[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


COMBATING WASTE, FRAUD, AND ABUSE IN MEDICAID'S PERSONAL CARE SERVICES 
                                PROGRAM

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 2, 2017

                               __________

                           Serial No. 115-29
                           
                           
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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania             ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas            GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee          DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana             MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio                JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
PETE OLSON, Texas                    JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
ADAM KINZINGER, Illinois             BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
GUS M. BILIRAKIS, Florida            YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio                   DAVID LOEBSACK, Iowa
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana               JOSEPH P. KENNEDY, III, 
BILL FLORES, Texas                   Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma           RAUL RUIZ, California
RICHARD HUDSON, North Carolina       SCOTT H. PETERS, California
CHRIS COLLINS, New York              DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia

                                 7_____

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana             PAUL TONKO, New York
CHRIS COLLINS, New York              YVETTE D. CLARKE, New York
TIM WALBERG, Michigan                RAUL RUIZ, California
MIMI WALTERS, California             SCOTT H. PETERS, California
RYAN A. COSTELLO, Pennsylvania       FRANK PALLONE, Jr., New Jersey (ex 
EARL L. ``BUDDY'' CARTER, Georgia        officio)
GREG WALDEN, Oregon (ex officio)

                                  (ii)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     4
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
    Prepared statement...........................................     7
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     9
    Prepared statement...........................................    10

                               Witnesses

Christi A. Grimm, Chief of Staff, Office of Inspector General, 
  Department of Health and Human Services........................    12
    Prepared statement...........................................    14
    Answers to submitted questions...............................    94
Katherine M. Iritani, Director, Health Care, Government 
  Accountability Office..........................................    26
    Prepared statement...........................................    28
    Answers to submitted questions...............................    99
Tim Hill, Deputy Director, Center for Medicaid and CHIP Services, 
  Centers for Medicare and Medicaid Services, Department of 
  Health and Human Services......................................    55
    Prepared statement...........................................    57
    Answers to submitted questions...............................   103

                           Submitted Material

Subcommittee memorandum..........................................    89

 
COMBATING WASTE, FRAUD, AND ABUSE IN MEDICAID'S PERSONAL CARE SERVICES 
                                PROGRAM

                              ----------                              


                          TUESDAY, MAY 2, 2017

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:16 a.m., in 
Room 2322, Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, Griffith, Brooks, 
Collins, Walberg, Walters, Costello, Carter, Walden (ex 
officio), DeGette, Schakowsky, Tonko, Clarke, Ruiz, and Pallone 
(ex officio).
    Staff present: Jennifer Barblan, Chief Counsel, Oversight 
and Investigations; Ray Baum, Staff Director; Elena Brennan, 
Legislative Clerk, Oversight and Investigations; Lamar Echols, 
Counsel, Oversight and Investigations; Blair Ellis, Press 
Secretary/Digital Coordinator; Emily Felder, Counsel, Oversight 
and Investigations; Jennifer Sherman, Press Secretary; Julie 
Babayan, Minority Counsel; Jeff Carroll, Minority Staff 
Director; Christopher Knauer, Minority Oversight Staff 
Director; Miles Lichtman, Minority Policy Analyst; Kevin 
McAloon, Minority Professional Staff Member; Jon Monger, 
Minority Counsel; Dino Papanastasiou, Minority GAO Detailee; 
and C.J. Young, Minority Press Secretary.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Good morning. The subcommittee convenes this 
hearing today to examine Medicaid Personal Care Services, a 
critical lifeline for our Nation's most vulnerable populations.
    Medicaid is the largest provider of long-term care services 
for disabled and elderly individuals. Lately, long-term care 
has shifted from nursing homes and institutional settings to 
services provided to beneficiaries in their homes.
    Personal care services, or PCS, provides essential services 
to Medicaid beneficiaries with significant needs so that they 
can stay in their homes. As they enter this ever more 
vulnerable stage of life, most elderly persons prefer to live 
in familiar surroundings.
    These are not health services, but rather they assist 
beneficiaries with daily activities they can no longer do 
without assistance such as meal preparation, laundry, and 
transportation so that they can continue to live in their 
communities.
    PCS now makes up a large component of home- and community-
based care and continues to grow rapidly. In 2015, Federal and 
State expenditures for PCS amounted to $15 billion, up from 
$12.7 billion in 2011. The actual figure is probably 
significantly higher because this number only reflects fee-for-
service claims, and does not include managed care.
    The U.S. Department of Labor projected that employment of 
personal and home health aides will grow by 46 percent between 
2008 and 2018, which far exceeds the average growth of 10 
percent for all occupations.
    While the move toward home care has undoubtedly improved 
the lives of Medicaid beneficiaries by allowing them to stay at 
home and saves money for taxpayers, we cannot turn a blind eye 
to waste, fraud, and abuse in the Personal Care Services 
program.
    More than 29 reports by the HHS Office of Inspector General 
have uncovered systemic fraud in PCS. The OIG has uncovered 
schemes between PCS attendants and Medicaid beneficiaries to 
submit claims for services that were not provided. This type of 
fraud is difficult to detect because attendants can often be a 
beneficiary's spouse, child or friend.
    Even more troubling is the abuse that HHS OIG's 
investigations found. Stories like that of a beneficiary in my 
home State of Pennsylvania dying of exposure to the cold while 
under the care of a PCS attendant. This beneficiary had autism 
and a history of running away, but the attendant left her alone 
in a crowded shopping mall and waited an hour to call 
authorities.
    In Maryland, a disabled woman was left alone in a locked 
car on a hot and sunny day, while her attendant went shopping 
with a friend. This woman was unable to open the car door. A 
concerned citizen noticed her in distress and called the 
police.
    In Vermont, an attendant stole the opioid painkillers 
prescribed for the beneficiary, even though the beneficiary was 
in significant discomfort and pain. This same attendant was on 
probation for drug possession at the time.
    These are just some of the many stories of abuse uncovered 
by the OIG and other authorities. We will discuss them more 
today.
    We talk about program integrity and high improper payments 
a lot on this subcommittee. We are used to getting into the 
weeds on error rates, methodology, and data collection.
    To help curb fraud in PCS and protect vulnerable 
beneficiaries, Congress acted in the Helping Families in Mental 
Health Crisis Act of 2016 to require the use of an electronic 
visit verification system for Medicaid-provided PCS and home 
health services. This became law as part of 21st Century Cures, 
and when implemented, will help ensure that information 
regarding the services provided are verified.
    Having verified data that will help identify waste, fraud, 
and abuse is important because there are real people at risk. 
Those who use the PCS program include our friends and 
neighbors, who may not have the resources or ability to speak 
up when they encounter abuse. This subcommittee and this 
Congress will not tolerate these abuses.
    While it is undoubtedly good policy to keep beneficiaries 
in their homes, it also raises difficult questions which must 
be addressed.
    How do we protect vulnerable people from abuse in their 
homes, when no one else is around to assess an attendant's 
performance?
    What changes can we make, by both Congress and CMS, to 
improve the program while maintaining access for Medicaid 
beneficiaries who need these services?
    Both the HHS OIG and the Government Accountability Office 
have done excellent work to highlight the problems within PCS. 
These offices have also suggested ways to solve these problems, 
such as additional beneficiary safeguards, higher standards for 
attendants, and pre-payment controls.
    I am grateful for your work and look forward to hearing 
more about your findings.
    I understand that CMS has already acted to address some of 
these, but not all, these findings, and we will discuss what 
CMS is doing to address our concerns.
    So thank you to all of our witnesses today for your 
dedication, and great work to protect Medicaid beneficiaries 
and root out waste, fraud, and abuse. I look forward to a 
productive discussion today.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    The subcommittee convenes this hearing today to examine 
Medicaid Personal Care Services--a critical lifeline for our 
Nation's most vulnerable populations.
    Medicaid is the largest provider of long-term care services 
for disabled and elderly individuals. Lately, long-term care 
has shifted from nursing homes and institutional settings to 
services provided to beneficiaries in their homes.
    Personal care services, or PCS, provide essential services 
to Medicaid beneficiaries with significant needs so that they 
can stay in their homes. As they enter this ever more 
vulnerable stage of life, most elderly persons prefer to live 
in familiar surroundings.
    These are not health services, but rather they assist 
beneficiaries with daily activities they can no longer do 
without assistance such as meal preparation, laundry, and 
transportation so that they can continue to live in their 
communities.
    PCS now makes up a large component of home- and community-
based care, and continues to grow rapidly. In 2015, Federal and 
State expenditures for PCS amounted to $15 billion, up from 
$12.7 billion in 2011. The actual figure is probably 
significantly higher because this number only reflects fee-for-
service claims, and does not include managed care.
    The U.S. Department of Labor projected that employment of 
personal and home health aides will grow by 46 percent between 
2008 and 2018, which far exceeds the average growth of 10 
percent for all occupations.
    While the move toward home care has undoubtedly improved 
the lives of Medicaid beneficiaries by allowing them to stay at 
home--and saves money for taxpayers--we cannot turn a blind eye 
to waste, fraud, and abuse in the Personal Care Services 
program.
    More than 29 reports by the HHS Office of Inspector General 
have uncovered systemic fraud in PCS. The OIG has uncovered 
schemes between PCS attendants and Medicaid beneficiaries to 
submit claims for services that were not provided. This type of 
fraud is difficult to detect because attendants can often be a 
beneficiary's spouse, child or friend.
    Even more troubling is the abuse the HHS OIG's 
investigations found. Stories like that of a beneficiary in my 
home State of Pennsylvania dying of exposure to the cold while 
under the care of a PCS attendant. This beneficiary had autism 
and a history of running away, but the attendant left her alone 
in a crowded shopping mall and waited an hour to call 
authorities.
    In Maryland, a disabled woman was left alone in a locked 
car on a hot and sunny day, while her attendant went shopping 
with a friend. This woman was unable to open the car door. A 
concerned citizen noticed her in distress and called the 
police.
    In Vermont, an attendant stole the opioid painkillers 
prescribed for the beneficiary, even though the beneficiary was 
in significant discomfort and pain. This same attendant was on 
probation for drug possession at the time.
    These are just some of the many stories of abuse uncovered 
by the OIG and other authorities--We will discuss them more 
today.
    We talk about program integrity and high improper payments 
a lot on this subcommittee. We are used to getting into the 
weeds on error rates, methodology, and data collection.
    To help curb fraud in PCS and protect vulnerable 
beneficiaries, Congress acted in the Helping Families in Mental 
Health Crisis Act of 2016 to require the use of an electronic 
visit verification system for Medicaid-provided PCS and home 
health services. This became law as part of 21st Century Cures, 
and, when implemented, will help ensure that information 
regarding the services provided are verified.
    Having verified data that will help identify waste, fraud, 
and abuse is important because there are real people at risk--
those who use the PCS program include our friends and 
neighbors, who may not have the resources or ability to speak 
up when they encounter abuse. This subcommittee, this Congress, 
will not tolerate these abuses.
    While it is undoubtedly good policy to keep beneficiaries 
in their homes, it also raises difficult questions which must 
be addressed.
    How do we protect vulnerable people from abuse in their 
homes, when no one else is around to assess an attendant's 
performance?
    What changes can we make--by both Congress and CMS--to 
improve this program while maintaining access for Medicaid 
beneficiaries who need these services?
    Both the HHS OIG and the Government Accountability Office 
have done excellent work to highlight the problems within PCS. 
These offices have also suggested ways to solve these 
problems--such as additional beneficiary safeguards, higher 
standards for attendants, and pre-payment controls.
    I am grateful for your work and look forward to hearing 
more about your findings.
    I understand that CMS has already acted to address some--
but not all--of these findings, and we will discuss what CMS is 
doing to address our concerns.
    Thank you to our witnesses today for your dedication and 
great work to protect Medicaid beneficiaries and root out 
waste, fraud, and abuse. I look forward to a productive 
discussion today.

