those changes were limited. CMS
ongoing assessment of performance to help a lacked procedures for monitoring the effects of temporary changes during
government agency remain aligned with
changing objectives.
an emergency and determining the need for mid-course changes. CMS’s
Evaluation occurs after the event to measure Pandemic Plan establishes the need for CMS to monitor the efficacy of
impact, determine effectiveness, and identify temporary changes to successfully respond to an ongoing pandemic.
corrective actions to address deficiencies on
a timely basis.
However, the Pandemic Plan does not detail any procedures for doing
Source: GAO. | GAO-21-104401 so—including what information could or should be collected from states—
and, according to agency officials, CMS has no other documented
procedures for monitoring temporary changes during an emergency.
CMS officials told us they generally relied on states to monitor the effects
of the changes during the COVID-19 emergency, emphasizing that states
have the responsibility to monitor their HCBS programs. While CMS has
some general requirements for state monitoring of HCBS programs, the
agency provided limited guidance to states on what to monitor during the
emergency. CMS also did not request or require states to share any data
during the emergency that would allow the agency to assess the
effectiveness of the temporary changes and determine whether mid-
course changes were needed.
• Limited guidance to states on monitoring temporary changes.
CMS has provided limited guidance to states on monitoring the effects
of the temporary HCBS changes during the public health emergency,
such as what information to track. During the COVID-19 emergency,
states faced different operating environments and the additional
objective of limiting disease spread, both of which have implications
for monitoring. 33 Though CMS has issued multiple guidance
33CMS issued a technical assistance document for states on the implications of COVID-19
for section 1115 demonstration monitoring. The document describes monitoring-related
issues that states are likely to face due to the public health emergency. With regard to
HCBS, the document suggests states should describe any related shifts in data trends
such as gaps in data on safety measures or changes in data on HCBS access when
reporting on those trends to CMS. See Centers for Medicare & Medicaid Services,
Implications of COVID-19 for Section 1115 Demonstration Monitoring: Considerations for
States, 2021.
Page 19 GAO-21-104401 Medicaid Home and Community-Based Services
documents during the first year of the COVID-19 emergency to help
implement the temporary HCBS changes, none of those included
guidance on monitoring. In July 2021, CMS issued a voluntary
framework to help states address certain risks related to temporary
changes. This framework encouraged states to identify program
integrity risks—such as paying for services that were not delivered or
were not appropriate—and assess whether additional mitigation
strategies are needed. 34
• Lack of data collection from states. According to CMS officials, the
agency has not requested or required states to provide either
quantitative or qualitative data that would allow the agency to monitor
the effectiveness of the temporary changes during the COVID-19
emergency. 35 CMS officials told us they sought to limit the
administrative burden associated with states monitoring the effects of
temporary changes. Further, according to CMS officials, the agency
considered issuing regulations during the emergency requiring states
to provide monitoring information about HCBS, as it had done for
34The framework CMS provided to states mirrored the framework CMS used to complete
a national assessment of program integrity risks associated with temporary changes to
Medicaid HCBS. This assessment used GAO’s Framework for Managing Fraud Risks in
Federal Programs, which identifies leading practices. For the purposes of this report, we
did not review the extent to which CMS’s assessment followed these practices. CMS
officials determined that the biggest program integrity risks would occur after the COVID-
19 emergency ends, when states must resume normal program integrity activities, such as
provider screening, to avoid improper payments. See Department of Health and Human
Services, Centers for Medicare & Medicaid Services, Risk Assessment Tool for Evaluating
COVID-19 Flexibilities and Waivers (July 15, 2021), and GAO, A Framework for Managing
Fraud Risks in Federal Programs, GAO-15-593SP (Washington, D.C.: July 28, 2015).
35While CMS has not requested these data on temporary changes to HCBS, officials from
certain states mentioned temporary changes to HCBS during broader conversations with
CMS about states’ approaches to Medicaid program changes in response to COVID-19,
according to CMS officials. Specifically, according to agency officials, CMS interviewed
Medicaid directors from seven states in January 2021. CMS officials explained that these
interviews did not focus on HCBS, but officials in some of these states identified
temporary changes to HCBS—such as retainer payments—as being among the Medicaid
program changes that they thought had the greatest impact.
Page 20 GAO-21-104401 Medicaid Home and Community-Based Services
nursing homes, but decided not to do so. 36 Agency officials confirmed
that they did not have state data on critical incidents (which include
incidents of abuse and neglect) and did not know if critical incidents
had increased or decreased during the COVID-19 emergency, though
the officials said states are required to continue tracking these
incidents of actual or potential harm to beneficiaries during the
emergency. 37 CMS also did not have state data on COVID-19
infections or deaths among HCBS beneficiaries, though CMS was
aware that at least nine states were tracking infections and our work
with selected states indicated at least three more were doing so. CMS
officials said they met regularly with their partners from the Centers for
Disease Control and Prevention to identify data on COVID-19 related
deaths that CMS could use to monitor Medicaid HCBS, but these
efforts had not resulted in usable data as of March 2021.
