Background Medicare Hospice Benefit Eligibility and Coverage To be eligible for the Medicare hospice benefit, an individual must be eligible for Medicare Part A (which covers inpatient care) and be medically certified as having a terminal illness with a life expectancy of 6 months or less if the illness runs it normal course. For individuals to receive care from a Medicare-approved hospice program, they must elect the hospice benefit by signing a statement indicating they are waiving their rights to Medicare payment for services related to curative treatment of their terminal illness. When enrolling in Medicare hospice care, beneficiaries can receive several different types of services in various settings. Most hospice beneficiaries receive hospice care in their own home, but they can also receive care in other settings, such as a nursing home, assisted living facility, hospice facility, or hospital. The Medicare hospice benefit covers a variety of services and supplies for the palliation and management of the terminal illness, including physician and nursing services, medical equipment and supplies including drugs for pain and symptom management, hospice aide and homemaker services, physical and occupational therapy, and spiritual and grief and loss counseling. A hospice interdisciplinary team (in collaboration with the beneficiary’s primary care provider, if any) works with the beneficiary, family, and caregiver(s) to develop a plan of care that addresses the physical, psychosocial, spiritual, and emotional needs of the beneficiary, family members, and caregiver(s). The hospice provider must make all services under the Medicare hospice benefit available to beneficiaries as needed, 24 hours a day, 7 days a week. Although hospice care is designed for beneficiaries with a life expectancy of 6 months or less, beneficiaries can receive hospice care beyond 6 months if they continue to meet hospice eligibility requirements. In addition, beneficiaries can disenroll from the hospice benefit at any time and re-enroll in hospice care at a later time. Medicare Hospice Payment CMS pays hospices based on the level of hospice care provided to beneficiaries on a given day. There are four levels of hospice care, which are paid at either a daily rate or an hourly rate depending on the location and intensity of services provided. (See table 1.) Each care level has a payment rate that is adjusted for geographic differences in wages, and CMS updates these payment rates annually. The most common level of care is called routine home care (accounting for 98 percent of all Medicare hospice care in 2017), and hospices receive the routine home care payment daily rate regardless of whether beneficiaries receive any services on a given day. In addition, CMS imposes two payment limitations (referred to as caps) on Medicare payment for hospice services—one that limits a hospice’s number of inpatient days and one that limits a hospice’s total Medicare payments in a given year. Hospice Quality Reporting Program In response to requirements in the Patient Protection and Affordable Care Act, CMS established the Hospice Quality Reporting Program, which currently includes two sets of data to assess the quality of hospice providers’ care; CMS publishes these data on its Hospice Compare website. Medicare hospice providers are required to submit these data to CMS for all patients regardless of payer source (e.g., Medicare, Medicaid, or private insurance). The two data sets are the following: Provider-reported quality measure data. This set of data (which CMS refers to as the Hospice Item Set) is used to calculate a hospice provider’s performance on quality measures, which include seven measures that reflect the percentage of all hospice patients’ stays where the provider completed various key care processes, such as screening patients for pain and shortness of breath. CMS also recently implemented an eighth measure, called the composite measure, which calculates the percentage of patients’ hospice stays in which the hospice provider completed all seven care process quality measures. Caregivers’ experience survey data. This set of data (referred to as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey) is a national survey that captures, from the caregiver’s (family member or friend) perspective, the patient’s experience with hospice care. The survey includes questions that are used to calculate eight quality measures based on survey responses. For example, one measure scores how well the hospice communicated with the patient’s family. CMS’s Hospice Oversight CMS oversees the quality of Medicare hospice care primarily through inspections—referred to as surveys—which are conducted by state survey agencies contracted by CMS or CMS-approved national private accrediting organizations. These surveys are used to determine whether the hospice is in compliance with federal health and safety requirements detailed in Medicare’s hospice conditions of participation. A hospice must be in compliance with these conditions to participate in the Medicare program. Medicare’s hospice conditions of participation include requirements related to patient care and organizational environment (e.g., the hospice must organize, manage, and administer its resources to provide necessary care). Each condition of participation is composed of standards associated with the condition, and a standard may have associated sub-components. For example, the “patient’s rights” condition includes standards such as “notice of rights and responsibilities” and “rights of the patient.” The “rights of the patient” standard includes sub- components, such as the patient has the right to receive effective pain management and symptom control. There are three main types of survey inspections—an initial certification survey when a provider first seeks to participate in Medicare; a re- certification survey to ensure ongoing compliance; and surveys to investigate complaints or incidents related to federal requirements. If a hospice is found to be out of compliance with hospice health and safety requirements during a survey, CMS cites the provider for non- compliance—referred to as a deficiency. These deficiencies are categorized at one of two levels: Condition-level deficiencies. These deficiencies are the most serious. A condition-level deficiency is one in which the provider violates one or more standards and the deficiencies are of such character as to substantially limit the provider’s capacity to furnish adequate care or which adversely affect the health and safety of patients. When a hospice provider is cited for a condition-level deficiency, CMS places the provider on a 90-day termination track (or 23 days if the situation is determined to pose “immediate jeopardy” to beneficiaries) within which the provider must correct the issue(s) and the correction must be confirmed via a follow-up survey visit. If this does not happen within 90 days of the survey date, CMS terminates the hospice’s Medicare provider agreement; termination is an enforcement remedy CMS uses to ensure compliance. Standard-level deficiencies. These deficiencies are less serious. A hospice provider that has a standard-level deficiency can be certified or re-certified only if the provider has submitted an acceptable plan of correction for achieving compliance within a reasonable period of time. According to CMS officials, standard-level deficiencies must also have follow-up to ensure correction, although the type of follow-up depends on the nature of the deficiency. If a standard-level deficiency is very minor and does not place any beneficiaries at risk, the follow-up may be handled through email or telephone instead of a follow-up visit. According to CMS officials, if a provider fails to submit or implement an acceptable plan of correction within a reasonable period of time acceptable to CMS, the provider is placed on the 90-day termination track noted above. Despite Treating a Similar Number of Beneficiaries as Non- profits, For-profit Providers Received Larger Share of Hospice Payments, Reflecting Differences in Lengths of Stay For-profit and non-profit hospices served roughly the same percentage of the approximately 1.5 million Medicare hospice beneficiaries in 2017, even though for-profit hospices make up about two-thirds of all hospice providers. According to our analysis of CMS data, for-profit providers treated about 50 percent of those beneficiaries and non-profit providers treated about 48 percent in 2017. This distribution has been about the same in each year from 2014 through 2017. For example, for these years, the percentages of