    Mr. Murphy. I'll recognize Ms. DeGette for 5 minutes. Our 
main clock is not working, so as a reminder, I will just tap 
this when you reach 5 minutes. Thank you.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thanks, Mr. Chairman. Today, thanks to 
Medicaid, 74 million vulnerable Americans including seniors, 
children, adults, and people with disabilities have access to 
quality healthcare. And despite what we often hear from our 
colleagues on the other side of the aisle, the Medicaid program 
delivers this care efficiently and effectively. In fact, not 
only are Medicaid's costs for beneficiaries substantially lower 
than that of private insurance, but they have also been growing 
more slowly per beneficiary. What is more, we know that the 
Medicaid program literally saves lives.
    Last year, more than 12 million low-income adults had 
healthcare coverage because of the Affordable Care Act Medicaid 
expansion, something I think is an astonishing achievement. 
Coupled with other important provisions of the ACA, the 
Medicaid expansion has helped drive the uninsured rate to the 
lowest level in our Nation's history.
    One of the key components of Medicaid is the Personal Care 
Services program. Personal care services which include 
assistance with activities like bathing, dressing, and meal 
preparation are an important part of long-term care that 
Medicaid offers to beneficiaries. This allows beneficiaries to 
hold on to their independence longer and to stay in their homes 
with dignity. Furthermore, personal care services can save the 
Government money because they can be cheaper than enrolling 
patients in a nursing home, a lot cheaper.
    However, just like other home healthcare services, personal 
care services can be susceptible to improper payment or even to 
fraud. Fraud, abuse, and mismanagement happen wherever large 
amounts of money are spent, both in the public sector and in 
the private sector, and we need to always look for ways to 
address this. But that doesn't mean the program is ill-
conceived or should be drastically cut. Instead what it means 
is we need to focus our efforts on ensuring that the program 
receives more effective oversight and that we prevent and 
address these issues.
    As I pointed out before, the ACA provided the Department of 
Health and Human Services and its Office of Inspector General 
with a wide range of new tools and authorities to fight fraud. 
For example, the ACA provided nearly $350 million in new funds 
for fraud control efforts, as well as new means for screening 
potential providers and suppliers. It also provided the HHS and 
OIG with new authorities to impose stronger penalties on those 
who commit fraud and gave the Centers for Medicare and Medicaid 
Services the ability to temporarily halt payments to those 
suspected of fraud. These new tools allow program 
administrators to better protect tax dollars and to move away 
from the pay-and-chase model by preventing bad providers from 
ever entering the program. These are positive developments.
    But today, we are going to hear from the agencies that 
there are still vulnerabilities related to the PCS program, as 
well as additional actions that CMS should better take to 
oversee this program. For example, an October 2016 
investigative advisory from HHS OIG detailed some disturbing 
cases of PCS fraud and beneficiary neglect. These bad actors 
not only defrauded the program, they harmed the patients they 
were supposed to serve. That advisory follows other HHS OIG 
reports highlighting PCS program vulnerabilities that 
contributed to questionable care services and improper 
payments.
    The OIG continues to recommend that CMS use its authorities 
more effectively to oversee PCS programs across all States to 
improve program integrity and help the risk of beneficiary 
harm.
    Similarly, GAO has also found areas for improvement in the 
PCS program. Specifically, the State-reported data that CMS 
relies on for oversight lacks key investigation and there are 
variations in the program requirements across different States. 
This is an important point because States are ultimately 
responsible for overseeing their programs.
    Along these lines, the GAO is also going to testify that 
some States continue to provide inaccurate or untimely data to 
CMS. We need to explore the challenges that States are facing 
in collecting this data and determine why States don't have 
additional resources to better oversee the program. We need to 
make sure the program is fully resourced and that includes 
sufficient money to collect and analyze data. Given that the 
States are on the front lines of running this important 
program, I think we need to hear from the States about what 
they are doing.
    And finally, Mr. Chairman, as we talk about waste, fraud, 
and abuse, we should be mindful that the President's budget 
blueprint threatens agencies like HHS OIG to oversee these 
programs. The OIG said on average it has one full-time employee 
to oversee more than $680 million a year. So I think we need to 
remedy that if we want to stop waste, fraud, and abuse.
    So anyway, in conclusion, thanks for having this hearing. I 
think we are all against waste, fraud, and abuse and we all 
need to work together to make sure that it ends. I yield back.
    Mr. Murphy. I thank the gentlelady. She yields back. I now 
recognize the chairman of the full committee.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. I thank the gentleman for holding this hearing 
and for our witnesses' good work and good testimony. We are 
here today to talk about this program which serves our Nation's 
most vulnerable individuals. Through Medicaid, personal care 
services provide essential care to millions of elderly people, 
disabled children and adults, and those who need long-term care 
to cope with crippling diseases. It used to be that many of 
these people ended up having to be institutionalized or cared 
for in a nursing home. Instead, personal care services provide 
an attendant to help people do the things like shop for 
groceries, do the laundry, make sure that they are taking their 
medications right on the schedule.
    Without personal care services and home healthcare at 
large, these folks would not be able to live at home in their 
communities. Personal care services are quite literally a life 
saver for many.
    I truly believe in programs like personal home services and 
home healthcare. Oregon experimented in these types of programs 
a long time ago. The vast majority of personal care workers are 
really solid people who work hard and take care of people and 
they care, especially they care for these vulnerable 
populations. They make their lives better, healthier, brighter, 
and easier.
    That is why it is so disturbing when the Office of 
Inspector General reported these instances of fraud, abuse, and 
mismanagement in this very essential program. Stories of 
attendants stealing pain meds, abandoning mentally ill 
beneficiaries in public places, leaving elderly folks alone for 
weeks at a time. This is outrageous and it is unacceptable.
    What's worse is that OIG has made clear that these are not 
just some isolated individual bad actors. The OIG 
investigations have uncovered more than 200 cases of fraud and 
abuse in the program just since 2012. And as we learned from 
witnesses earlier this year, the Government Accountability 
Office has Medicaid designated as a high-risk program since 
2003. So we have an obligation to get to the bottom of this for 
the taxpayers and for patients alike.
    Late last year, GAO released a report on the need to 
harmonize requirements for personal care services across 
various States. GAO reviewed the policies and procedures in my 
home State of Oregon and three other States while performing 
this work. While I was heartened to learn about the safeguards 
Oregon has in place to prevent this fraud, the audit made clear 
there is more work to be done.
    More recently, GAO released a second report on the need for 
better data on PCS. The most recent data at the time of the 
audit released in 2017 was from 2012. That was 5 years ago. And 
the data GAO did release was incomplete. Without complete and 
up-to-date data, those who are tasked with rooting out waste, 
fraud, and abuse in this program are frankly hamstrung.
    So both the OIG and GAO sounded the alarm for years. This 
fraud and abuse is happening because the States and the Federal 
Government failed to put in safeguards to protect these 
beneficiaries. It is sickening to see hard-earned tax dollars 
going to people who take advantage and mistreat the elderly and 
disabled in their own homes. And these beneficiaries are 
particularly suspect to harm because they are often lack the 
physical or mental ability to speak up. Many times a personal 
care worker is the only person a beneficiary may see for weeks 
at a time, so they go along with the fraud or abuse because 
they are so dependent on that person for help.
    We can do better for them. Our citizens deserve to know the 
attendant they allow into their home, the attendant paid by 
State and Federal taxpayers, will take good care of them and 
have their best interests at heart. And while most do--and most 
do--it is clear we have a serious problem in the program.
    Today, we are here to talk about the steps we're going to 
take to correct the problems identified for us by the good work 
by the Office of Inspector General and the GAO.
    I would like to thank Ms. Grimm from the OIG, and Ms. 
Iritani from the GAO, for your extraordinary work that exposed 
this fraud, abuse, and mismanagement in the program. You have 
done a good job. Your decades of work culminated in some 
common-sense recommendations for CMS that will better protect 
beneficiaries and taxpayers. So I look forward to discussing 
those recommendations today and also learning about how 
Congress can do its part to solve these problems.
    Mr. Hill, I especially appreciate your testimony today, 
too. I understand CMS has taken steps to implement some of the 
recommendations and is working to make other improvements in 
the program. That is encouraging. I look forward to hearing 
more about your work as well.
    With that, Mr. Chairman, and with apologies to our 
witnesses, we have a couple of subcommittees going on at the 
same time and my duties as full committee chairman drag me 
between the two. So thank you for your good work. I have your 
testimony. It is most helpful. And I return the balance of my 
time.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    We are here today to talk about a program that serves our 
Nation's most vulnerable individuals. Through Medicaid, 
personal care services provide essential care to millions of 
elderly people, disabled children and adults, and those who 
need longterm care to cope with crippling disease.
    It used to be that these folks had to be institutionalized 
or cared for in a nursing home. Instead, personal care services 
provide an attendant to help people do things like shop for 
groceries, do the laundry, drive to the doctor and take 
medication on the right schedule.
    Without personal care services--and home health care at 
large--these folks would not be able to live at home, in their 
communities. Personal care services are quite literally a life-
saver for many.
    I truly believe in programs like personal care services and 
home health care. The vast majority of personal care workers 
are good people who serve vulnerable populations and make the 
lives of others healthier, brighter and a little easier.
    That's why I was so disturbed when the Office of Inspector 
General reported instances of fraud, abuse, and mismanagement 
in this important program. Stories of attendants stealing pain 
medication, abandoning mentally ill beneficiaries in public 
places, leaving elderly folks alone for weeks at a time--this 
is outrageous and unacceptable.
    What's worse, is that OIG has made clear that these are not 
just individual bad actors. The OIG investigations have 
uncovered more than 200 cases of fraud and abuse in the program 
just since 2012. And as we learned from witnesses earlier this 
year, the Government Accountability Office has Medicaid 
designated Medicaid as a ``high risk'' program since 2003. We 
have an obligation to get to the bottom of this, for the 
taxpayers and for the patients, alike.
    Late last year, GAO released a report on the need to 
harmonize requirements for Personal Care Services across the 
various States. GAO reviewed the policies and procedures of my 
home State of Oregon and three other States while performing 
this work. While I was heartened to learn of the safeguards 
Oregon has in place to prevent this fraud, the audit made clear 
that there is more work to be done.
    More recently, GAO released a second report on the need for 
better data on PCS. The most recent data at the time of the 
audit-released in 2017-was from 2012. Five years ago. And the 
data GAO did receive was incomplete. Without complete and up-
to-date data those who are tasked with rooting out waste, 
fraud, and abuse in this program are hamstrung.
    So, both the OIG and GAO have sounded the alarm for years.
    This fraud and abuse is happening because the States and 
the Federal Government failed to put in safeguards to protect 
these beneficiaries.
    It is sickening to see hard-earned taxpayer dollars going 
to people who take advantage of and mistreat elderly and 
disabled people in their own homes.
    And these beneficiaries are particularly susceptible to 
harm because they often lack the physical or mental ability to 
speak up.
    Many times, a personal care worker is the only person a 
beneficiary will see for weeks, so they go along with fraud or 
abuse because they are dependent on their attendant for help.
    We can do better. Our citizens deserve to know that the 
attendant they allow into their home, the attendant paid by 
State and Federal taxpayers, will take good care of them and 
have their best interests at heart. And while most do, it's 
clear we have a serious problem in this program.
    Today, we are here to talk about the steps we are going to 
take to correct the problems identified for us by the Office of 
Inspector General and others.
    I would like to thank Ms. Grimm from the OIG and Ms. 
Iritani from GAO for your extraordinary work that has exposed 
fraud, abuse, and mismanagement in this program. Your decades 
of work have culminated in some common-sense recommendations 
for CMS that will better protect beneficiaries.
    I look forward to discussing those recommendations today, 
and also learning about how Congress can do its part to solve 
these problems.
    Mr, Hill, I appreciate your testimony today too. I 
understand that CMS has taken steps to implement some of these 
recommendations and is working toward improvements. That's 
encouraging, and I look forward to learning more about your 
work as well.
    Thank you, Mr. Chairman, for holding this important hearing 
today. I yield back the remainder of my time.