CMS officials described some limited steps taken to monitor the effects of
the temporary changes. For example, CMS analyzed retainer payment
data from two states that, according to CMS officials, typically report high-
quality data. 38 CMS found average retainer payments were slightly lower
than previous average payments in one state, and was not able to
complete the analysis for the other state, because of data reliability
issues. CMS also compiled data on service use to determine the number
and percentage of beneficiaries who received home health and personal
care services during the COVID-19 emergency. 39 However, officials
36CMS officials explained that the agency has infrastructure in place to respond to
monitoring information from nursing homes and other institutional providers, whereas it
does not have this infrastructure for HCBS. For example, CMS officials said that the
agency could help mitigate a COVID-19 outbreak in a nursing home by sending in the
team that conducts regular inspections. In contrast, for a COVID-19 outbreak associated
with an HCBS provider, CMS does not have the infrastructure to take direct action and
would have to rely on states to do so, according to agency officials. For more information
on how CMS’s oversight differs for HCBS and institutional long-term services and
supports see GAO, Elder Abuse: Federal Requirements for Oversight in Nursing Homes
and Assisted Living Facilities Differ, GAO-19-599 (Washington, D.C.: Aug. 19, 2019).
37Our past work has identified that oversight of state monitoring of HCBS programs is
limited by gaps in state reporting, including of critical incidents. See GAO, Medicaid
Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is
Needed, GAO-18-179 (Washington, D.C.: Jan. 5, 2018).
38These data are from the Transformed Medicaid Statistical Information System, which
CMS uses to collect detailed claims, managed care encounters, and eligibility data from all
states.
39These data were also from the Transformed Medicaid Statistical Information System.
Page 21 GAO-21-104401 Medicaid Home and Community-Based Services
explained these data have important limitations and CMS has not used
them to measure the effectiveness of temporary changes.
CMS’s lack of monitoring procedures and limited monitoring of the effects
of the temporary HCBS program changes during the COVID-19
emergency are not consistent with its Pandemic Plan or federal internal
control standards. 40 CMS’s Pandemic Plan establishes that, during a
pandemic, the agency will monitor data on the efficacy of temporary
changes in order to carry out its role, including ensuring Medicaid
beneficiaries maintain access to quality health care. 41 Federal internal
control standards state that management should use quality information
to achieve objectives and establish and operate monitoring activities to
monitor the internal control system and evaluate the results. 42
Without monitoring quality information during public health emergencies
on the effects of the temporary changes on the HCBS program, CMS
cannot assess whether the temporary changes states have implemented
are achieving their intended objectives—which for COVID-19 included
limiting disease spread and maintaining access to services—and make
mid-course changes as needed. Our prior work found that the
unprecedented scale of the COVID-19 emergency has stressed the
capabilities of federal agencies, and CMS officials told us the emergency
has limited the agency’s capacity to develop and carry out monitoring
procedures. 43 Without developing monitoring procedures in advance of
future public health emergencies, CMS is unlikely to conduct necessary
monitoring.
40Department of Health and Human Services, Centers for Medicare & Medicaid Services,
Pandemic Plan, V. 3.1. Public Release (updated Jan. 11, 2021).
41CMS’s Center for Medicaid and CHIP Service’s Strategic Planning Framework, which is
a guide to the center’s response to a public health emergency, was included as an annex
to the Pandemic Plan. According to the framework, the center needs to establish a
mechanism for monitoring during an emergency and monitoring temporary changes is
especially important when the center has approved a large volume of these changes, such
as has been the case during the COVID-19 emergency.
42See GAO-14-704G.
43See GAO-21-387.
Page 22 GAO-21-104401 Medicaid Home and Community-Based Services
CMS’s Plan to Evaluate As of June 2021, CMS officials said they intend to evaluate the temporary
the Effects of the HCBS changes approved in response to COVID-19, but they had no
documented plan for doing so. CMS officials told us that planning around
Temporary HCBS
evaluating temporary changes after the COVID-19 emergency ends was
Changes after the COVID- ongoing, because the emergency remains underway and agency capacity
19 Emergency Is Unclear remains limited. CMS officials told us they formed a workgroup to
evaluate the various tools CMS provides to states to respond to public
health emergencies, including determining whether there is a need to
update the templates states use to apply for temporary changes to HCBS
programs. However, as of June 2021, the workgroup did not have
documentation of its plans, including whether it will evaluate the extent to
which the changes helped limit disease spread and maintain access to
HCBS.
