Senior Policy Analyst
Lack of transparency in how the Centers for Medicare & Medicaid Services (CMS) reviews state Medicaid waiver requests “may leave the agency and the public without key information to fully understand the potential impact of the changes being proposed, including on beneficiaries and costs,” according to a new report from the Government Accountability Office (GAO). While acknowledging CMS’ progress in improving transparency, GAO identified areas for further improvement and made two recommendations — but CMS appears unlikely to adopt them fully.
States can request section 1115 Medicaid waivers allowing them to deviate from various federal Medicaid requirements to implement demonstration projects promoting Medicaid’s objectives. Waivers can significantly affect beneficiaries, so transparency in developing and approving them is critical. That’s particularly true under the Trump Administration, which has approved waivers allowing states to take coverage away from beneficiaries who don’t meet work requirements, pay premiums, complete a health assessment, or renew their coverage on time.
As the Affordable Care Act (ACA) required, CMS adopted regulations in 2012 detailing what information state waiver proposals must include and providing opportunity for public comment at both the state and federal levels. The GAO report examined waiver approvals granted from January 2017 through May 2018 and identified several weaknesses in CMS’ approach to transparency:
GAO made two recommendations to address the weaknesses it found. First, CMS should “develop and communicate a policy” that defines when changes to waiver applications are substantial enough to require a new review against the transparency requirements, which would effectively treat the proposal as a new submission. CMS responded, the GAO report notes, by stating that it would develop standards for determining when changes are substantial enough to warrant another federal comment period. But this wouldn’t satisfy the GAO recommendation that states solicit public comments before submitting a revised application to CMS.
Second, GAO recommended that CMS apply the same transparency requirements to waiver amendments as to new applications and renewals. CMS responded that it doesn’t intend to fully adopt this recommendation but instead “will review its current processes and develop additional policies and processes, as needed, to enhance the transparency of such applications [amendments].”
Medicaid waivers can have significant — and potentially harmful — impacts on Medicaid beneficiaries, so transparency is vital. CMS should fully adopt GAO’s recommendation and apply transparency requirements consistently to new applications, renewal requests, and waiver amendments.