    Mr. Murphy. The chairman returns the balance of his time 
and yields back. I now recognize the gentleman from New Jersey, 
Mr. Pallone, for 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman. This committee has a 
long-standing history of examining fraud and abuse in Medicaid 
and we should continue to find ways to improve the vital 
programs, including the Personal Care Services program. But it 
is important to keep these issues in context. Medicaid is a 
critical program that provides essential healthcare to more 
than 74 million Americans, including seniors, children, 
pregnant women, and people with disabilities. Now with the 
expansion of Medicaid under the Affordable Care Act, more than 
12 million people gained health insurance coverage last year. 
Additional achievements under the ACA have helped improve the 
quality, accessibility, and affordability of healthcare for 
millions of Americans.
    We have made historic gains and we must not roll back this 
progress by cutting essential health programs such as Medicaid. 
The Republican Trumpcare bill which the Republican leadership 
is still trying to convince members to support, drastically 
cuts and caps the Medicaid program. It rations care for 
millions in order to give giant tax breaks to the wealthy and 
corporations. By allowing a State to arbitrarily cap coverage 
or provide a block grant for certain enrollees, Trumpcare would 
result in mass rationing of care for seniors in nursing homes, 
pregnant women, working parents, and people living with 
disabilities.
    Instead, it is imperative that we make every effort to 
ensure Federal and State dollars are spent effectively. While 
Medicaid is already an incredibly lean program that has among 
the lowest improper payment rates of any Federal health 
program, we should always be looking at ways to prevent any 
fraud, waste, or abuse in any Federal program. The HHS Office 
of Inspector General has reported on improper payments, 
questionable care quality, and fraud in the PCS program and I 
am particularly concerned by OIG's investigative advisory that 
highlighted stories of vulnerable patients who were neglected 
and even harmed by the PCS providers entrusted with their care.
    So I am committed to working with my colleagues to address 
these issues and the root causes of fraud, waste, and abuse. 
However, any solution we consider to address the problems in 
the PCS program should be designed primarily to serve one 
constituency, and that is vulnerable Medicaid patients. We must 
root out fraud and abuse, but we should not use potential fraud 
and abuse as an excuse to harm the people these programs are 
intended to serve. In other words, the answer to Medicaid fraud 
is not to cut coverage or reduce benefits. The answer to 
beneficiary harm and neglect is not to institute work 
requirements and the answer to abusive providers is not to drug 
test low-income beneficiaries. Instead, we should be 
strengthening oversight so that bad actors are not allowed into 
the program, all beneficiaries get the care they need, and the 
American tax dollars are protected.
    The PCS program is a great example of the type of crucial 
services that we should be protecting and strengthening. PCS 
attendants help patients with daily activities such as bathing 
and dressing which gives Medicaid patients more freedom and 
dignity by allowing them to stay in their homes. Medicaid is 
the majority payer of long term care services and supports for 
seniors and individuals with disabilities and personal care 
services are a critical benefit for these populations.
    The HHS OIG has done important work on this issue that has 
benefitted the committee's past bipartisan work and no doubt 
will continue to benefit this committee if given the proper 
resources and that is one of the many reasons why I'm so 
concerned about President Trump's budget blueprint which 
threatens to undermine the important work of agencies like the 
HHS OIG.
    We will also hear from GAO about the challenges posed by 
various PCS program requirements across different States and 
how the States have not provided accurate data on the PCS 
program. Because Medicaid is a Federal-State partnership, we 
need both CMS and the States to do their part in conducting 
oversight.
    And finally, Mr. Chairman, I would like to thank the 
witnesses today for their commitment to strengthening the 
Medicaid program and serving its beneficiaries. Instead of 
rolling back the progress we've made, we must continue to find 
ways to improve oversight of these vital programs and I don't 
think anybody else wants my time, so I will yield back, Mr. 
Chairman.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Thank you, Mr. Chairman. This committee has a longstanding 
history of examining fraud and abuse in Medicaid. We should 
continue to find ways to improve these vital programs, 
including the Personal Care Services (PCS) program. But it is 
important to keep these issues in context.
    Medicaid is a critical program that provides essential 
health care to more than 74 million Americans--including 
seniors, children, pregnant women, and people with 
disabilities.
    Now with the expansion of Medicaid under the Affordable 
Care Act (ACA), more than 12 million people gained health 
insurance coverage last year. Additional achievements under the 
ACA have helped improve the quality, accessibility, and 
affordability of health care for millions of Americans.
    We have made historic gains, and we must not roll back this 
progress by cutting essential health care programs such as 
Medicaid. The Republican Trumpcare bill, which the Republican 
leadership is still trying to strong-arm Members into 
supporting, drastically cuts and caps the Medicaid program. It 
rations care for millions in order to give giant tax breaks to 
the wealthy and corporations. By allowing a State to 
arbitrarily cap coverage or provide a block grant for certain 
enrollees, Trumpcare would result in mass rationing of care for 
seniors in nursing homes, pregnant women and working parents, 
and people living with disabilities.
    Instead, it is imperative that we make every effort to 
ensure Federal and State dollars are spent effectively. While 
Medicaid is already an incredibly lean program that has among 
the lowest improper payment rates of any Federal health 
program, we should always be looking at ways to prevent any 
fraud, waste, or abuse in any Federal program.
    The HHS Office of Inspector General has reported on 
improper payments, questionable care quality, and fraud in the 
PCS program. I am particularly concerned by OIG's investigative 
advisory that highlighted stories of vulnerable patients who 
were neglected and even harmed by the PCS providers entrusted 
with their care.
    I am committed to working with my colleagues to address 
these issues and the root causes of fraud, waste, and abuse. 
However, any solution we consider to address the problems in 
the PCS program should be designed primarily to serve one 
constituency: vulnerable Medicaid patients. We must root out 
fraud and abuse, but we should not use potential fraud and 
abuse as an excuse to harm the people these programs are 
intended to serve.
    In other words, the answer to Medicaid fraud is not to cut 
coverage or reduce benefits. The answer to beneficiary harm and 
neglect is not to institute work requirements. And the answer 
to abusive providers is not to drug test low-income 
beneficiaries.
    Instead, we should be strengthening oversight so that bad 
actors are not allowed into the program, all beneficiaries get 
the care they need, and Americans' tax dollars are protected.
    The PCS program is a great example of the type of crucial 
services that we should be protecting and strengthening. PCS 
attendants help patients with daily activities such as bathing 
and dressing, which gives Medicaid patients more freedom and 
dignity by allowing them to stay in their homes. Medicaid is 
the majority payer of long-term care services and supports for 
seniors and individuals with disabilities, and personal care 
services are a critical benefit for these populations.
    The HHS OIG has done important work on this issue that has 
benefitted the committee's past bipartisan work, and no doubt 
will continue to benefit this committee if given the 
appropriate resources. That is one of the many reasons why I am 
so concerned about President Trump's budget blueprint, which 
threatens to undermine the important work of agencies like the 
HHS OIG.
    We will also hear from GAO about the challenges posed by 
varying PCS program requirements across different States, and 
how the States have not provided accurate data on the PCS 
program. Because Medicaid is a Federal-State partnership, we 
need both CMS and the States to do their part in conducting 
oversight.
    Mr. Chairman, I would like to thank the witnesses today for 
their commitment to strengthening the Medicaid program and 
serving its beneficiaries. Instead of rolling back the progress 
we have made, we must continue to find ways to improve 
oversight of these vital programs.
    Thank you, and I yield back.

    Mr. Murphy. The gentleman yields back. So let's begin. I 
ask unanimous consent that the Members' written opening 
statements be introduced into the record, and without objection 
the documents will be entered into the record.
    I now would look to introduce our panel of Federal 
witnesses for today's hearing. First, we welcome Ms. Christi 
Grimm, Chief of Staff of the Department of Health and Human 
Services, Office of Inspector General. With nearly 2 decades of 
leadership and expertise in HHS programs, Ms. Grimm manages the 
operation and resources of the immediate Office of Inspector 
General and is responsible for effective execution of OIG 
priority initiatives, advising on a wide variety of policy and 
operational matters.
    Next, we welcome Ms. Katherine Iritani. Have I said that 
right? Good. Director of Healthcare Issues at the U.S. 
Government Accountability Office. In her 36-year career with 
GAO, Ms. Iritani has helped lead a wide variety of programs and 
evaluation assignments for Congress. In recent years, she has 
overseen Medicaid financing, payment, access, and long-term 
care issues, including program oversight issues contributing to 
Medicaid being designated as a high-risk program.
    And last, we would like to welcome Mr. Timothy Hill, Deputy 
Director for the Center for Medicaid and CHIP Services, CMCS, 
and the Centers for Medicaid and Medicare Services at HHS. As 
Deputy Director at CMCS, Mr. Hill leads activities related to 
national Medicaid and CHIP policy and program operations and 
works closely with States in the implementation of their 
Medicaid and CHIP programs.
    So I thank all the witnesses for being here today and 
providing testimony. We look forward to productive discussion 
on how we can strengthen and combat waste, fraud, and abuse 
reform in the PCS program.
    As you are aware, the committee is holding an investigative 
hearing and when doing so has the practice of taking testimony 
under oath. Do any of you have objection to testifying under 
oath?
    Seeing no objections, the Chair then advises you that under 
the rules of the House and the rules of the committee, you are 
entitled to be advised by counsel. Do any of you desire to be 
advised by counsel during testimony today? And seeing none 
there, then will you please rise and raise your right hand. I 
will swear you in.
    Do you swear the testimony you are about the give is the 
truth, the whole truth, and nothing but the truth?
    [Witnesses sworn.]
    Thank you. All of you are now sworn in under oath and 
subject to the penalties set forth in Title 18 Section 1001 of 
the United States Code.
    We will have you each give a 5-minute summary of your 
written statement and we'll begin with Ms. Grimm, you are 
recognized.

   STATEMENT OF CHRISTI A. GRIMM, CHIEF OF STAFF, OFFICE OF 
  INSPECTOR GENERAL, DEPARTMENT OF HEALTH AND HUMAN SERVICES; 
    KATHERINE M. IRITANI, DIRECTOR, HEALTH CARE, GOVERNMENT 
 ACCOUNTABILITY OFFICE; AND TIM HILL, DEPUTY DIRECTOR, CENTER 
   FOR MEDICAID AND CHIP SERVICES, CENTERS FOR MEDICARE AND 
   MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                 STATEMENT OF CHRISTI A. GRIMM