CMS officials told us they will continue to assess regular state reporting
on HCBS program performance after the COVID-19 emergency, including
annual HCBS reports and quality assurance reports. 44 However, it is
unclear whether the information included in these reports will allow CMS
to determine the effects of the temporary changes, and whether the
information will be timely. In particular:
• Annual HCBS reports. These reports include information on the
number of participants, expenditures, and the steps states have taken
to assure program quality. CMS officials told us that these reports
would allow them to compare the number of beneficiaries served
before the emergency with the number served after the changes
expire. However, information on the effects of temporary changes on
COVID-19 spread, such as COVID-19 infection or death rates, may
not be included in those reports. It is also unclear whether these
reports would provide timely information. For our six selected states,
the most recent reports that CMS had received as of May 2021
included reporting end dates that ranged from December 2017 to
June 2019, and one state had not submitted a report. 45 CMS has also
approved delays in state reporting due to COVID-19.
• Quality assurance reports from states. CMS requires states to
submit a quality assurance report on the results of states’ quality
measures before renewing HCBS programs for 5 years. These
measures include, for example, indicators that the state has an
44These reports are required for HCBS programs authorized under section 1915(c).
45CMS officials told us that they were working with the state, Rhode Island, to come into
compliance with the reporting requirements.
Page 23 GAO-21-104401 Medicaid Home and Community-Based Services
incident management system in place to identify and resolve
instances of abuse or neglect. The reports also include corrective
actions taken by states when performance on a quality measure falls
below required thresholds. However, it is unclear whether these
reports would provide needed information to evaluate changes made
during the emergency. For example, the reports may not indicate how
well states prevented the spread of COVID-19. In addition, for states
that recently renewed their HCBS programs, these reports will not be
due for more than 3 years. 46
CMS collects other information the agency could leverage to evaluate the
effects of the temporary changes made in response to COVID-19. This
information includes state utilization data, ongoing program integrity
reviews, and evaluation reports from those states that implemented
temporary changes through section 1115 demonstrations. States
regularly report service use data through CMS’s Transformed Medicaid
Statistical Information System and, as mentioned above, CMS was
already using the data to compile the number and percentage of
beneficiaries who received HCBS at both the state and national level. In
addition, CMS periodically conducts program integrity reviews of states,
which could be leveraged. While reviews done after the emergency may
largely focus on the extent to which states are successful in
reestablishing compliance with requirements waived during the
emergency, such information could be useful in evaluating which changes
resulted in longer-term program integrity risks. For temporary changes to
HCBS programs authorized by section 1115 demonstrations—which were
approved for roughly one quarter of states as of December 2020—CMS
required states to provide evaluation reports within one year of the end of
the COVID-19 emergency, which could include information on lessons
learned.
CMS’s lack of a documented plan for evaluating its response to COVID-
19 makes it unclear whether such an evaluation will occur and inform
planning for future emergencies. According to agency officials, CMS had
not evaluated the effects of temporary HCBS changes in response to
prior emergencies or developed corrective action plans to improve the
46States are required to submit quality assurance reports 18 months prior to the expiration
of their HCBS waiver period, which typically last 5 years.
Page 24 GAO-21-104401 Medicaid Home and Community-Based Services
effectiveness of the changes. 47 Not evaluating its response would be
inconsistent with CMS’s Pandemic Plan. The plan indicates that CMS
anticipates more pandemics related to novel viruses and the need to
evaluate its current response to integrate opportunities for improvement
into future planning efforts. Specifically, the plan indicates that CMS
should consider leveraging qualitative and quantitative results from the
agency’s response to develop a corrective action plan that informs
planning for future emergencies. Though agency officials recognized the
importance of evaluation, CMS is likely to continue to face competing
priorities after the emergency ends. 48 Without evaluating its response to
the COVID-19 emergency, CMS may miss opportunities to identify areas
for improvement and take any needed corrective action as it prepares for
future public health emergencies.
COVID-19 is an unprecedented public health emergency in its national
Conclusions scope and duration. It required states and CMS to take swift action to
prevent the spread of disease among Medicaid beneficiaries and
providers, while also maintaining access to HCBS. In taking these
actions, states sought, and CMS approved, the waiver of a range of
program requirements designed to safeguard beneficiaries and Medicaid
funds. Many of these temporary changes have now been in place for over
a year.
CMS’s Pandemic Plan indicates that the agency should monitor
temporary changes during an emergency and evaluate their impact after
the emergency is over. To date, CMS has taken limited actions to
monitor, and the agency’s plan for evaluating is unclear. While CMS has
issued guidance and provided technical assistance that has provided
important support to states, none of that support acknowledged the need
to monitor the effects of the temporary changes. COVID-19 is the second
47Examples of prior emergencies for which states received approval to make temporary
changes to HCBS programs include the wildfire emergency in California in 2018 and
Hurricane Florence in North Carolina in 2018. Other public health emergencies declared
due to novel viruses include the H1N1 influenza outbreak in 2009 and the Zika outbreak in
2016.