beneficiaries treated by for-profit providers ranged from 48.7 percent to 50.2 percent (see additional details in app. I, table 7). When comparing the beneficiary populations treated by for-profit and non- profit hospice providers, we found that they generally had similar demographic characteristics. We identified two primary exceptions to this general finding: (1) non-profit hospices had slightly higher percentages of white beneficiaries, and (2) for-profit hospices had a greater proportion of patients enrolled in both Medicare and Medicaid. See table 2 (for more detailed data, see app. I, table 8). While beneficiary demographic characteristics were generally similar, we found differences in beneficiary diagnoses between for-profit and non- profit hospices. Specifically, for-profit hospices had, on average, a greater percentage of patients with non-cancer diagnoses—77 percent of for-profit hospice beneficiaries compared to 69 percent of non-profit hospice beneficiaries in 2017. Our analysis found that for-profit providers received a higher proportion of Medicare hospice payments than did non-profit providers. For 2017, about $10.4 billion (58 percent) of the $17.9 billion dollars in Medicare payments were made to for-profit providers and $7.2 billion (40 percent) of payments were to non-profit providers. Our analysis found this same pattern in each year from 2014 through 2017. One reason for-profit hospices received a higher portion of Medicare hospice payments for the period we reviewed is because (as previously noted) they had, on average, a greater percentage of beneficiaries with non-cancer diagnoses, and we found non-cancer beneficiaries, on average, had longer lengths of stay. (See table 3.) Since hospices are typically paid a set amount per day of a hospice stay, longer stays generally result in higher payments. Beneficiaries with non-cancer diagnoses can often have longer lengths of stay compared to other beneficiaries because the progression of these diseases (such as dementia) can be harder to predict; this may result in beneficiaries being enrolled in hospice earlier than appropriate (meaning that their projected life expectancy may actually be longer than 6 months). For instance, one study noted that dementia beneficiaries’ decline may include periods of stabilization where their health stays the same or even improves, which differs from a constant and predictable decline in most beneficiaries with terminal cancer. There are likely other factors beyond a greater percentage of beneficiaries with non-cancer diagnoses that contributed to for-profit providers’ higher portion of Medicare hospice payments. We found that for-profit providers had, on average, longer lengths of stay for both cancer and non-cancer beneficiaries compared to non-profit providers. (See table 3.) For example, non-cancer beneficiaries at for-profit providers had an average length of stay of 108 days, while non-cancer beneficiaries at non- profit providers had an average length of stay of 67 days. This suggests other factors besides beneficiary diagnosis contributed to longer average length of stay for for-profit providers. (For more detailed beneficiary diagnosis data from 2014 to 2017, see app. I, table 9.) For-profit and Non- profit Providers Scored Similarly on CMS’s Quality Measures, though Performance Varied on Other Indicators of Quality For-profit and non-profit hospice providers had similar scores on CMS’s current quality measures (provider-reported measures and caregivers’ experience measures assessed through a survey of the beneficiaries’ caregiver). CMS uses these measures to assess the quality of care provided by hospices. In addition to CMS’s current quality measures, researchers we interviewed noted that there are other care indicators that can also be used to assess the quality of care provided by hospices. According to CMS documents, CMS is working to account for other care indicators by developing additional quality measures. We assessed hospice providers’ performance on these indicators and found that performance varied between for-profit and non-profit hospices. For-profit and Non-profit Hospices Had Similar Scores on CMS’s Current Quality Measures, Though For-Profits Were More Often Among Subset with Lowest Scores on Certain Measures Our review of CMS data found that for 2017, both for-profit and non-profit hospices, on average, had similar scores on the seven quality measures that are provider-reported and that CMS currently uses to assess the quality of hospice care. (See table 4.) For six of the seven measures, for-profit and non-profit hospices had average scores of 94.7 percent or better. We also found that for-profits and non-profits had similar scores (83.6 percent and 87.0 percent, respectively) on a new composite measure that CMS implemented in 2017. This composite measure was designed to provide a more comprehensive evaluation of the hospice’s care by determining whether the hospice provider completed all of the applicable parts of hospice care that are measured by the seven quality measures. When looking at the subset of providers with the lowest scores on the composite quality measure, we found that for-profit hospices were more often in this subset, even when accounting for differences in the number of for-profit and non-profit providers: For the composite measure, there were 329 providers (261 for-profits and 68 non-profits) in the 10th percentile of scores or lower, meaning that the providers had a composite measure score of 64.3 percent or lower. Among these providers, we found that for-profits were more likely to be within this grouping, with about 12 percent of all for-profit providers having scores in the 10th percentile or lower compared to 6 percent of all non-profit providers. We also assessed the subset of these 329 providers that had composite measure scores below 50 percent, meaning that they only completed all of CMS’s seven quality measures for half or fewer of the beneficiaries they treated. We found that 130 providers (112 for-profits and 18 non-profits) had scores below 50 percent on this measure. These providers treated over 24,000 beneficiaries. In addition to the provider-reported quality measures, CMS also uses the caregivers’ experience survey to assess quality of care. We analyzed CMS data on caregivers’ experience surveys for 2016 to 2017 and found that caregivers’ reported experience with hospice care was generally similar for both for-profits and non-profits. The survey assesses care in a number of areas, such as communication, training, and help with pain and symptoms. See table 5 (for more detailed data, see app. I, table 10). Although for-profit and non-profit providers’ average scores on the caregivers’ experience survey were generally similar, we found that for- profit providers were more often among those providers with the lowest scores on certain caregivers’ experience measures than were non-profit providers. For example, on the rating measure that asks caregivers to give an overall rating of the hospice, 290 providers (248 for-profit providers and 42 non-profits) had scores at the 10th percentile or lower, meaning that their score was 72 percent or lower. For this measure, lower scores mean that fewer caregivers provided a rating of 9 or 10 on a 10- point scale, with 10 being the highest possible rating. We found that 15 percent of for-profit providers were among providers with scores in the 10th percentile or lower compared to 4 percent of non-profit providers. Performance Varied between For-profit and Non-profit Hospices for Other Indicators of Quality Identified by Researchers We used Medicare claims data to calculate certain measures researchers told us could be indicators of quality of care in hospice settings. (As noted previously, CMS is working to account for other care indicators by developing additional quality measures.) These indicators fall into two categories: (1) the number of beneficiaries discharged prior to death (often referred to as the live discharge rate) and (2) provider visits to provide medical and emotional support to the beneficiary and caregivers near the end of a beneficiary’s life. Researchers told us that such measures can fill gaps in assessing the quality of care provided by hospices, and show greater variability across hospices than CMS’s current quality measures; as previously noted, our data analysis found that providers’ quality measure scores were generally very high. Live Discharges According to researchers we interviewed and studies we reviewed, some discharges from hospice care prior to death should be expected because, for example, patients change