    Ms. Grimm. Good morning, Chairman Murphy, Ranking Member 
DeGette, and other distinguished members of the subcommittee. I 
am Christi Grimm, Chief of Staff of the Office of Inspector 
General for the U.S. Department of Health and Human Services.
    Thank you for the opportunity to appear before you to 
discuss the importance of protecting Medicaid personal care 
services from fraud, waste, and abuse and protecting 
beneficiaries from abuse and neglect. The Personal Care program 
has been one of OIG's top management concerns for the past 8 
years. My testimony today will highlight our work overseeing 
the Personal Care program and progress the Department has made 
in implementing our recommendations.
    In the last 5 years, often with our State partners, OIG has 
opened more than 200 investigations involving fraud and patient 
harm in the Personal Care program. For example, as the chairman 
pointed out in his opening, in Pennsylvania, a personal care 
attendant who was hired to provide close supervision to a 
beneficiary lost her while shopping in a department store. The 
attendant waited an hour before notifying the authorities. The 
beneficiary was found the next day dead from exposure to the 
cold. This harm is something no one should ever have to 
experience. Systemic problems must be rectified so that the 
Federal and State Governments can prevent similar tragedies.
    In the past decade, OIG has issued more than 30 reports 
pertaining the Personal Care which recommended the recovery of 
almost $700 million. OIG's November 2012 Personal Care 
portfolio summarized the findings of OIG's body of work which 
found that Personal Care payments were often improper because 
the services did not comply with basic requirements.
    OIG's October 2016 Investigative Advisory documented common 
fraud schemes including payments for services that were 
unnecessary or not provided and resulted in death, 
hospitalization, and less degrees of beneficiary harm. 
Collectively, our work demonstrates the persistent 
vulnerabilities in personal care that contribute to high 
improper payments, significant fraud, and that place vulnerable 
beneficiaries at risk. Bad actors are exploiting policy 
vulnerabilities and diverting Personal Care resources.
    OIG's long history of oversight and enforcement has 
consistently demonstrated that basic pillars of program 
integrity prevention, detection, and enforcement are lacking in 
the Personal Care program. We must prevent bad actors from 
participating in our programs, detect potential fraud, waste, 
and abuse and beneficiary harm, and enforce the laws through 
Federal and State investigations and prosecutions.
    When these basic safeguards are in place, they have a 
dramatic effect on our ability to identify and stop fraud, 
waste, and abuse. For example, Alaska implemented a requirement 
that all Personal Care attendants enroll with the State 
Medicaid Agency. Attendant enrollment data helped Alaska detect 
potential patterns of fraud and help strengthen cases for 
prosecution. In 2 short years, that data helped Alaska to 
investigate and obtain 108 criminal convictions and recover 
$5.6 million.
    CMS has concurred with our top recommendations for 
improving the Personal Care program. In 2016, CMS issued a 
request for information, guidance, and provided training to 
States and providers resulting in improvements to the Personal 
Care program. Notwithstanding this progress, much remains to be 
done. As of today, four OIG recommendations from the 2012 
portfolio remain unimplemented.
    First, CMS should establish minimum Federal qualifications 
and screening standards for all personal care attendants.
    Second, CMS should require States to enroll or register all 
personal care attendants and assign them unique identification 
numbers.
    Third, CMS should require that Personal Care claims 
identify the dates of services and who provided those services.
    Finally, CMS should consider whether additional controls 
are needed to ensure that Personal Care Services are allowed 
under program rules and are provided.
    OIG work has demonstrated that Personal Care is subject to 
persistent fraud and beneficiary harm. CMS, in partnership with 
States, must implement basic safeguards to protect this 
critical benefit that allows millions of beneficiaries to 
remain in their homes and communities. Combating fraud and 
patient harm in Personal Care not only protects beneficiaries 
and programs, but also elevates the many honest, professional, 
and dedicated care attendants that enable beneficiaries to live 
independently.
    Again, thank you for the opportunity to testify this 
morning. I am happy to answer any questions you have.
    [The prepared statement of Ms. Grimm follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you, Ms. Grimm.
    Ms. Iritani, you are recognized for 5 minutes.

               STATEMENT OF KATHERINE M. IRITANI

    Ms. Iritani. Chairman Murphy, Ranking Member DeGette, and 
members of the subcommittee, I am pleased to be here to discuss 
GAO's work on Medicaid personal care services. The number of 
people receiving these services is significant and growing. 
Medicaid is the Nation's primary payer of long-term services 
and supports including those provided in homes and community 
settings.
    Personal care services are critical to helping people age 
in place, maintain independence, and participate in community 
life to the fullest extent possible. These services are not 
without risk, both for beneficiary safety and for improper 
payments. Regarding safety, beneficiaries receiving these 
services include older adults and individuals with 
disabilities, some of whom could be vulnerable.
    Regarding improper payments, personal care services are 
among the higher types at risk of being improper. One known 
concern is with Medicaid being billed for care that was never 
provided to the beneficiary.
    My testimony today is based on two recent GAO reports that 
examined Federal requirements for programs providing personal 
care services and data available for oversight.
    Now, typically, I would start my statement with some key 
facts about these services, such as the Federal requirements in 
place to protect beneficiaries from harm and to ensure that 
services billed to Medicaid were actually provided, and basic 
facts about these important services, such as the number of 
beneficiaries receiving them in States and at what cost. But as 
you'll hear today, these key points of fact are not easily laid 
out.
    I have three key observations from our work. First, there 
are multiple different program authorities under which States 
can provide personal care services in Medicaid. Since the 
program's inception in 1965, States have been required to cover 
institutional, but not home and community-based care. Since 
1975, several different options to provide home and community 
services have been provided to States. All States have adopted 
one or more different programs to varying degrees. How States 
screen, train, and monitor attendants and ensure billed 
services are provided varies, not only between States, but even 
within States, by program.
    A second key finding in our work: the Federal requirements 
CMS has in place for oversight of beneficiaries' safety and 
provision of services vary significantly between the different 
types of programs. Approaches for measuring quality assurance, 
defining and monitoring critical incidents, screening 
attendants to ensure they are not bad actors and then ensuring 
billed services are provided can and do vary significantly 
between programs. These differing requirements result in uneven 
safeguards for beneficiaries, depending on the program they are 
enrolled in; uneven assurances regarding oversight of billed 
services; and complexities for States and others administering 
and overseeing services.
    A third key finding of our work relates to the data CMS 
needs for oversight. Our work found that data available to CMS 
on the provision of and spending on personal care services are 
not always timely, complete, consistent, or accurate. For 
example, data lags caused by late submissions from States and 
other problems can mean CMS lacks good data for years on the 
services States have provided.
    At the time of our work conducted in 2016 largely, the best 
available data were for 2012 and only available for 35 of the 
States that provided these services. For those 35 States where 
we had data, 15 percent, amounting to nearly $5 billion in 
claims, lacked provider identification numbers; 34 percent, 
amounting to over $5 billion in claims, lacked information on 
the quantity of services provided; and more than 400 different 
procedure codes were used by States to identify personal care 
services.
    Without good data, CMS cannot effectively perform key 
management functions such as ensuring State claims are 
appropriate, ensuring appropriate Federal matching, identifying 
program risks, and monitoring access and spending trends.
    In recent years, Congress has directed HHS to improve 
coordination of home and community-based programs in Medicaid. 
CMS has taken steps to do so, and more can be done. In view of 
the growth in, the demand for, and the cost of Medicaid home 
and community-based services and the importance of these 
services to the beneficiaries who rely on them, Federal 
leadership to improve data and better harmonize requirements 
among different types of programs is needed.
    Mr. Chairman, this concludes my statement. I'm happy to 
answer any questions.
    [The prepared statement of Ms. Iritani follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you, Ms. Iritani.
    Mr. Hill, you're recognized for 5 minutes.