48For example, we have previously found there may be challenges in resuming Medicaid
to normal operations after the end of the public health emergency. See GAO-21-387. In
addition, CMS may continue the need to implement new policies, including the oversight
of temporary enhanced funding for certain Medicaid HCBS expenditures. See American
Rescue Plan Act of 2021, Pub. L. No. 117-2, § 9817, 135 Stat. 4, 216-17. See Centers for
Medicare & Medicaid Services, State Medicaid Director letter No. 21-003, Implementation
of American Rescue Plan Act of 2021 Section 9817: Additional Support for Medicaid
Home and Community-Based Services during the COVID-19 Emergency (May 13, 2021).
Page 25 GAO-21-104401 Medicaid Home and Community-Based Services
novel virus in 5 years that has resulted in a declaration of a public health
emergency, and CMS anticipates more to come. By not setting monitoring
and evaluation as a priority, CMS is missing opportunities to learn from
experience. Learning from the COVID-19 emergency could help CMS
during future emergencies to protect the health and welfare of
beneficiaries and program dollars.
We are making the following two recommendations to CMS:
Recommendation for
Executive Action The CMS Administrator should develop procedures to monitor temporary
changes to Medicaid HCBS programs during public health emergencies.
This should include procedures for collecting and analyzing data during
emergencies on the effects of these changes. (Recommendation 1)
The CMS Administrator should evaluate the temporary changes to
Medicaid HCBS programs after the COVID-19 emergency and develop
corrective action plans to address any opportunities for improvement it
identifies. (Recommendation 2)
We provided a draft of this report to HHS for review and comment. HHS
Agency Comments concurred with both recommendations. HHS’s comments are reproduced
in appendix I. HHS also provided technical comments, which we
incorporated as appropriate.
Regarding our first recommendation—to develop procedures to monitor
temporary changes to Medicaid HCBS programs during public health
emergencies—HHS agreed with the importance of monitoring during
emergencies, but also noted CMS’s and states’ capacity constraints to do
so. HHS indicated that CMS will conduct an evaluation after the COVID-
19 emergency to determine the extent to which monitoring is needed for
future public health emergencies, and will seek state input on any future
monitoring plans. However, we maintain that taking the next step of
developing monitoring procedures, which could be designed with capacity
constraints in mind, will prepare CMS to effectively monitor program
changes made during future emergencies.
Regarding our second recommendation—to evaluate temporary changes
to Medicaid HCBS programs after the COVID-19 emergency and develop
corrective action plans to address any opportunities for improvement—
HHS expressed its full intention for CMS to conduct an evaluation and
address opportunities for improvement. HHS said that planning for this
evaluation is ongoing and CMS will conduct the evaluation after the public
health emergency has ended.
Page 26 GAO-21-104401 Medicaid Home and Community-Based Services
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the
Administrator of CMS, and other interested parties. In addition, the report
will be available at no charge on GAO’s website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at YocomC@gao.gov. Contact points for our
Office of Congressional Relations and Office of Public Affairs can be
found on the last page of this report. Other major contributors to this
report are listed in appendix II.
Carolyn L. Yocom
Director, Health Care
Page 27 GAO-21-104401 Medicaid Home and Community-Based Services
List of Committees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 28 GAO-21-104401 Medicaid Home and Community-Based Services
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
Page 29 GAO-21-104401 Medicaid Home and Community-Based Services
Appendix I: Comments from the Department
Appendix I: Comments from the Department of
Health and Human Services
of Health and Human Services
Page 30 GAO-21-104401 Medicaid Home and Community-Based Services
Appendix I: Comments from the Department of
Health and Human Services
Page 31 GAO-21-104401 Medicaid Home and Community-Based Services
Appendix I: Comments from the Department of
Health and Human Services
Page 32 GAO-21-104401 Medicaid Home and Community-Based Services
Appendix I: Comments from the Department of
Health and Human Services
Page 33 GAO-21-104401 Medicaid Home and Community-Based Services
Appendix II: GAO Contact and Staff
Appendix II: GAO Contact and Staff
Acknowledgments
Acknowledgments
Carolyn L. Yocom (202) 512-7114 or YocomC@gao.gov
GAO Contact
In addition to the contact named above, Susan Barnidge (Assistant
Acknowledgments Director), Russell Voth (Analyst in Charge), Leslie McNamara, and Marie
Suding made key contributions to this report. Other contributors included
Carolyn Garvey, Drew Long, Vikki Porter, and Emily Wilson Schwark.
(104401)
Page 34 GAO-21-104401 Medicaid Home and Community-Based Services
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