their mind about receiving hospice care or their condition improves and they are no longer eligible for hospice care. However, a high live discharge rate could in some cases be an indicator of poor quality of care provided or of provider misuse of the benefit, in that they may be enrolling beneficiaries who are not eligible for hospice. See text box. Live Discharges In some cases, a beneficiary may be discharged alive from hospice care prior to their death. This could be for reasons unrelated to the quality of care provided. For example, beneficiaries may reconsider their decision to start palliative treatment, and therefore leave hospice care to re-start curative treatments. In other instances, a live discharge may indicate quality of care issues. For example, a beneficiary may be unhappy with the quality of care she is receiving from her hospice provider and therefore she leaves that hospice provider to seek treatment from a different hospice provider. Given the various reasons for live discharges, we expect that hospices will have some live discharges, but interpret a high rate of live discharges as potentially suggestive of quality of care issues. We found that for-profits had higher rates of live discharges than non- profits, with 22.1 percent of beneficiaries served by for-profits being discharged alive compared to 12.0 percent of beneficiaries served by non-profits in 2017. This disparity remained true after accounting for whether beneficiaries had a cancer or non-cancer diagnosis. (See table 6; for more detailed data from 2014 to 2017, see app. I, table 11.) We found that 472 hospice providers (462 for-profit and 10 non-profit providers) had live discharge rates of 50 percent or more in 2017, meaning that half or more of their beneficiaries were discharged from hospice care prior to death. These providers provided care to about 6 percent of all beneficiaries discharged alive in 2017. According to researchers we interviewed and one of the studies we reviewed, provider visits near the end of a hospice beneficiary’s life are critical to providing quality care, including for emotional support and for training the beneficiary’s family members or other caregivers on the signs and process of dying. Assessing the number of visits near the end of life may provide insight into the quality of a hospice provider’s care; fewer visits in that time period could indicate poor quality of hospice care. CMS is currently developing a quality measure that assesses the frequency of provider visits at the beneficiary’s end of life. When analyzing CMS claims data, we found that for-profit and non-profit hospices, on average, provided a similar number of provider visits (such as nurse, doctor, social worker, or hospice aide visits) within the last 7 days of a beneficiary’s life. Specifically, in 2017, for-profits and non-profits both averaged about 6 provider visits within the last 7 days of life. We also looked at the average percentage of hospice beneficiaries who received different types of provider visits either within the last 3 days of life or last 7 days of life (consistent with CMS’s new quality measure) and found performance varied among for-profit and non-profit providers: 77 percent of for-profit beneficiaries and 85 percent of non-profit beneficiaries received at least one visit from registered nurses, physicians, or nurse practitioners in the last 3 days of life. 68 percent of for-profit beneficiaries and 57 percent of non-profit beneficiaries received at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life. We also found more for-profits than non-profits among a subset of hospices that did not provide any visits during the last 3 or 7 days of life in 2017. Specifically, our analysis shows that 83 hospice providers (80 for- profits and 3 non-profits) did not provide any visits in 2017 from registered nurses, physicians, or nurse practitioners in the beneficiaries’ last 3 days of life. This means that all of the 800 hospice beneficiaries treated by these providers did not receive these types of provider visits at the end of life. In addition, we found that 58 providers (55 for-profits and 3 non- profits) did not provide any visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life in 2017; all of the 613 beneficiaries treated by these providers did not receive these specific provider visits at the end of life. Opportunities Exist to Strengthen CMS Oversight through Increased Use of Information in Survey Process and Expanded Statutory Authority for Enforcement CMS Could Strengthen Oversight of Hospice Providers by Using Additional Information to Enhance the Survey Process In our review of CMS’s oversight of hospice providers, we found CMS does not instruct surveyors to review, prior to surveying hospice providers, providers’ performance on CMS quality measures (those based on provider-reported quality data or caregivers’ experience surveys) or other indicators of quality that could identify potential areas of concern. CMS issues guidance that surveyors use when conducting surveys to assess a hospice provider’s compliance with federal health and safety requirements. According to this guidance, surveyors are to prepare for hospice surveys by reviewing documents of record including licensure records, previous survey findings and complaints, media reports, and other publicly available information about the provider. A representative for an association representing state surveyors confirmed that this is the type of information surveyors typically review prior to a hospice provider survey. However, according to CMS officials and the surveyor association, CMS does not instruct surveyors to review other information such as providers’ performance on CMS quality measures or other indicators of quality that surveyors could use to identify potential areas of concern that they could focus on more closely during a survey. For example, it might be helpful for surveyors to know if a hospice provided no visits during beneficiaries’ last days of life. According to CMS officials, CMS does not use such information to target hospices for additional survey review. Several studies we reviewed and researchers we interviewed noted CMS could strengthen its survey process by incorporating additional information into the survey process, such as information on how hospice providers perform on CMS quality measures or other potential indicators of quality. For example, one study suggested that hospices with poor reported beneficiary experiences based on caregivers’ experience survey data could be identified for more frequent surveys and that such information could be used to identify care processes for closer review during surveys. Another study we reviewed concluded that claims- based measures could help guide surveyors to more closely review key processes of care to ensure Medicare beneficiaries receive high quality hospice care. In addition, a researcher we interviewed suggested when claims data show no visits during the last 2 days of life, the survey team could interview the deceased patients’ families to see if there was any harm done by the lack of visits at the end of life. And, in July 2019, the Department of Health and Human Services’ Office of the Inspector General (HHS OIG) reiterated recommendations from prior HHS OIG work that CMS analyze claims and deficiency data to identify specific patterns identified by the HHS OIG that could indicate potential issues— such as hospices that infrequently provide physician services—and that CMS instruct surveyors to pay special attention to these areas during surveys. In contrast to hospice surveys, home health agency surveyors utilize information in addition to survey findings and complaints to identify potential areas of concern. According to CMS officials and the surveyor association we interviewed, home health surveyors review certain CMS quality measures to focus the survey on specific areas of concern or to identify beneficiaries who experienced potential care issues for a more detailed survey review. According to CMS officials, the agency is considering making changes to the survey process but has not yet made any decisions. CMS officials told us they last updated the survey process in 2010, and since then, they have implemented quality measures for hospice providers (provider- reported measures in 2014 and caregivers’ experience survey measures in 2015). They also said that CMS is “currently monitoring the implementation of these programs and considering the potential benefit of incorporating review of the data into the survey process.” According to federal standards of internal control, agencies must