                     STATEMENT OF TIM HILL

    Mr. Hill. Thank you. Good morning, Chairman Murphy, Ranking 
Member DeGette, and members of the subcommittee. Thank you for 
the invitation and the opportunity to discuss personal care 
services in Medicaid.
    Speaking as a career executive with over 25 years of 
experience to Medicare and Medicaid service, to Medicare and 
Medicaid beneficiaries, I can state with confidence that CMS 
shares your commitment to protecting beneficiaries and ensuring 
the taxpayer dollars are spent on legitimate items and 
services. This fiduciary commitment is the forefront of all of 
our activities. In that regard, we greatly appreciate the 
ongoing work done by the IG and the GAO to highlight potential 
vulnerabilities in these important programs and we rely on 
their recommendations to inform our program improvement 
activities across all our programs.
    As you know, States are primarily responsible for day-to-
day operation of the Medicaid program and for designing 
programs that best serve the needs of the beneficiaries in any 
particular State. While we at CMS have an important role to 
play in terms of providing overall guidance and direction, 
States are in charge of administering the Medicaid programs and 
have significant flexibility to choose options that enable them 
to deliver high quality, cost effective care for their 
residents.
    Perhaps nowhere in the Medicaid program is that flexibility 
more important than in designing and administering home and 
community-based service programs including the provision of 
personal care services. Personal care services provide vital, 
person-centered care that allows individuals to remain in their 
homes or community instead of a nursing facility or other 
institution. In Medicaid, coverage of these important services 
is generally optional for States. However, because States see 
the value in these services, nearly all 50 States provide some 
level of coverage.
    It's hard to overstate the ways in which maintaining home 
and community based service programs benefits both the 
communities and the beneficiaries they serve. These programs 
cost less for both States and beneficiaries. They empower 
patients to have more control over their daily lives and the 
management of their health and they provide essential and 
culturally appropriate support to patients and their families.
    It's precisely because of the importance of these programs 
to Medicaid that it's paramount that we do all we can to 
protect these programs from fraud, waste, and abuse. Not solely 
to protect against financial losses, but as we've heard this 
morning, but more importantly to protect against abuse or 
neglect of vulnerable beneficiaries, many of whom are elderly 
or individuals with disabilities and may have no other 
practical alternative to institutionalization.
    Even one case of fraud, abuse or neglect is too many. In 
our efforts to protect these programs and the beneficiaries 
they serve, we pursue a balanced approach that recognizes the 
unique needs of every State while preserving their flexibility 
to design programs that will best serve their residents, while 
at the same time analyzing when and where to use national 
standards or guidance.
    We take a number of actions and we'll continue to help 
States safeguard their Medicaid beneficiaries and program 
resources by providing them with the tools they need to be 
successful. For example, to help States better understand 
requirements and share best practices, we publish guidance that 
highlights suggested approaches to strengthening and 
stabilizing the Medicaid home care workforce and other options 
to strengthen program integrity in Medicaid Personal Care 
Services programs.
    We've provided training for State officials and other 
stakeholders creating space for them to collaborate, share best 
practices, while staff is simultaneously staying up to date on 
emerging program vulnerabilities.
    CMS also uses focused program integrity reviews, assessing 
State program integrity effectiveness related to their 
administration of personal care services, providing States with 
feedback on vulnerabilities and possible corrective actions.
    This year, we plan to conduct focused reviews on PCS in 
five additional States.
    We also use our Medicaid Integrity Resources to work 
collaborative with States to identify improper payments through 
review of claims. Using these resources, we've conducted over 
40 audits on personal care services in 8 States. In one recent 
audit of PCS services in one State resulted in over $500,000 
being returned to the Treasury.
    Even as we continue to work with States to help them 
implement their programs, we are interested in understanding 
what changes need to be made at the Federal level. That is why 
last November, we published a request for information to gather 
stakeholder feedback on a provision of HCBS services. We are 
particularly interested in the benefits and consequences of 
implementing standard Federal requirements for personal care 
services and what these standards could include and how they 
could be developed.
    We're reviewing the comments we received to inform our 
approach to supporting States and their program integrity 
efforts in a way that maximizes State flexibility while 
protecting personal care service programs and beneficiaries 
from fraud, waste, and abuse.
    As we continue our efforts for PCS, we must also work to 
ensure that any additional oversight requirements do not create 
administrative burden, increase costs or impact beneficiary 
choice or control. The successful delivery of PCS in Medicaid 
ensure that both individual needs and preferences are met and 
that the program has adequate safeguards in place.
    We look forward to continuing our work with States, our 
oversight partners, and other stakeholders. This concludes my 
statement. I'm happy to take any questions.
    [The prepared statement of Mr. Hill follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you, Mr. Hill. I'll recognize myself for 
5 minutes. First of all, Ms. Grimm, Ms. Iritani, I want to 
commend you and your offices. It doesn't happen a lot in 
Congress, but in terms of a branch of the Federal Government 
that do their job, we thank you for doing that. We are 
absolutely indebted to you for these discoveries, and there's a 
real trust we have in this committee for the work you do. So 
please pass that compliment on to your other workers as well.
    That being the case, it bothers us about the stories you're 
telling us, the fraud and abuse and how it really hurts the 
beneficiaries, the elderly, and disabled individuals.
    And there's certain elements of this, Ms. Grimm, that you 
talked about, the PCS, that make it more susceptible to fraud 
for the vulnerable. You mentioned in some of your testimony 
some of the stories that beneficiaries often feel reliant on or 
loyal to their attendant--it sort of reminds you of the 
Stockholm Syndrome here--but even if that attendant is 
committing fraud or abuse and harm. So why is that, and what is 
in the system inherent in that that leads to that and, of 
course, how do we change it?
    Ms. Grimm. Thank you for your question. I think inherent to 
personal care services is sort of the intimate nature of those 
services, going into beneficiaries' homes and providing 
services like bathing, dressing, light housekeeping, food 
preparation. And in many of those instances, as you point out, 
the beneficiary becomes very reliant on those services, and in 
their mind services, even if they're suboptimal, are better 
than no services, and we have found apprehension on having 
fraud and abuse reported by beneficiaries. Often referrals come 
to us from families or loved ones that are witnessing neglect.
    Mr. Murphy. Are there threats made, subtle threats in terms 
of--that sometimes occur under these circumstances?
    Ms. Grimm. I'm not aware of a specific instance where the 
beneficiary was told they could not report, but we certainly 
have plenty of examples of harm that's resulted from fraud.
    Mr. Murphy. And I'm wondering in these cases, too, at times 
maybe a family puts up a hidden camera in the home, too, and 
also records events. Have those occurred? Have you seen 
anything like that?
    Ms. Grimm. Hidden cameras in beneficiaries----
    Mr. Murphy. Families many times do that with their 
babysitters, too, that may actually record some instances where 
a PCS worker was causing some problems. Have you seen any 
instances of that yet?
    Ms. Grimm. I don't have any instances of that, but we do 
have examples of family members that are perpetrating the harm 
and neglect with the beneficiary, so even in those scenarios 
where it's self-directed PCS, we are still seeing instances of 
family members committing that harm.
    Mr. Murphy. So given all of these stories and the heart-
breaking nature of them, if you could choose a recommendation 
you think would make the biggest impact, what would it be?
    Ms. Grimm. We want to know who we're doing business with at 
the attendant level. So the number one recommendation that I 
would put forward is that you enroll and register attendants 
and make sure that those identifiers are on the claims.
    Mr. Murphy. And background checks, full background checks 
on them, too?
    Ms. Grimm. We do recommend background checks. Many of the 
instances that we included in our investigative advisory would 
have revealed a history of criminal conduct, including drug 
diversion.
    Mr. Murphy. And what other kinds of backgrounds would be in 
this besides drugs? Felonies, burglaries?
    Ms. Grimm. We do have another example of a case in Illinois 
where a nurse had lost her licensure because she was stealing 
drugs from her employer. And in that instance, she was excluded 
from all Federal healthcare programs and a check, like we 
recommend for other programs and looking at the exclusions 
list, would have revealed that.
    Mr. Murphy. OK, thank you. Ms. Iritani, what impact does 
CMS have? How is it, in fact, not getting data on time? You 
made references to this data. How does this affect the 
oversight ability for CMS on PCS workers?
    Ms. Iritani. Data is critically important to really 
overseeing the program. CMS needs data to ensure that payments 
are appropriate and to assess trends and to ensure that the 
Federal matching is appropriate for what States are claiming 
from the Federal Government in terms of provided services.
    Mr. Murphy. Thank you. And Mr. Hill, given the kind of 
things here, what steps do you see moving forward that you 
could use to improve this whole process?
    Mr. Hill. So I think I would focus on two areas that have 
been highlighted. First, on the policy side and the 
recommendations with respect to standards. We've talked to the 
IG. We issued our RFI last year. For us, it's a balance, right, 
so every State is a little different. The requirements in one 
State may not be the requirements we want to have in every 
State, so we're anxious to continue our analysis there to 
determine whether or not we should be putting more requirements 
on States that internally have their own set of standards or 
whether we should be doing that nationally at the Federal 
level.
    Second, and I couldn't agree more, I think, with our 
colleague from the GAO that the dearth of data in the Medicaid 
program is a problem. We've done a lot over the last year to 
get data in in a much more timely way in a way that will let us 
do analysis, not only for our own selves, but also to give 
information back to the States about how their programs are 
operating and so continuing our effort to get data in to make 
that data timely and accurate I think is very important.
    Mr. Murphy. Thank you. I'm out of time. Ms. DeGette, you're 
recognized for 5 minutes.
    Ms. DeGette. Thank you, Mr. Chairman. I'm gratified to hear 
that members on both sides of the aisle recognize the 
importance of the Personal Care Services program to Medicaid 
beneficiaries and also the potential cost savings that we can 
get. But I do think that we can work together to address where 
controls need to be improved.
    A little note, one of the many little known provisions in 
21st Century Cures which, of course, this entire committee 
worked together on, required an electronic visit verification 
system for personal healthcare services and home healthcare 
services under Medicaid. What this requirement said is by 2019 
all personal care visits have to be electronically verifiable 
and that standard background information would be collected on 
every claim which I think would help. That would be a help.
    I just want to ask the panel some of the questions about 
the scope of the Personal Care Services program and what we can 
do.
    Mr. Hill, you heard Ms. Grimm talk about some of these 
services, particularly to the elderly who can stay in their 
