CMS should ensure no conflicts of interest in HCBS assessments, GAO says

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CMS Administrator Seema Verma
CMS Administrator Seema Verma

A new report from the Government Accountability Office recommends that Centers for Medicare & Medicaid Services Administrator Seema Verma ensure that no conflicts of interest exist among entities that conduct the needs assessments that are used to determine eligibility for Medicaid home- and community-based services and to develop HCBS plans of service.

The requirements should address both service providers and managed care plans conducting the assessments, the GAO said in the report, dated Dec. 14, 2017, and publicly released Tuesday.

“HCBS needs assessments can directly affect whether individuals are eligible to receive HCBS and the amount of services they receive,” the report authors wrote. “Given the growth in spending for Medicaid HCBS and the potential vulnerability of individuals seeking HCBS, it is critical that needs assessments are effective in ensuring that beneficiaries receive the help they need to live independently while at the same time reducing the risk of over-utilization of HCBS.”

The 1915(c) waivers often used by assisted living operators, together with the 1915(k) and 1915(j) programs, accounted for 60% of estimated expenditures for Medicaid HCBS in fiscal year 2015, the GAO said. Under these programs, states are required to establish standards that generally prohibit HCBS providers from conducting assessments of need used to develop service plans, but this requirement does not apply to assessments that states may use to determine functional eligibility, according to the report.

The Department of Health and Human Services has a regulatory structure in place to protect against conflicts, the GAO said, but there are gaps in standards, and existing conflict of interest requirements related to service plans do not apply to all programs. Developing additional requirements across all types of state programs will improve efficiency and effectiveness, the GAO said.

The study, which based its findings on a review of practices in six states — Connecticut, Kentucky, Minnesota, New York, North Carolina and Washington — was conducted at the request of Sens. Charles E. Grassley (R-IA) and Ron Wyden (D-OR), chairman and ranking member, respectively, of the Senate Finance Committee.

CMS officials also told the GAO that the health agency plans to make the Testing Experience and Functional Tools assessment questions they determine to be valid and reliable available to all states in spring 2018. The questions are being tested in six states.

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