identify, analyze, and respond to risks related to achieving objectives. By not utilizing additional information in the survey process that would allow it to identify providers and areas where risk of noncompliance is greatest, CMS is missing an opportunity to strengthen its ability to identify and respond to such risks and ensure the quality of care that hospice beneficiaries receive. CMS Has Limited Enforcement Remedies Due to Lack of Statutory Authority, Which Could Restrict Its Ability to Ensure Compliance CMS is limited to one hospice enforcement remedy—termination of the Medicare provider agreement. By law, to qualify for payment under the Medicare program, hospice providers must meet the program’s conditions of participation. If the agency finds a provider is not complying with the program’s conditions of participation, CMS may terminate the provider’s participation in the program. In the Medicare program, termination of a provider is the most significant action CMS can take to address provider non-compliance. As a result, CMS generally only terminates a hospice provider on the basis of a deficiency when the provider fails to correct a condition-level deficiency (the most severe) within the required time frame. Our review of CMS hospice survey data found termination happens rarely. Specifically, 19 hospices were involuntarily terminated from 2014 through 2017. This is less than half of 1 percent of the total number of hospices operating during this time period. In contrast to hospice care, where CMS’s enforcement authority is limited to termination, Congress has given the agency authority to impose additional enforcement remedies for other provider types. Additional statutory and regulatory penalties for home health agencies and nursing homes include civil money penalties, denial of payment for all new Medicare and Medicaid admissions, and imposition of training requirements for situations where it is determined that education will likely lead to provider compliance (referred to as directed in-service training). Such remedies, if available, could enable the agency to more effectively address a broader range of hospice risks. For example, additional remedies could be used in situations that warrant a remedy other than termination or that could further incentivize providers to comply with health and safety requirements or improve their quality of care. According to federal standards of internal control, agencies must identify, analyze, and respond to risks related to achieving objectives. Because CMS lacks the authority to establish such additional remedies, the agency’s ability to respond to risks and ensure quality of care for beneficiaries is limited. The HHS OIG and one researcher we interviewed have recommended CMS seek statutory authority to establish additional enforcement remedies for hospices, explaining that less severe remedies could help address performance problems that may not merit termination and incentivize agencies to improve quality of care. CMS agreed with this recommendation in March 2016 and stated it would consider submitting a request that would seek legislative authority to establish additional enforcement remedies through the President’s annual budget proposal to Congress. In a July 2018 HHS OIG report, the HHS OIG again recommended CMS seek this authority. CMS neither agreed nor disagreed with this recommendation and stated again that it would consider this recommendation when developing the agency’s proposals for the President’s annual budget. However, a request for such legislative authority was not included in the President’s fiscal year 2017, 2018, or 2019 budget proposals. The HHS OIG reiterated this recommendation in two July 2019 reports. Conclusions Since 2000, the number of Medicare hospice beneficiaries has almost tripled to nearly 1.5 million in fiscal year 2017. In addition, the number of hospice providers has doubled. Given this growth, it is imperative that CMS’s oversight of the quality of Medicare hospice care keeps pace with changes so that the agency can ensure the health and safety of these terminally ill beneficiaries. While recent steps have been taken to strengthen CMS’s hospice quality oversight, including the requirement that hospices be re-certified every 3 years and CMS’s ongoing development of new quality measures, we identified additional opportunities to strengthen CMS’s oversight. Specifically, our review found that CMS could strengthen oversight by using additional information—based on currently available data—to identify potential quality issues that could focus and enhance the survey process. We also found that CMS’s lack of authority to establish additional enforcement remedies before termination, which CMS rarely uses, limits its ability to ensure hospice providers’ compliance with health and safety requirements and quality of care for beneficiaries. Matter for Congressional Consideration Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. (Matter for Consideration 1) Recommendation for Executive Action The Administrator of CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers. (Recommendation 1) Agency Comments We provided a draft of this report to HHS for review and comment. HHS provided written comments, which are reprinted in appendix II. HHS concurred with our recommendation. HHS stated that it recognizes that meaningful quality measures can also serve as key indicators of provider quality and it will look into ways to incorporate the use of these data into the hospice survey process. In its comment letter, HHS also noted the importance of monitoring patient safety and quality of care to HHS’s hospice oversight efforts and the agency provided an overview of the key efforts it has in place to perform such monitoring. For example, in addition to survey and quality measure requirements, HHS requires hospices to implement a data-driven quality assessment and performance improvement program, intended to have hospices take a proactive approach in improving their performance using objective data. HHS also provided technical comments, which we incorporated into the report as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services, the CMS administrator, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Appendix I: Additional Data on Medicare Hospice Beneficiaries, Providers, and Payments Dollars Percentage Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice Non-profit hospice providers’ average scores Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice Government-owned hospice providers’ average scores Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice 2.5 survey within three categories (top scores, middle scores, and bottom scores). These data were not available for all hospice providers; our analysis of CMS caregivers’ experience survey quality measure data was for the 2,832 hospice providers that had data for the caregivers’ survey. In general, the top-box scores represent the percentage of caregivers that selected the response of “always” for the particular measure. For the rating measure, the top-box score represents caregivers that rated the hospice provider as a 9 or 10 on a 10-point scale with 10 being the highest rating. For the recommendation measure, the top-box score represents caregivers that responded that they “would definitely recommend the hospice provider.” In general, the middle-box scores represent the percentage of caregivers that selected the response of “usually” for the particular measure. For the rating measure, the middle-box score represents caregivers that rated the hospice provider as a 7 or 8 on a 10-point scale with 10 being the highest rating. For the recommendation measure, the middle-box score represents caregivers that responded that they “would probably recommend the hospice provider.” Percentage of beneficiaries discharged prior to death Appendix II: Comments from the Department of Health and Human Services Appendix III: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Gregory Giusto, Assistant Director; Christie Enders, Analyst-in-Charge; Todd Anderson, Leia Dickerson, Rob Dougherty, Krister Friday, Barbara Hansen, Jennifer Whitworth, and Chris Wickham made key contributions to this report.