homes. I think we all agree this program can be very beneficial 
to people like that, is that right?
    Mr. Hill. It's incredibly beneficial. For every example and 
every conversation we have with the IG about abuse and the 
horrible things that are going on, I think there's also as 
unreported sort of hundreds of examples of folks who are now 
living in their home, in their community with attendants and 
workers who make their lives fulfilling in a way that would not 
be if they were in an institution, people who have suffered 
broken limbs, broken back or where they have intellectual 
disabilities or any number of medical conditions that normally 
keep them in an institution are keeping them in their 
communities.
    Ms. DeGette. And not only that, but it also is more cost 
effective than putting them in nursing homes, is that correct?
    Mr. Hill. Absolutely, even as the GAO has noted, the 
highest spending State for PCS is close to $30,000 per 
beneficiary. Nursing homes are easily three to four times that 
amount.
    Ms. DeGette. Thank you. Now Ms. Iritani, I think you 
testified to this, your January 2017 audit found that the CMS 
data is of limited value for oversight purposes because it's 
often not timely and it's inconsistent across State lines and 
has errors. Is that correct?
    Ms. Iritani. That's correct.
    Ms. DeGette. And also, this is important. Although there 
are problems with the quality of data, it doesn't necessarily 
mean there's widespread fraud in the program, is that right?
    Ms. Iritani. That's correct.
    Ms. DeGette. And so why do you think the States are having 
such a hard time providing accurate and timely data to the CMS?
    Ms. Iritani. There are a host of different reasons and we 
didn't look at that specifically. We have on-going work 
actually looking at challenges that States are having with 
implementing T-MSIS, the utilization claims system. More work 
needs to be done. But some of the things that we are aware of 
in terms of some reasons States haven't submitted is related to 
new systems that they're putting in, maybe to comply with T-
MSIS and other reasons.
    Ms. DeGette. Don't you think it would be a good idea to 
work with the States so that we can get the data that we need 
because we can't really even begin to get our arms around the 
extent of the problem until we have that data?
    Ms. Iritani. Yes.
    Ms. DeGette. Can anybody testify what efforts we're making 
to standardize and to get that data? Mr. Hill?
    Mr. Hill. I'll speak briefly on where we are with the data 
collection. As GAO has pointed out, historically, the Medicaid 
data that we've gotten into CMCS has not been timely. It's not 
been accurate. Beginning 4 years ago, we began implementing a 
transformed system, a new system to collect use data, 
utilization data, claims data from States in a much more timely 
and standard format. We now have requirements in terms of what 
data the States have to submit, how it has to be submitted and 
the timeliness of that.
    We now have 35 States representing more than 60 percent of 
the beneficiaries and expenditures in the country reporting 
data into that system. We're beginning to share that data with 
our partners to do quality assessment and be sure that it's 
useable and it has fixed a lot of the vulnerabilities that have 
been identified by the GAO and are hoping, we, CMS, will be 
ready to accept data from all States by the end of the summer.
    Ms. DeGette. Great. Let me stop you there because I'm out 
of time.
    Mr. Hill. Yes.
    Ms. DeGette. Let me just say I think this would be a 
perfect hearing for the fall, Mr. Chairman, to bring the States 
in to talk about are they complying with that deadline of this 
summer and to see what else they need.
    Mr. Murphy. Right, and we also had that briefing before 
that most States are not even getting data.
    Ms. DeGette. Right.
    Mr. Murphy. So we're kind of flying blind. So appreciate 
it.
    Ms. DeGette. OK, thanks. I yield back.
    Mr. Murphy. I recognize the chairman of the committee for 5 
minutes.
    Mr. Walden. Thank you, Mr. Chairman. Ms. Iritani, in your 
report on PCS data, you were only able to analyze 35 States 
because 15 had not reported the data yet, as you all are having 
this discussion from 2012. So you conducted this audit from 
July 2015 to January of 2017 and as of then, 35 of 50 States 
had enough data from 2012 to analyze, correct?
    Ms. Iritani. Correct.
    Mr. Walden. Why were the data so late? Is this a common 
problem? Once it gets there, it just seems like it can take 
several years for CMS to process it, and why is that?
    Ms. Iritani. And I think there are two issues. One is that 
States submit data late, and it could be because they are 
largely managed care, and managed-care plans may submit data 
late or may not submit data at all.
    The other problem is that when the data comes in, it is not 
good and so CMS needs to go through a lengthy validation 
process which is part of why we only had data for 35 States 
several years later, is that the data had not been validated 
for those other States.
    Mr. Walden. Makes is it pretty hard to do appropriate 
oversight and reconciliation and everything else then?
    Ms. Iritani. Yes.
    Mr. Walden. Mr. Hill, GAO's January 2017 report raised 
concerns about these processing times. What's the average time 
it takes to process 1 year's worth of data, if there is such a 
thing as an average time?
    Mr. Hill. Right, so as identified, the data that the GAO 
looked at in the system that they were looking at was the 
system that is prior to the one we're using now. So for a 
State, for example, that's what we call live, submitting data 
into our system. For the 35 that I've identified that are 
processing, we have up-to-date data within a month current to 
the year, right, so if it's March and they submitted the data 
on the 1st of--from January and it's consistent, current for 
January.
    Mr. Walden. All right.
    Mr. Hill. Now as I said, we've built in a lot of the front-
end control to be sure that we don't have to take as long as we 
were taking in the prior system to do the quality check. Those 
quality checks are built in upfront. So we're confident and 
hopeful, I should say, and confident that this new system will 
both provide data much more timely, much more consistently, and 
in a way that will allow us to do the analysis and the 
oversight in a way that we could not.
    Mr. Walden. OK. Ms. Iritani, a question back to your 
comment about the managed-care plans, could the States or the 
Federal Government make a condition of the contract with the 
managed-care plans that they have to submit data on a regular 
basis in a format that works for the expedited review and do we 
do that?
    Ms. Iritani. Yes, they are required to. It's more a 
question of enforcement.
    Mr. Walden. What's the penalty if they don't?
    Ms. Iritani. I think that will depend on the contract that 
the States have put in place with the managed-care 
organization.
    Mr. Walden. And we could probably weigh in on that contract 
requirement since we're a partner in this process?
    Ms. Iritani. That would be a policy decision.
    Mr. Walden. Yes. OK. Ms. Grimm, I understand a beneficiary 
in Pennsylvania died of exposure to the cold while under the 
care of a PCS attendant according to some of the reports. In 
another case, a hot July day, a PCS attendant in Maryland left 
a beneficiary with developmental disabilities in a locked car 
while shopping with a companion.
    What's the most important thing CMS can do to prevent 
beneficiaries from being subject to neglect and abuse by PCS 
attendants?
    Ms. Grimm. Move to require States to enroll or register a 
care attendant so that we're able to keep track of what's 
happening at that attendant level.
    Mr. Walden. OK, and what reaction, if you get any, from the 
States when this is suggested?
    Ms. Grimm. We have a report coming out at the end of the 
summer that provides survey data from the Medicaid Fraud 
Control Unit Directors on the recommendations that we have put 
forward, also fraud trends related to personal care. We know 
that that group very much endorses the recommendation that 
we've put forward related to enrollment and registry. And the 
report will also have some other solutions States have 
explored.
    Mr. Walden. OK, perfect. How do you investigate fraud when 
it involves beneficiaries' family members because we understand 
that's a problem, too?
    Ms. Grimm. One thing that I think this committee could also 
do is to give our Medicaid Fraud Control Units the authority to 
investigate stand-alone harm in patients' homes. They currently 
only have the authority to investigate when it's associated 
with billing fraud. So it does become challenging to 
investigate harm when it is not linked to some of those other 
billing issues.
    Mr. Walden. My time has expired. Thank you again for the 
good work that you are doing and your counsel to us. We 
appreciate it.
    Mr. Chairman, I yield back.
    Mr. Murphy. All right, I now recognize Mr. Tonko for 5 
minutes.
    Mr. Tonko. Thank you, Mr. Chair. It's good to see CMS here 
today to talk about improvements that CMS can make and should 
make to this program. But let's not forget that the Medicaid 
program and PCS, in particular, is a partnership between the 
Federal Government and the States. States are given flexibility 
to design their given programs to fit the needs of their 
populations, but in exchange they have to do their part to 
ensure the integrity of the programs.
    States are the first line of defense in protecting Federal 
and State Medicaid dollars. So with that being said, Mr. Hill, 
in your testimony you stated, and I quote, ``Both the Federal 
Government and States have key roles as stewards of the 
program.''
    So is it accurate to state that CMS cannot perform 
effective oversight without cooperative State partnerships?
    Mr. Hill. I think oversight is always more effective when 
there's cooperation between us and the States. We have our 
role. The State has their role. Sometimes there will be 
tension, right, between what we view as a direction the State 
needs to be or whether or not they're in compliance with 
Federal rules. But we always prefer to be working--particularly 
on issues of beneficiary harm and abuse--working hand in glove 
to make sure that we mitigate those.
    Mr. Tonko. So what does CMS need from the States to improve 
this whole outcome?
    Mr. Hill. As I've indicated earlier, I think in any 
oversight context, the more data we have and the better data we 
have with States and States being up to date with submitting 
that data is going to give everybody a leg up in terms of 
understanding what our problems are and how we meet those gaps. 
Beyond that, I think States as identified by the IG, each have 
their own requirements for how they oversee and maintain the 
integrity, in particular, of personal care attendants and how 
those services are being delivered. And we need to make sure 
that States are following through and enforcing those 
individual State compliance, right?
    We don't have the resources, nor is it our job, to on a 
day-to-day basis be monitoring claims and understanding how the 
benefits are being delivered in any particular State. So the 
State really needs to be in a position to step up and be doing 
that work on behalf of those beneficiaries.
    Mr. Tonko. Thank you. And Ms. Iritani, would you agree that 
the responsibility for program integrity falls on both CMS and 
the State Medicaid programs?
    Ms. Iritani. Yes.
    Mr. Tonko. So the OIG has done a lot of excellent work 
looking at different State programs and pointing out 
vulnerabilities and short comings. I understand that OIG's 
audits of some States have found problems with PCS claims such 
as providers claiming more hours than were recorded.
    And again, that being said, Ms. Grimm, it seems clear that 
States need to make improvements. Do you believe that the 
provision passed by the last Congress which does require States 
to ensure PCS visits are electronically verified will help 
address some of the issues that have been raised by the OIG?
    Ms. Grimm. Thank you for that question. We very much 
appreciate some of the protections and collection of data 
that's offered by that provision in 21st Century Cures. We know 
that that does not currently include managed care and, with the 
high percentage of services in Medicaid being provided through 
a managed-care model, it definitely does not sort of wrap 
around those services, but it is a terrific step forward and it 
does collect some of the information that would allow our 
criminal investigators to detect potential patterns of fraud. 
Yes.
    [The HHS Office of Inspector General submitted the 
following amended portion of Ms. Grimm's response:]

