United States Government Accountability Office
Highlights of GAO-20-149, a report to
congressional requesters
October 2019
MEDICAID DEMONSTRATIONS
Actions Needed to
Address Weaknesses in
to Administer Work Requirements
What GAO Found
Medicaid demonstrations enable states to test new approaches to provide
Medicaid coverage and services. Since January 2018, the Centers for Medicare
& Medicaid Services (CMS) has approved nine states’ demonstrations that
require beneficiaries to work or participate in other activities, such as training, in
order to maintain Medicaid eligibility. The first five states that received CMS
approval for work requirements reported a range of administrative activities to
implement these requirements.
These five states provided GAO with estimates of their demonstrations’
administrative costs, which varied, ranging from under $10 million to over $250
million. Factors such as differences in changes to information technology
systems and numbers of beneficiaries subject to the requirements may have
contributed to the variation. The estimates do not include all costs, such as
ongoing costs states expect to incur throughout the demonstration.
Selected States’ Estimates of Administrative Costs to Implement Work Requirements in
Approved Medicaid Demonstrations and Federal Share of those Costs
Number of beneficiaries
subject to requirements
Estimated costs
(dollars in millions)
Estimated federal
share (percentage)
Source: GAO analysis of data reported by selected states and selected state documents. | GAO-20-149
Notes: Estimates of beneficiaries subject to work requirements include those who may be eligible for
an exemption. Estimates of costs do not include all costs, and in Kentucky and Wisconsin include
some costs not specific to work requirements. Estimates generally cover from 1 to 3 years of costs.
GAO found weaknesses in CMS’s oversight of the administrative costs of
demonstrations with work requirements.
• No consideration of administrative costs during approval. GAO found
that CMS does not require states to provide projections of administrative
costs when requesting demonstration approval. Thus, the cost of
administering demonstrations, including those with work requirements, is not
transparent to the public or included in CMS’s assessments of whether a
demonstration is budget neutral—that is, that federal spending will be no
higher under the demonstration than it would have been without it.
• Current procedures may be insufficient to ensure that costs are
allowable and matched at the correct rate. GAO found that three of the
five states received CMS approval for federal funds—in one case, tens of
millions of dollars—for administrative costs that did not appear allowable or
at higher matching rates than appeared appropriate per CMS guidance. The
agency has not assessed the sufficiency of its procedures for overseeing
administrative costs since it began approving demonstrations with work
requirements.
View GAO-20-149. For more information,
contact
Carolyn L. Yocom at (202) 512-7114
Why GAO Did This Study
Section 1115 demonstrations are a
significant component of Medicaid
spending and affect the care of millions
of low-income and medically needy
individuals. In 2018, CMS announced a
new policy allowing states to test work
requirements under demonstrations
and soon after began approving such
demonstrations. Implementing work
requirements can involve various
administrative activities, not all of
which are eligible for federal funds.
GAO was asked to examine the
administrative costs of demonstrations
with work requirements. Among other
things, this report examines (1) states’
estimates of costs of administering
work requirements in selected states,
and (2) CMS’s oversight of these
costs. GAO examined the costs of
administering work requirements in the
first five states with approved
demonstrations. GAO also reviewed
documentation for these states’
demonstrations, and interviewed state
and federal Medicaid officials.
Additionally, GAO assessed CMS’s
policies and procedures against federal
internal control standards.
What GAO Recommends
GAO makes three recommendations,
including that CMS (1) require states to
submit projections of administrative
costs with demonstration proposals,
and (2) assess risks of providing
federal funds that are not allowable to
administer work requirements and
improve oversight procedures, as
warranted. CMS did not concur with
the recommendations and stated that
its procedures are sufficient given the
level of risk. GAO maintains that the
recommendations are warranted as
discussed in this report.