Background Medicare and Medicaid Coverage for Dual-Eligible Beneficiaries Dual-eligible beneficiaries qualify for both Medicare and Medicaid, and may enroll in and receive benefits covered by each program. Individuals ages 65 or older can qualify for Medicare based on age, and individuals ages 18 to 64 can qualify for Medicare based on disability. Medicaid eligibility varies by state, but beneficiaries may qualify based on having a low level of income, a need for nursing home care, high medical expenses, or other criteria. For dual-eligible beneficiaries, Medicare is the primary payer for any benefits covered by both programs. As a result, Medicare is the primary payer for acute and post-acute care, such as physician services, hospitalizations, prescription drugs, and skilled nursing facility care. For many dual-eligible beneficiaries, Medicaid covers benefits not covered by Medicare. This includes long-term services and supports, which may include nursing home care, personal care services, or adult day care. Whether Medicaid covers these benefits varies between the two main categories of dual-eligible beneficiaries. Those in the first category are known as full-benefit, dual-eligible beneficiaries, because they may receive all Medicaid benefits, in addition to Medicare benefits. Medicaid also pays for their Medicare premiums and, in some cases, the cost- sharing for their Medicare benefits. Those in the second category are known as partial-benefit, dual-eligible beneficiaries, because Medicaid assistance is limited to payment of their Medicare premiums and, in some cases, the cost-sharing for their Medicare benefits. Partial-benefit, dual- eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for full Medicaid benefits in their state. For Medicare, dual-eligible beneficiaries can choose to receive their Medicare services from either traditional Medicare or from MA plans. These options differ in key ways. For example, traditional Medicare may have a more extensive provider network than MA plans. However, MA plans may cover additional benefits, such as vision or dental care, which are generally not covered under traditional Medicare. If dual-eligible beneficiaries choose to enroll in MA plans, they may also have the choice between regular MA plans and D-SNPs, which offer certain services targeted at the needs of dual-eligible beneficiaries. For example, D-SNPs are required to perform health risk assessments, create individualized care plans, and provide an interdisciplinary care team for each beneficiary enrolled. They may also cover transportation services, home modifications, or other specialized services that are more likely to be used by dual-eligible beneficiaries. For Medicaid, states may allow or require Medicaid beneficiaries, including dual-eligible beneficiaries, to receive their Medicaid benefits through an MCO. In this managed care model, Medicaid MCOs are responsible for arranging for and paying providers’ claims for a specific set of Medicaid benefits provided to beneficiaries. More recently, some states have created new Medicaid managed care programs or expanded the benefits covered by existing Medicaid managed care programs in order to include additional populations previously covered through Medicaid fee-for-service. The new populations include seniors, persons with disabilities, and those who need long-term services and supports— many of whom may be dually eligible. Aligned Enrollment in D- SNPs in States with MLTSS A dual-eligible beneficiary may be able to enroll in a D-SNP and Medicaid MCO that are offered by the same or related companies, an arrangement known as aligned enrollment. In states with MLTSS, aligned enrollment means the same or related companies provide a beneficiary’s Medicare benefits, such as primary and acute care, through a D-SNP and Medicaid benefits, such as long-term services and supports, through a Medicaid MCO. State Medicaid agencies enter into contracts with both D-SNPs and Medicaid MCOs, and these contracts may include provisions to facilitate and encourage aligned enrollment. Since January 2013, all D-SNPs have been required to have an executed contract with the Medicaid agency in each state in which it operates. A state can enter into contracts with all, some, or none of the D-SNPs seeking to operate in the state, and any D- SNPs that the state declines to contract with cannot operate in the state. Each year, CMS reviews D-SNPs’ contracts with states to ensure that they include eight required elements, including the D-SNP’s responsibility for providing or arranging the provision of Medicaid benefits, among other things. According to CMS officials, in these reviews, CMS does not collect information regarding whether states are imposing requirements pertaining to aligned enrollment. States also have contracts with Medicaid MCOs, which can include requirements that could facilitate or encourage aligned enrollment. As shown in table 1, CMS’s Integrated Care Resource Center has identified five types of approaches that states can use to encourage aligned enrollment. For example, states can manage which D-SNPs operate in the state, such as only allowing D-SNPs with an aligned Medicaid MCO (that is, a MCO offered by the same company or a related company). This gives dual-eligible beneficiaries greater options for choosing aligned enrollment. As another example, states can allow the automatic assignment of certain dual-eligible beneficiaries to a D-SNP aligned with a Medicaid MCO, a process known as default enrollment. Default enrollment, which requires CMS approval, can directly increase the number of dual-eligible beneficiaries with aligned enrollment. Coordinated Care for Dual-Eligible Beneficiaries Inside and Outside of D- SNPs In addition to D-SNPs with aligned enrollment, two other types of Medicare plans—Medicare-Medicaid plans and Program of All-Inclusive Care for the Elderly plans—exclusively or primarily serve dual-eligible beneficiaries and are responsible for both Medicare and Medicaid benefits. These three types of Medicare plans jointly served approximately 818,000 dual-eligible beneficiaries as of January 2019. Aligned enrollment in D-SNPs: As of January 2019, approximately 386,000 dual-eligible beneficiaries enrolled in D-SNPs had aligned enrollment, according to a report by the Medicare Payment Advisory Commission. This includes beneficiaries in a subset of D-SNPs that have been designated as fully integrated D-SNPs, which must meet additional specific requirements. For example, they must provide both Medicare and Medicaid benefits through a single managed care plan. In addition, the Medicaid benefits provided by the fully integrated D- SNPs must include long-term services and supports. Medicare-Medicaid plans: As of January 2019, approximately 388,000 dual-eligible beneficiaries in nine states were enrolled in these types of plans. These plans, which were established through CMS’s Financial Alignment Initiative, provide all Medicare benefits and all or almost all Medicaid benefits, and have some administrative processes that have been combined. In April 2019, CMS sent a letter to state Medicaid directors inviting additional states to express interest in the use of Medicare-Medicaid plans. Program of All-Inclusive Care for the Elderly plans: As of January 2019, approximately 44,000 beneficiaries in 31 states were enrolled in these types of plans. Most, but not all, are full-benefit, dual-eligible beneficiaries, and they are ages 55 or older and need the level of care provided in a nursing home. The plans are provider-sponsored and provide all Medicare and Medicaid benefits. In addition, each plan is required to have a physical site to provide adult day services. Most States that Can Encourage Aligned Enrollment Have Begun to Do So As of July 2019, of the 19 states with MLTSS and where aligned enrollment of dual-eligible beneficiaries in D-SNPs is possible, 16 have implemented at least one of the five approaches to encourage aligned enrollment identified by CMS’s Integrated Care Resource Center. (See fig. 1.) Of those 16 states, 11 managed which D-SNPs operate in the state, which is the foundation for promoting aligned enrollment, according to officials from the Integrated Care Resource Center. Of our seven selected states, all of them had implemented at least one of the five approaches to encourage aligned enrollment in 2019. The three most common approaches among our selected states were (1) managing which D-SNPs operate in the state; (2) limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries; and (3) encouraging D-SNP marketing to better support informed beneficiary decision-making. The details of the approaches implemented in each state varied widely. Managing which D-SNPs operate in the state. Five of the seven selected states (Arizona, New Jersey, Pennsylvania, Tennessee, and Virginia) managed which D-SNPs operated in 2019, but they varied in how they implemented this approach. For example, when Virginia established its Medicaid MLTSS program in 2017, only one D-SNP operated in