        We know that that may not currently include managed care and, 
        with the high percentage of services in Medicaid being provided 
        through a managed-care model, it may not sort of wrap around 
        those services, but it is a terrific step forward and it does 
        collect some of the information that would allow our criminal 
        investigators to detect potential patterns of fraud.

    Mr. Tonko. Thank you. And what additional resources do 
States need in order to conduct better oversight of the PCS 
programs?
    Ms. Grimm. I think having uniformity in the kinds of 
standards that are required, the qualifications, some floor 
requirements for the care attendants upon which States can 
build and customize according to the special needs of those 
States. I think that would better put States in a good position 
to make sure care being rendered to their beneficiaries is of a 
high quality.
    Mr. Tonko. Thank you. And Mr. Hill, what steps is CMS 
taking to encourage or require States to do more in this area?
    Mr. Hill. So we've taken a number of steps in terms of 
working with States on education, giving them best practices 
and feedback about program integrity, methods and standards, be 
it through review of claims, how to put edits in place to 
review claims for high-dollar or unsubstantiated services, 
helping them think about putting together registries or 
enrollments for PCS attendants. But beyond that, we're also 
working with States to provide direct training. We have a 
facility where we can bring States in and bring our law 
enforcement partners in to do hands-on work to understand 
better how to do investigations around PCS types of work and 
what kind of policies to put in place to prevent those types of 
abuses from occurring.
    And finally, we're doing our own work to understand whether 
or not more Federal requirements are needed beyond just 
requiring States to have their own internal policies, 
particularly around enrollment of attendants should there be a 
Federal standard, should we have nationwide standards for how 
these attendants ought to be monitored and overseen.
    Mr. Tonko. And that training is up and running now?
    Mr. Hill. Yes, we had training back in February. We had 36 
States, a number of our partners from law enforcement and the 
oversight community, and we'll continue to do that.
    Mr. Tonko. Thank you very much, Mr. Chair. I yield back.
    Mr. Murphy. Thank you, Vice Chairman Mr. Griffith is 
recognized for 5 minutes.
    Mr. Griffith. Thank you very much. Ms. Iritani, it's my 
understanding that States can receive more Federal money in the 
form of a higher match for some activities related to 
collection and compliance with Federal reporting requirements. 
Am I correct in that?
    Ms. Iritani. Yes, that's correct.
    Mr. Griffith. And so you're having difficulty getting 
States to get some of the reporting and so forth. And I'm going 
to switch gears in a minute on that. But do you have a stick? 
You've got the carrot. Do you have a stick that they might 
receive a lower match if you they're not collecting some of the 
data that you want?
    Ms. Iritani. CMS does have authority to reduce the Federal 
matching for system areas that are experiencing problems from a 
75 match to a 50 percent match.
    Mr. Griffith. Now let me switch gears a little bit because 
I am worried about the States and I think that some of the 
resistance from the States may come from a fear that they'll 
chase some folks out of this industry, particularly when you're 
dealing with family members and we all want to stop the abuse, 
but when you're talking about family members I heard, I believe 
it was you who earlier said that some States had 400 different 
codes, and so it was hard to get the coding straight. And I can 
see a family member who is trying to take care of their loved 
one is receiving some monies for bathing or doing some daily 
activity where the mom or the dad of theirs needs help and then 
they're faced with having to learn 400 codes. So I think if 
we're going to do something, we have to make it simple. Would 
you not agree?
    Ms. Iritani. Yes, we would agree with the harmonization of 
requirements. The 400 codes was actually at the Federal level 
in terms of how PCS was coming in in terms of the coding.
    Mr. Griffith. So if we're going to require electronic 
verification which I think is fine as long as it can be done on 
the phone because most people will have their electronic phones 
with them, their little gadgets, and this is where tele stuff 
can be of great help, technology can be of great help to us, 
but it needs to be simplified because you're going to have a 
hard time--if you're just a 50-some- or 60-some-year-old child 
trying to do the best you can for your parents because Mr. 
Hill, you did point out earlier, we see in the news all the 
horror cases. What we don't see are the thousands of people, 
whether they be the professionals who are coming in or the 
agencies that are sending people in or whether it's a family 
member, where that person's life is greatly enhanced by having 
a PCS individual helping them out through one of these programs 
and I get that.
    It also raises some concerns for me that not only do we 
have to simplify it, but we have to be careful because there's 
a difference between somebody who's working for an agency that 
sends in folks and that family member. Because while we want 
family members monitored to a certain degree, I'm not sure we 
want to create a whole new bureaucracy to monitor them. We have 
the Department of Social Services, at least in the Commonwealth 
of Virginia that already is aware of that and if something is 
going on a neighbor can report and they go out just like they 
would with a child, for child abuse, and look for that.
    Then we also have this whole thing where everybody is like 
let's do background checks. The question is if we're going to 
do background checks and I'm not against that, but we need to 
make sure that we're not throwing the baby out with the bath 
water. Because absolutely, if you've got a history of child 
abuse or spousal abuse or abuse of a parent, even if you're a 
family member, you ought not be involved. But a theft--I was a 
criminal defense attorney, by the way, for 28 years--so a theft 
of four tires off of an automobile when you're 18, it's a 
theft, Mr. Chairman raised that issue and he was right to do 
so. It's a theft. It may want to be something that you take a 
look at, but I'd hate to see a son who's now in his 40s or 50s 
being precluded because he came back with a felony conviction 
20-some years ago on stealing tires or doing something that, 
when you look at the facts, it's a whole different case than 
just running it through.
    And the problem is when Government gets a hold of a 
criminal background check, oftentimes they come up with hard 
and fast rules. If you've been convicted of X, you can't be 
involved. And I think we need to set that bar fairly high. I'm 
not sure it shouldn't be our responsibility. What do you all 
have to say about that?
    Go ahead, Ms. Grimm. I think you're the right person to 
start on that.
    Ms. Grimm. OK, I very much appreciate the question and that 
context absolutely matters. We believe that those background 
checks can reveal information that consumers can use and their 
family members can use to make informed decisions about the 
care that's provided.
    Mr. Griffith. OK, so you would look for if we were going to 
craft some language along those lines to say have the 
background check done, but then it would be the family members 
who would decide or it would be forwarded to Department of 
Social Services, something along those lines? Would that be 
your proposal?
    Ms. Grimm. I think we would want there to be guidance to be 
accompanying the types of convictions and histories that are 
revealed through those background checks, but we have not gone 
forward with a recommendation that says this specific kind of 
crime should preclude them from providing personal care. CMS 
can provide some exemptions and we've had those conversations 
with CMS.
    Mr. Griffith. And if you all decide to go with guidance, 
I'm happy to assist in any way I can to have you come up with 
ways that you may be able to ferret out the bad actors without 
throwing out the folks who might have made a mistake at one 
point in time. Likewise, maybe you all can help us come up with 
the proper guidelines to put into the legislation that would 
give you that authority.
    With that, Mr. Chairman, I yield back.
    Mr. Murphy. I recognize the gentleman from California, Dr. 
Ruiz, for 5 minutes.
    Mr. Ruiz. Thank you very much, Mr. Chairman. I think 
everyone can agree that we must do all that we can to maintain 
program integrity in the Medicaid Personal Care Services 
program and continue to work to eliminate fraud and abuse, and 
we must continue to identify common sense improvements to this 
program such as better data collection and Federal baseline 
standards, but we must do so by maintaining patient access to 
this critical program that allows individuals to remain at home 
and live independently when they might otherwise be forced to 
move to a nursing home or assistive living facility.
    Data collection is integral in evidence-based policy 
development. And I think many of you had mentioned that there 
are some exciting opportunities here and if we don't use data, 
then we're at the whims of ideological partisanship that then 
kind of makes the wrong decision, contrary to what's best for 
the patient and for the American people.
    One of the problems we've seen regarding this program 
integrity in the Personal Care Services program is inadequate 
data. A GAO report stated that CMS is developing an enhanced 
Medicaid claims data system known as the Transformed Medicaid 
Statistical Information System pronounced as ``T-MISSIS,'' 
right? Under T-MSIS, States will be expected to report claims 
data that are more timely and more complete.
    Mr. Hill, it's clear that T-MSIS is a critical tool to 
ensure timely, accurate, and complete data from States, and it 
is my understanding States have been working for years to 
implement the new system. What steps has CMS taken to complete 
T-MSIS this year?
    Mr. Hill. So this year, we've actually had a good year this 
year. As I mentioned earlier, we've now got 35 States reporting 
and I think most of them are current with their data reporting. 
We're working with the remainder of the States to meet them 
where they are, to make sure that they have everything they 
need in place to begin reporting and will be ready to take 
their data by the end of the summer. Whether they can meet that 
deadline or not is something we'll continue to work with them 
on.
    Mr. Ruiz. How many States? What's the percentage? And what 
year do you think we'll have everybody on board?
    Mr. Hill. I'm hopeful that by the end of this year we can 
have all States in. Now again, that all depends on whether 
States are going to be able to internally meet their own 
deadlines. As you know, Medicaid is incredibly complex at the 
State level and they're integrating State data from many State 
systems. And so it's a challenge for them to be able to put it 
into a common core.
    Mr. Ruiz. So what additional claims information will be 
included under T-MSIS, and how will this improve the integrity 
of the Medicaid claims data?
    Mr. Hill. I think the single biggest piece of information 
that we'll have out of--and this is where--it's hard to know 
when you're supposed to correct a congressman, but it's ``T-M-
SIS.''
    Mr. Ruiz. ``T-M-SIS.''
    Mr. Hill. When we have the T-MSIS data in, particularly 
data around providers, right, so there's just a statutory 
requirement now to be providing, referring, and ordering 
information on a claim so we'll know who referred, who ordered 
a service and we'll know more information about the providers 
that are submitting claims. Under the old prior information, we 
didn't have that enrollment information and we didn't have the 
ordering and referring information from providers.
    Mr. Ruiz. Ms. Iritani, how will any further delay impact 
the integrity of the Medicaid claims data in the near future?
    Ms. Iritani. Significantly. Reliable data is really 
important for overseeing improper payments and other functions, 
and we have recommendations to CMS on personal care services in 
particular that CMS should issue guidance that is standard on 
reporting of personal care services and, with regard to T-MSIS, 
should really prioritize the data that CMS needs for oversight.
    Mr. Ruiz. So I understand that while there are reported 
benefits of implementing T-MSIS, it is not a cure-all, correct?
    Ms. Iritani. Correct.
    Mr. Ruiz. For example, in your report, you stated that CMS 
will need to develop plans for how it can be used for 
oversight. Can you give me some examples of how that can be 
used for oversight?
    Ms. Iritani. Well, ensuring, for example, that the Federal 
matching for what States are claiming as expenditures is 
appropriate. Our work found, for example, that 17 percent of 
the expenditure line reporting for personal care services was 
incorrect.
    Mr. Ruiz. Would you say this is the number one most 
impactful way to start providing oversight for potential fraud 
and abuse, is if we were to focus on one thing would it be the 
data collection system, Mr. Hill?
    Mr. Hill. For me, I mean we are focusing on it now and it 
continues to be a priority. You can't run a program of the size 
and scope of Medicaid without good, accurate data.
    Mr. Ruiz. So what do you need to finish this in a timely 
manner?
    Mr. Hill. We need the continued cooperation of States to 
get their data in and to do the work they need to do to get the 
data in a timely way and we have that and we'll continue to 
work with them.
    Mr. Ruiz. Thank you very much.
    Mr. Murphy. Mr. Collins, you're recognized for 5 minutes.
    Mr. Collins. Thank you, Mr. Chairman. I want to thank the 
witnesses also.
    Now I'm a private-sector guy. I spent 30 years in the 
private sector and at one point I also was the county executive 
of the largest upstate county in New York. It was bankrupt. I'm 
a Lean Six Sigma guy. I brought Lean Six Sigma into a large 
municipal government for the first time in the United States 
about 8 years ago. And it worked. But we also had a program 
called Just Do It. We would put together a team of a lot of 
different commissioners and we'd deep dive some issue that 
touched on a lot of different departments and it would take us 
6 months. And then every once in a while we'd come up with what 
we'd called the Just Do It. It was so obvious, so direct. We 
knew the problem. We really knew 90 percent of the solution. We 
said why are we going to waste our time with this 6 months' 
program. Let's just do it.
    And kind of sort of what I'm hearing today is a lot of just 
do it. So what am I missing here? The Federal Government sends 
money out to the States. In the case of New York, our program 
is $60 billion a year. So with 6 percent of the Nation's 
population, we spend 12 percent of the Nation's Medicaid money 
and it just keeps flowing.
    In the private sector, if I have a vendor and he sends me 
an invoice and he doesn't have the proper numbers on it, I 
don't pay it. If he sends me an invoice and whatever 
requirements that I've had aren't there, I don't pay it. So 
here's my just do it.
    Now no disrespect intended, but why are we wasting our time 
analyzing 2012 data? It's worthless. Completely, utterly 
worthless. There's nothing to compare 2012 to 2017. If we've 
got a bunch of people crunching 2012 data, if I'm Tom Price or 
Seema Verma, I'd go what? Are you joking me?
    So if we've got the power of the purse strings, why don't 
we just stop paying people, sending money to States who don't 
adhere by our responsibilities? The requirements. Why don't we? 
Why don't we?
    OK, there's my just do it. I call you and I say we're just 
going to do it. No money goes out without the data in a timely 
fashion. Thirty-five States--well, 15 States--just wouldn't be 
getting any more money. If you start cutting off the flow of 
cash, you will get their attention and you will get your data. 
You'll get your data in a timely fashion. And if you have--I'm 
just somewhat dumbfounded by this. The solution is staring us 
in the face and we're sitting here talking about something. I 
don't get it. What am I missing?
    Ms. Iritani. Well, we agree that CMS needs to take 
immediate steps to----
    Mr. Collins. So why don't we do it? Do it today. Is there a 
reason? We can do it today.
    Ms. Iritani. To improve the data, yes.
    Mr. Collins. Today.
    Ms. Iritani. And to issue guidance to States on standard 
elements that they should be reporting.
    Mr. Collins. Require that the attendants register. And if 
there's not a number, they don't get their money.
    Ms. Iritani. There has been a longstanding, also, interest 
in making sure that there is access to services.
    Mr. Collins. We do. But money talks.
    Ms. Iritani. Yes.
    Mr. Collins. The minute you cut off the funds, I mean, 
that's what I find. When we talk about waste, fraud, and abuse, 
and we find that the Federal Government is sending this money 
out and then we're finding out after the fact through data 
that's 5 years old when in the case of 15 States they don't 
submit data, you know where the problem lies, in CMS, for 
sending the money out, for approving the voucher. Don't we have 
to approve payments?
    Mr. Hill. So a couple of issues to unpack there, and I 
think it's a fair comment and it's a true comment that the 
money speaks. Right? And if we withhold funds, States are 
definitely going to get somebody's attention much quicker than 
other corrective actions. I think for us to consider, as we 
talk to States and try to--particularly on their compliance 
issues, not so much now talking about program abuse of 
providers, billing inappropriately.
    Let's talk about States meeting our requirements, for 
example, for submitting data. We try very hard, recognizing 
it's a complex system to get States to get into compliance in a 
way short of having to withhold the funds. It's sort of 
nuclear, right, to say we're immediately going to go to 
withholding funds from the State of New York or any other 
particular State without first going through as much as we can 
with the State to be sure they've got all the TA, all the 
information they need, all the help they can get from us to get 
into compliance. If after that, they still are unwilling or 
unable to come into compliance, then the purse strings is 
definitely the place that we go to sort of make sure that we 
have their attention.
    Mr. Collins. And I do agree. You want to give somebody at 
least a glide path, 3 months, even 6 months, but to hear that 
we're analyzing 2012 data, I mean what a tragic waste of time. 
2012 doesn't tell you anything about 2016, '17. I mean truly 
not to be insulting here, I think we could get there very 
quickly. I'm certainly hoping that Tom Price and Seema Verma 
get there quickly and this has been kind of eye opening again 
in a frustrating way.
    Thank you, Mr. Chairman. I yield back.
    Mr. Murphy. Thank you. I now recognize the gentlewoman from 