the state, and Virginia required the companies with Medicaid MLTSS contracts to also start offering D-SNPs within 3 years. In contrast, when Pennsylvania and Tennessee implemented this approach, multiple D-SNPs already operated in each state. Pennsylvania and Tennessee required new D-SNPs to have aligned Medicaid MCOs, but allowed existing D-SNPs to continue operating. As a result, beneficiaries had the choice between D-SNPs that had aligned Medicaid MCOs and D-SNPs that did not have aligned Medicaid MCOs. Medicaid officials in these two states told us they chose not to cancel existing D-SNPs that did not have aligned Medicaid MCOs, as doing so could have disrupted beneficiary- provider relationships. As a result of the selected states’ differing approaches to managing which D-SNPs operated, the proportion of aligned to unaligned D-SNPs in each state varied. (See fig. 2.) Limiting D-SNP enrollment to full-benefit, dual-eligible beneficiaries. Five of the selected states (Arizona, Kansas, New Jersey, Pennsylvania, and Virginia) limited D-SNP enrollment in some or all of their D-SNPs to full-benefit, dual-eligible beneficiaries in 2019. In particular, Arizona and New Jersey Medicaid officials said that limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries allowed D-SNPs to provide a more straightforward benefit package. In turn, this can be more easily described in D-SNP materials and communications, which may help beneficiaries to make more informed decisions around aligned enrollment. Encouraging D-SNP marketing to better support informed beneficiary decision-making. Five of the selected states (Arizona, New Jersey, Pennsylvania, Tennessee, and Virginia) took steps to encourage D-SNP marketing to support informed beneficiary decision-making in 2019. For example, Arizona and Pennsylvania encouraged D-SNPs to directly market themselves to beneficiaries in the D-SNP’s aligned Medicaid MCO, in order to promote aligned enrollment. In addition, New Jersey Medicaid officials told us they review D-SNP marketing and work directly with D-SNPs to develop standard marketing language. In particular, the officials said some D-SNPs had marketed themselves as offering certain extra benefits, but those benefits were already a standard part of the state’s Medicaid package. The officials said they worked with the D-SNPs to correct the marketing, and they also developed standard language for marketing in the state. This can help reduce beneficiary confusion when making enrollment decisions. Automatically assigning certain beneficiaries to plans with aligned enrollment. Four selected states (Arizona, Florida, Pennsylvania, and Tennessee) allowed automatic assignment of certain beneficiaries to plans with aligned enrollment in 2019. For example, Arizona, Pennsylvania, and Tennessee allowed default enrollment by which certain Medicaid beneficiaries were automatically assigned to aligned D- SNPs. Under federal rules, beneficiaries have the opportunity to opt out prior to being default enrolled and select a different source of Medicare coverage; they also have the opportunity to disenroll within the first 90 days after default enrollment and select a different source of Medicare coverage. In addition, Florida and Pennsylvania automatically assigned certain dual- eligible beneficiaries to aligned Medicaid MCOs. For example, Florida law requires the state Medicaid agency to automatically assign certain D-SNP enrollees to aligned MLTSS plans when beneficiaries become eligible for long-term services and supports and have not voluntarily chosen an MLTSS plan. Engaging counselors to assist beneficiaries with aligned enrollment decisions. Two of the seven selected states (Arizona and Pennsylvania) engaged enrollment counselors to encourage aligned enrollment in 2019. For example, Arizona’s state Medicaid office works with the state’s Aging and Disability Resource Center and State Health Insurance Assistance Program counselors to increase beneficiary understanding of aligned enrollment and options to enroll in aligned plans. In 2019, Pennsylvania’s contracts with D-SNPs required collaboration between the D-SNPs and the state’s independent enrollment broker that assists beneficiaries with Medicaid enrollment. In addition to there being variation in the selected states’ use of approaches to encourage aligned enrollment, the proportion of D-SNP enrollees with aligned enrollment varied from 20 percent in Pennsylvania to 100 percent in New Jersey among the selected states that were able to provide data for 2019. (See fig. 3.) There can be multiple reasons for the varied levels of aligned enrollment between D-SNPs and MLTSS. For example, Arizona recently entered into new Medicaid MCO contracts, and this resulted in changes to the parts of the state served by each Medicaid MCO. According to state Medicaid officials, these new contracts somewhat reduced the extent of aligned enrollment. Medicaid Officials in Selected States Described Challenges with Aligned Enrollment Medicaid officials in the seven selected states described various challenges with aligned enrollment. The most common challenge mentioned was difficulty using D-SNP data to implement and evaluate aligned enrollment policies. Medicaid officials in the selected states told us many of these challenges require ongoing monitoring and collaboration with CMS and the companies offering D-SNPs. Difficulty using data to implement and evaluate aligned enrollment. Medicaid officials in six of the selected states (Florida, Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) told us that using D-SNP and Medicare data to implement and evaluate aligned enrollment policies can be difficult. For example, Tennessee Medicaid officials told us that getting the data from CMS needed for default enrollment was a challenge. In particular, they said that, when the state was first starting to implement default enrollment, they had challenges with getting data from CMS in a timely fashion to identify which Medicaid beneficiaries were about to become dually eligible for Medicare, particularly those with eligibility due to disability. This meant that the state could not provide D-SNPs with the information needed by the D-SNPs to send notices to those beneficiaries in the required time frame. CMS officials also acknowledged that its data do not always identify individuals becoming eligible for Medicare early enough for D-SNPs to send notices in the required time frame. Tennessee Medicaid officials told us that CMS has worked with the state on this issue and it has now become easier for the state to receive the needed data. Furthermore, CMS and its Integrated Care Resource Center have also developed materials and, according to CMS officials, provided ongoing technical assistance for states on accessing data for default enrollment and other aspects of implementation of aligned enrollment. Medicaid officials in Virginia and New Jersey described related challenges with using D-SNP data to determine whether their policies work. Virginia Medicaid officials told us that it can be difficult to evaluate the health benefits of aligned enrollment, because data on quality measures can span multiple states. Specifically, one of the state’s D- SNPs operates in multiple states and therefore reports health outcome data to CMS for its entire service area. Virginia Medicaid officials told us they are not able to separate data for Virginia residents from those of other states. As a result, they said they currently cannot determine the effect of their aligned enrollment policies, and they plan to require the D- SNP to report Virginia-specific quality data in the future. New Jersey Medicaid officials described a challenge with receiving the relevant data to evaluate health outcomes for dual-eligible beneficiaries with aligned enrollment. The state has CMS approval to receive Medicare data directly from CMS. However, as of November 2019, the state’s data vendor was not in compliance with federal Medicare data security requirements for storing certain data, which meant that the state could not accept the Medicare data. The Bipartisan Budget Act of 2018 encourages CMS to require reporting of MA quality measures, including D-SNP quality measures, at the plan level. However, CMS has identified several challenges to developing such a requirement. One challenge CMS has identified is that about two- thirds to three-quarters of D-SNPs would not have reliable ratings, for example, because those plans had too few participants in the survey. Another challenge CMS has identified is the additional complexity and administrative burden for plans completing this reporting. As of December 2019, CMS officials told us they are continuing to work to determine the best reporting level for each quality measure. They also plan to collect additional feedback from stakeholders and a technical expert panel. Difficulties with information dual-eligible beneficiaries receive about Medicare enrollment choices. Medicaid officials in five of the selected states (Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) told us they have experienced challenges in ensuring that beneficiaries receive quality information about their Medicare enrollment choices. For example, in 2019, Pennsylvania’s contracts with D-SNPs required collaboration between the D-SNPs and the state’s independent enrollment broker that assists beneficiaries with Medicaid enrollment. However, Pennsylvania Medicaid officials told us the state’s independent enrollment broker did not have the capacity to provide this type of assistance in addition to its primary responsibility of assisting beneficiaries with Medicaid enrollment. As another example, Virginia Medicaid officials told us they have faced challenges using state D-SNP contracts to regulate D-SNP marketing. They told us that certain provisions in the state’s contracts with D-SNPs were intended to regulate the extent of D-SNP marketing in 2019. In particular, each D-SNP was supposed to only market to beneficiaries enrolled in that D-SNP’s aligned Medicaid MCO, which was intended to increase the extent of aligned enrollment in the state. However, state Medicaid officials told us that D-SNPs had different interpretations of the contract provisions, and one D-SNP had billboards and television advertisements available to the general public. Due to the difficulty of enforcement, among other reasons, Virginia Medicaid officials told us they chose to not include these provisions in the D-SNP contracts for 2020. Through the Integrated Care Resource Center, CMS has developed materials describing how states can regulate D-SNP marketing in their contracts with D-SNPs, and the agency reviews and may disapprove D- SNP marketing materials that do not follow federal requirements. CMS officials also told us they make themselves available to states to explain how to include marketing restrictions in the contracts that states have with D-SNPs. Limits of staff knowledge. Medicaid officials in four of the selected states (Florida, Kansas, New Jersey, and Pennsylvania) told us that limited staff knowledge of Medicare presents a challenge. For example, Medicaid officials in Kansas told us only one or two staff in the state’s Medicaid agency are knowledgeable about Medicare and would have the knowledge to implement aligned enrollment approaches. Similarly, Medicaid officials in Florida said they only recently learned about one of the approaches for encouraging aligned enrollment, which is that the state can decline to contract with certain D-SNPs. In addition, New Jersey and Pennsylvania Medicaid officials told us staff knowledge of Medicare is limited and that they would like to increase their level of knowledge as they continue to foster aligned enrollment. Competition from look-alike MA plans targeted to dual-eligible beneficiaries. Medicaid officials in four of our selected states (Arizona, Pennsylvania, Tennessee, and Virginia) identified certain MA plans that are so-called “look-alike” plans to the D-SNPs, which create a potential challenge to fostering aligned enrollment. According to CMS, look-alike plans are MA plans that are designed for and marketed exclusively to dual-eligible beneficiaries, but that are not D-SNPs. Therefore, look-alike plans do not need a contract with the state to operate and do not have to comply with state approaches that foster aligned enrollment. Medicaid officials from our selected states and the Medicare Payment Advisory Commission gave examples of the impact of look-alike plans. For example, Tennessee Medicaid officials told us that dual-eligible beneficiaries in look-alike plans do not receive care coordination between Medicare and Medicaid, in contrast with dual-eligible beneficiaries in D- SNPs, which are required to provide such coordination. In addition, Arizona Medicaid officials told us that look-alike plans have affected levels of aligned enrollment in the state. Similarly, according to the Medicare Payment Advisory Commission, look-alike plans can undermine states’ efforts to develop D-SNPs that integrate Medicare and Medicaid by encouraging dual-eligible beneficiaries to instead enroll in look-alike plans. CMS has also identified look-alike plans as a challenge and is considering some steps in response. In 2018, CMS revised its marketing guidelines to prohibit look-alike plans from marketing themselves as designed for dual-eligible beneficiaries and as having a relationship with the state Medicaid agency. In its April 2019 policy update for MA plans, CMS said that look-alike plans enable companies to offer plans that circumvent state and federal requirements for D-SNPs, which undermines efforts to improve the quality of care. In February 2020, CMS published a proposed rule that, if finalized, would prohibit the offering of MA plans whose enrollment of dual-eligible beneficiaries exceeds specific projected or actual enrollment thresholds in states with a D-SNP. According to CMS, this would prevent look-alikes from undermining the statutory and regulatory framework for D-SNPs. Extent of overlapping provider networks. Medicaid officials in two of our selected states (Pennsylvania and Tennessee) reported challenges with aligned D-SNPs and Medicaid MCOs that do not have completely overlapping networks of relevant providers. That is, even though the D- SNP and Medicaid MCO are offered by the same or related companies, certain providers may be in only the D-SNP network or only the Medicaid MCO network—but not both. For example, representatives from a beneficiary group in Pennsylvania told us that a dual-eligible beneficiary’s provider may be in the Medicaid MCO network, but not the D-SNP network. This can disrupt that beneficiary’s continuity of care if he or she is default enrolled into the D-SNP. There are no requirements for the state or D-SNP to ensure that a beneficiary’s primary care provider is in the D-SNP into which he or she is default enrolled. CMS’s model for the notice sent to beneficiaries identified for default enrollment suggests (but does not require) that the D-SNP include information on whether or not the beneficiary’s primary care provider is in the D-SNP’s network. CMS officials said they did not know of any complaints the agency has received on the issue. They also said they have not analyzed how the provider network of a D-SNP compares to the provider network of its aligned Medicaid MCO. Furthermore, in the preamble to the default enrollment final rule issued in April 2018, CMS said that it did not include any criteria related to provider networks, but that network adequacy requirements would apply and states can use their contracts with D-SNPs to create requirements for continuity of care. One state that does this is Tennessee, which specifically requires D-SNPs to develop provider networks that have substantial overlap with the provider network of their aligned Medicaid MCOs. The state also requires D-SNPs to ensure continuity of care for beneficiaries who have been default enrolled. For example, Tennessee Medicaid officials said that if a beneficiary who has been default enrolled has a long-standing primary care provider with the D-SNP’s aligned Medicaid MCO, the state requires the D-SNP to continue covering services by that provider for at least 30 days and to attempt to contract with the provider. CMS Has Assisted States with Aligned Enrollment, but Lacks Quality Information on the Experience of Beneficiaries Whose Aligned Enrollment Was Due to Default Enrollment CMS has assisted states with aligned enrollment. In particular, CMS has provided technical assistance to states on implementing the various approaches that encourage aligned enrollment. One way that CMS has done this is through its Integrated Care Resource Center, which has developed materials on how states can use their contracts with D-SNPs to align enrollment and promote integration. The Integrated Care Resource Center has also facilitated peer-to-peer assistance between states. For example, Integrated Care Resource Center officials said they facilitated conversations and assistance between state Medicaid officials in New Jersey and Pennsylvania on D-SNP marketing. Medicaid officials in six of our selected states said they had utilized CMS’s technical assistance, and they had overall positive views of CMS’s assistance. CMS reviews some aspects of the contracts between states and D-SNPs, including checking that the contracts include the eight required elements. According to CMS officials, in these reviews, CMS does not collect information regarding whether states are imposing requirements pertaining to aligned enrollment. CMS’s program audits of MA plans similarly do not include reviews of such state requirements pertaining to aligned enrollment. CMS has a direct role with one aspect of aligned enrollment: default enrollment. In particular, CMS approves D-SNPs to receive beneficiaries through default enrollment, and it processes the enrollment transactions of beneficiaries being default enrolled. D-SNPs’ approval for default enrollment: Before a D-SNP can receive beneficiaries through default enrollment, it must submit a proposal to CMS for approval. CMS reviews the D-SNP’s proposal and checks that the D-SNP meets an established list of requirements outlined in regulation. Among other requirements, the D-SNP must demonstrate it has the state’s support for default enrollment and that the required elements have been included in its template for the notice that is sent to beneficiaries identified for default enrollment. CMS also checks that the D-SNP is not facing any CMS enrollment sanctions and that the D-SNP has a quality rating of three or more stars. CMS grants approval for up to 5 years if it determines the D- SNP meets these requirements. Default enrollment transactions: CMS processes the enrollment transactions of dual-eligible beneficiaries being default enrolled, and it tracks these transactions in a monthly report. The monthly report lists the total number of beneficiaries identified for default enrollment for each applicable D-SNP, and the report lists numbers for certain subsets of beneficiaries who were ultimately not default enrolled. These subsets include beneficiaries who opted out prior to being default enrolled and beneficiaries whose default enrollment was not allowed by CMS for various reasons. Despite its direct role in default enrollment, CMS lacks quality information on the experiences of dual-eligible beneficiaries after they are default enrolled. This is inconsistent with federal internal control standards on information and communication, which state that management should use quality information to achieve the agency’s objectives. In particular, the monthly reports on enrollment transactions do not include data on the extent to which dual-eligible beneficiaries choose to disenroll after being default enrolled. Although the reports include data on the number of beneficiaries who opt out prior to being default enrolled (which CMS officials said was low), they do not include data on beneficiaries who choose to disenroll in the first 90 days after being default enrolled. This 90-day time frame for disenrollment is specified by federal regulation, and beneficiaries may choose to disenroll for various reasons. For example, one reason for disenrollment given by one beneficiary group we interviewed is that some beneficiaries may not realize they have been default enrolled into a D-SNP until they next see their provider, and that provider may not be in the D-SNP’s provider network. They said that beneficiaries may not have seen the notice or other information about being default enrolled, or they may not have understood the information. In addition, CMS cannot systematically review beneficiary complaints for trends or concerns related to default enrollment. Dual-eligible beneficiaries, like other Medicare beneficiaries, can submit complaints to CMS. These complaints are entered in the agency’s complaint tracking module, and D-SNP account managers, like other MA plan account managers, are responsible for monitoring complaints. CMS officials said that the D-SNP account managers have not identified any trends or concerns about default enrollment. However, CMS officials said default enrollment is not tracked as a distinct category in the complaint tracking module, and the guidance on monitoring complaints that is provided to the D-SNP account managers does not direct them to look for issues explicitly related to default enrollment. Quality information on the experiences of dual-eligible beneficiaries after they are default enrolled would allow CMS to better identify the extent to which these beneficiaries face challenges as a result of default enrollment and to determine how, if at all, to address the challenges. Future studies may provide CMS with additional information on beneficiaries in D-SNPs with aligned enrollment, but that information will not be available until 2022 or later. In particular, federal law directs the Medicare Payment Advisory Commission, in consultation with the Medicaid and CHIP Payment and Access Commission, to compare the quality of the different types of D-SNPs, including those with aligned enrollment, as well as comparing them to other types of plans. The commission is to develop an initial report by 2022 with subsequent reports afterward. Conclusions Better care for dual-eligible beneficiaries is one of CMS’s strategic initiatives, and the agency has supported states’ decisions to encourage aligned enrollment in order to encourage better coordination of care. However, CMS lacks quality information on the experiences of beneficiaries who have aligned enrollment as the result of the use of default enrollment. For example, CMS’s monthly reports on default enrollment do not include data on beneficiaries who choose to disenroll after being default enrolled. CMS lacks this information even though selected states and others have reported challenges that could affect the care received by those beneficiaries. Quality information on the experiences of these dual-eligible beneficiaries would allow CMS to better identify the extent to which beneficiaries are facing challenges as a result of default enrollment and to determine how, if at all, to address those challenges. Recommendation for Executive Action We are making the following recommendation to CMS: The Administrator of CMS should take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs, such as by obtaining information about the extent to which and reasons that beneficiaries disenroll from a D-SNP after being default enrolled. (Recommendation 1) Agency Comments We provided a draft of this report to the Department of Health and Human Services (HHS) for comment. In its comments, reproduced in appendix I, HHS concurred with our recommendation. HHS stated that it is committed to increasing the number of dual-eligible beneficiaries in integrated care and that it supports states with these efforts, such as the use of aligned enrollment. HHS also said that it has not identified any trends or areas of concern in its monitoring of beneficiaries who opted out prior to being default enrolled. In response to our recommendation, HHS stated it will evaluate opportunities to obtain more information on dual-eligible beneficiaries who disenroll from a D-SNP after being default enrolled. HHS also provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional committees, the Administrator of the Centers for Medicare & Medicaid Services, and other interested parties. In addition, the report is available at no charge on the GAO 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 cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Appendix I: Comments from the Department of Health and Human Services Appendix II: GAO Contact and Staff Acknowledgments GAO Contact Staff Acknowledgments In addition to the contact named above, Martin T. Gahart (Assistant Director), Corissa Kiyan-Fukumoto (Analyst-in-Charge), Jason Coates, Kelly Krinn, Virginia Lefever, Drew Long, Jennifer Rudisill, and Ethiene Salgado-Rodriguez made key contributions to this report. Related GAO Products Medicare and Medicaid: Additional Oversight Needed of CMS’s Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries. GAO-16-31. Washington, D.C.: December 18, 2015. Disabled Dual-Eligible Beneficiaries: Integration of Medicare and Medicaid Benefits May Not Lead to Expected Medicare Savings. GAO-14-523. Washington, D.C.: August 29, 2014. Medicare and Medicaid: Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and States. GAO-13-100. Washington, D.C.: December 5, 2012. Medicare Special Needs Plans: CMS Should Improve Information Available about Dual-Eligible Plans’ Performance. GAO-12-864. Washington, D.C.: September 13, 2012. Medicare and Medicaid: Implementing State Demonstrations for Dual Eligibles Has Proven Challenging. GAO/HEHS-00-94. Washington, D.C.: August 18, 2000.