Illinois, Ms. Schakowsky from Illinois.
    Ms. Schakowsky. I want to thank all of our witnesses. First 
of all, care services are incredibly important and I really 
want to emphasize that, even as we try and make it better, I 
hope all of us are really committed to making sure that those 
services are provided.
    In Illinois, we have the Community Care program which is 
one of the home and community-based care services provided by 
the Medicaid benefit, to Medicaid beneficiaries and provides 
services to about 84,000 individuals.
    We also know that these are the very programs that often 
are slated for huge cuts. In Illinois, unfortunately, we 
haven't had a budget for 2 years and Governor Bruce Rauner 
proposed cutting $200 million from the Community Care Program 
in his budget proposal which is one of the many reasons 
Illinois hasn't had a budget.
    In addition to funding for those programs, a high quality 
personal care workforce is absolutely critical to ensuring that 
beneficiaries have access to the services they need. As GAO has 
reported, many of the personal care service programs differ 
from State to State. We know that. And that includes the 
training or lack thereof that service agencies provide to the 
workforce. In some States, training is offered or required, 
either for new entrants into the workforce or for continuing 
education of existing workers. In other States, there's 
actually little or no guidance on training or continuing 
education for those workers.
    Mr. Hill, let me ask you, have you investigated what 
percentage of agencies providing personal care services in 
Medicaid have orientation or training programs that are in 
place?
    Mr. Hill. So as I sit here, I couldn't give you statistics 
by State where those requirements lie, which States require 
that and which particular agency.
    Ms. Schakowsky. Let me ask Ms. Iritani, do you know that or 
either one of you know that?
    Ms. Iritani. We know that it varies, yes.
    Ms. Schakowsky. OK. But you don't know.
    Ms. Iritani. No.
    Ms. Grimm. An analysis that we did in 2010, we did find 301 
sets of qualifications across States.
    Ms. Schakowsky. OK, and that would include the kind of 
orientation and training programs?
    Ms. Grimm. It would include that in the qualifications.
    Ms. Schakowsky. Back to Mr. Hill. Do you know what 
percentage--or any of you know what percentage of those 
specifically educate their employees and what constitutes 
waste, fraud, or program abuse?
    Mr. Hill. As I indicated earlier in response to a question, 
we have issued guidance to States on best practices. While I 
can't say which States require it as I sit here, I could not 
tell you which States require that level of training. We have 
identified for States that training, particularly around 
compliance issues, is the best practice for attendees. And we 
would expect that States would require that of particularly the 
attendant agencies to be sure that the folks that are coming 
into those agencies are properly trained, not just for patient 
safeguards, but also on the compliance side.
    Ms. Schakowsky. Well, what it seems to me is that the word 
has gone out that this would be important, but nothing has been 
done really to enforce that or to even survey that to find out 
who's doing exactly what when it comes to worker training.
    Finally, I just want to note that when a worker comes 
forward to report cases of waste, fraud, or neglect on behalf 
of the personal care agency they work for, I really think that 
it's critical that they are provided whistleblower protections.
    And again, to any of you, I'm just wondering if 
whistleblower protections are built in.
    Mr. Hill. Speaking for CMS--and I'm sure the IG and others 
would have it--we review tips and whistleblower complaints as 
valuable sources of information as we conduct investigations in 
concert with our law enforcement partners. I think the 
whistleblower protections vary by State in State law and that's 
something that--we value those sorts of activities highly, and 
it's something that we would encourage States to continue to 
support.
    Ms. Schakowsky. Well, again, are they protected by law if 
they were to come forward?
    Mr. Hill. On the whistleblower side, I think it's a State-
by-State determination as to how the State whistleblower laws 
apply.
    Ms. Schakowsky. Well, then let me just say I think we need 
to standardize that because one of the ways that I think that 
we can make the program operate effectively without waste, 
fraud, and abuse is to protect the out front, the upfront 
workers that are doing it because they are the most likely to 
see it.
    In my experience with those home care workers is that these 
are really dedicated people who are doing often for very little 
money some of the most important work in our country and I 
yield back.
    Mr. Murphy. Thank you. I now recognize Mr. Walberg for 5 
minutes.
    Mr. Walberg. Thank you, Mr. Chairman. Thanks to the panel. 
My wife and I were extremely concerned when a personal care 
worker stole a credit card from my mother and that was a deal 
from that point on dealing with the bank and then dealing with 
the court system. But I was disturbed, as I read the released 
investigative advisory coming from OIG, that there are 
significant number of instances where PCS workers steal 
painkillers and other medications from their beneficiaries.
    In the case, Ms. Grimm, that you noted in 2016 in Vermont 
specifically, how did OIG discover that?
    Ms. Grimm. So Vermont, that involved the husband. It was a 
wife, the beneficiary was a husband and the wife was splitting 
payments with the care attendant and as part of that scenario 
she would get or he would get pain pills as a form of payment. 
I don't know how that came into our office, but that was the 
scenario that was uncovered.
    Again, going back to some of the recommendations that we've 
offered, had there been a background check in place, it would 
have revealed a pattern of drug abuse.
    Mr. Walberg. How often is this happening? Is this a common 
occurrence that you're finding?
    Ms. Grimm. I think fraud is very common in personal care. 
We've opened 200 investigations since 2012 and our Medicaid 
Fraud Control Units, it comprises one third of their criminal 
convictions and have upward of 8,000 cases that have been 
opened in that time frame.
    Mr. Walberg. Are the painkillers that are stolen generally 
used by the individual themself or are they selling this?
    Ms. Grimm. We've seen patterns of both of them using 
painkillers for themselves and then also selling those. Drug 
diversion is a big issue in the fraud that we see.
    Mr. Walberg. Yes, and that's a concern when we see about 
the opioid problems, etcetera. The OIG recommended establishing 
some minimum Federal qualifications and screening standards for 
PCS workers. What kind of minimum qualifications do you have in 
mind?
    Ms. Grimm. We have recommended minimum age requirements, 
background checks, and we endorse training. Just to sort of de-
mystify things, all of those things right now are voluntary. 
They're not something that's required at the Federal level, so 
to the extent that it's happening, it's the State sort of 
acting on it. It is not currently required at the Federal 
level.
    Mr. Walberg. With the screening and the background checks, 
it makes sense to prohibit individuals with felony convictions 
for drug-related crimes and social services fraud. Is that part 
of your recommendation?
    Ms. Grimm. We have not specified, but there are guidelines 
in place for care workers that have direct interaction with 
patients in the home health context. And I think some good 
parameters could be taken from that context.
    Mr. Walberg. OK. It seems like that would make sense.
    Mr. Hill, is CMS able to enact stricter standards?
    Mr. Hill. We can certainly regulate. The question is how to 
regulate. As you know, we issued our request for information 
last fall, asking all the affected stakeholders on these very 
particular issues about whether or not Federal standards for 
enrollment or background screening or any number of things that 
the IG has recommended should be put in place.
    As you know, it's a tension between State flexibility and 
the flexibility of any particular program in terms of who it is 
and how it is they're overseeing those programs and the 
imposition of a Federal requirement. So before we were to 
implement a Federal requirement, we want to be sure that it's 
going to meet the needs of all the States, both from a program 
integrity standpoint and also from the service delivery 
standpoint as well.
    Mr. Walberg. Well, I appreciate that. I guess I would echo 
some of Mr. Collins' statements as well that it's time to push. 
And as you indicated as well, the financial push is sometimes 
the best way to get these recommendations dealt with and the 
States to get on board. Because it's one thing for an elderly 
lady with dementia to lose her credit card. That can be fixed. 
When you get into in this particular area of medications, 
painkillers, getting out and misused, it impacts lives and 
maybe get a good handle on that.
    Thank you. I yield back.
    Mr. Murphy. Thank you. I now recognize Ms. Clarke for 5 
minutes.
    Ms. Clarke. Thank you, Mr. Chairman. Mr. Chairman, I'm glad 
that we've had the opportunity to talk about the Medicaid 
program and how many people it helps across the country. 
Roughly 74 million Americans depend on Medicaid for healthcare 
coverage and the program is a lifeline to these individuals.
    The Affordable Care Act authorized States to expand 
Medicaid for low-income adults, helping to fill a major gap in 
insurance coverage. As a result, more than 12 million low-
income adults were able to gain coverage last year.
    As Republicans are contemplating repealing the Affordable 
Care Act's Medicaid expansion and making sweeping changes to 
Medicare, I'd like to put this program in context.
    Mr. Hill, CMS has reported that the ACA's Medicaid 
expansion has helped reduce the rate of uninsured to its lowest 
level in our Nation's history. Is that correct?
    Mr. Hill. That's correct.
    Ms. Clarke. And in a report this past January, CMS stated, 
and I quote, ``Medicaid is the most efficient healthcare 
program we have, covering people at lower costs than commercial 
insurance coverage or even Medicare. And at the same time 
Medicaid has that proven track record of enabling access to 
care, improving health, and helping children succeed in life.''
    Mr. Hill, do you agree that Medicaid is an efficient 
program and that is covers people at lower costs than Medicare 
and commercial coverage?
    Mr. Hill. My judgement is that Medicaid is an important 
program doing a lot of good for the 74 million people that we 
cover.
    Ms. Clarke. In CMS' January report, the Agency stated, 
``Research has shown that Medicaid expansion has helped improve 
quality, access, and affordability of care.''
    Mr. Hill, can you briefly explain how the Medicaid 
expansion has improved the healthcare coverage of its 
beneficiaries?
    Mr. Hill. Without speaking directly to the January report, 
let me just say that as a general proposition somebody who is 
covered, whether they're covered through the marketplace or 
whether they're covered by their employer, they have coverage 
through Medicaid. If you have health insurance coverage, you 
generally are going to be in a better place vis-a-vis be 
uninsured, particularly if you get sick.
    Ms. Clarke. So in addition to expanding Medicaid coverage 
to millions, the ACA also created the Community First Choice 
program. This program encourages more States to offer personal 
care services by providing an additional six percent Federal 
matching payment to these services. Unfortunately, in addition 
to gutting the entire Medicaid program, one provision of 
Trumpcare would actually repeal this option.
    Ms. Iritani, I understand from your report that States have 
begun to participate in the Community First Choice program, is 
that correct?
    Ms. Iritani. That's correct.
    Ms. Clarke. Can you tell me more about States' 
participation in this program?
    Ms. Iritani. Well, we know from our work that eight States, 
as of the time of our report, were participating in the 
Community First Choice program. And one of the concerns we have 
leading to our recommendation about harmonizing requirements is 
making sure that for those people who are in that program who 
require institutional level of care that the safeguards are in 
place to ensure beneficiaries' safety are similar to other 
programs that have served similar beneficiaries, because many 
States are moving their beneficiaries from waiver programs that 
have really strong or stronger safeguards into the Community 
First Choice program.
    Ms. Clarke. So you're saying that the Community First 
Choice program doesn't have strong safeguards?
    Ms. Iritani. I think that it doesn't have the same level of 
safeguards as others, other programs' authorities.
    Ms. Clarke. Are you saying that you believe that that may 
put some of its participants at risk?
    Ms. Iritani. We recommend that CMS actually needs to 
harmonize the requirements in place between programs to ensure 
that common risks for beneficiaries, depending on their level 
of need, are addressed in common ways across the programs.
    Ms. Clarke. And the Community First Choice program, do you 
believe that their services are less than traditional?
    Ms. Iritani. No, we did not do that work, no.
    Ms. Clarke. OK. Mr. Chairman, I hope my colleagues 
recognize the importance of this program, how many people rely 
on Medicaid for their insurance. Trumpcare proposes to 
dismantle the Medicaid program as we know it, capping coverage 
for children, pregnant women, individuals with disabilities, 
and of course, those who have gained coverage from the Medicaid 
expansion, not to mention Medicaid is the primary insurer of 
long term care services and support in this country.
    I hope my colleagues will reflect on that point and the 
immense responsibility we have to strengthen Medicaid and not 
tear it down. And I yield back.
    Mr. Murphy. Thank you. I now recognize Mr. Costello for 5 
minutes.
    Mr. Costello. Thank you, Mr. Chairman. Ms. Grimm, Mr. Hill, 
between 2014 and 2015, the improper payment for personal 
support services which includes PCS, as you know, nearly 
doubled from 6.3 percent in 2014 to 12.1 percent in 2015. 
That's a lot. Why did the error rate increase at such a level 
in your opinion?
    Mr. Hill. So some of it will have to do with measurement, 
right. That's not necessarily a statistically significant way 
to measure those services. I'm not discounting the fact that 
there's an error rate meaning to worry about it, but just as a 
technical matter, it's hard to make comparisons year to year 
the way the PERM rate is put together.
    I also think that the roll out of requirements around 
requiring ordering and referring physicians on claims began to 
get implemented over that time period. And so while in PCS that 
may not be an issue that category of services you had 
identified, there are claims in there that require ordering the 
referring physician to be on the claim. And I know States have 
had a struggle coming into compliance with that requirement.
    Ms. Grimm. I missed it, did you say Ms. Iritani or Ms. 
Grimm? I'm sorry.
    Mr. Costello. Ms. Grimm.
    Ms. Grimm. So the work that we've done, so we've looked at 
error rates in personal care services across eight States, and 
we have consistently found very high error rates in personal 
care services.
    Looking at recent information, Missouri, upwards of 47.8 
percent in error rate; New Jersey, 30.9 percent; New York City, 
18 percent. And this is consistent across States. So I think 
the core point there is that we do find high error rates in 
personal care services, so it's unsurprising that the error 
rate in PERM is what it is for personal care.
    Mr. Costello. Thank you. The Electronic Visitation 
Verification piece of the Cures Act I think holds great 
promise, and I would ask you to share, for those watching, the 
EVV captures exact time, date, location, and duration of each 
visit.
    The question--and there are several, so I'm just going to 
go through them and then open up to all three of you--is, where 
is CMS in the process of implementing that change and how much 
flexibility do States have? How much flexibility should States 
have in how they choose to use EVV? What enforcement mechanisms 
will CMS use to ensure State compliance with implementation by 
2019? Have you see any success stories so far? And finally, how 
can Congress be helpful?
    For GAO and OIG, do you believe EVV implementation will 
help curb fraud and result in more complete, accurate, and 
timely data and do you care to elaborate on any GAO or OIG 
recommendations to ensure smooth EVV implementation?
    So Mr. Hill and then right on down the line with those 
questions.
    Mr. Hill. Let me take these in turn. In terms of State 
flexibility and what we need to do to implement the provision, 
as you know, the effective date is 2019 with respect to the 
financing of EVV. And so between now and then we'll be 
regulating and as part of that process we'll have to make a 
determination as to how much flexibility, if flexibility is 
given to States in terms of how we implement. So there's a lot 
of policy work that we need to do in terms of the State 
flexibility on EVV.
    The enforcement here is withholding FFP. As you know, the 
statute articulates if the State doesn't have a program, we can 
reduce the Federal share. In terms of success stories, we know 
there are two States, Missouri and Texas, already who have 
begun rolling out EVV. We're working with them and learning all 
we can for how those particular States are rolling this out so 
that we can expand those successes and lessons learned in our 
oversight activity.
    Ms. Iritani. I can't speak to the implementation of EVV, 
but what I can speak to are the benefits. We spoke to four 
States, two have EVV in place. They spoke of cost savings when 
they implemented it, improved timekeeping, more accurate 
timekeeping, more accurate data, and absolving the beneficiary 
of the responsibility of having to record time charges.
    Additionally, EVV can help ensure that there is a process 
for notifying the agencies if an attendant doesn't show up.
    Mr. Costello. Have you offered any--will GAO be offering 
any recommendations as it relates to implementation?
    Ms. Iritani. We don't have current work on that.
    Ms. Grimm. Implementation is going to be key. I think that 
we've heard that just because the requirement exists doesn't 
necessarily mean that the data are going to be collected and 
that they're going to be reported and that there are any usable 
time or usable way to be used. Reduction in--so in that 
enforcement mechanism, the reduction in FMAP for EVVS is also 
going to be important. The enforcement authority, without the 
willingness to act on that enforcement authority, I think poses 
a little bit of an issue. But certainly the data that EVVS 
collects, that verification of services will go a very long 
way. A lot of our fraud schemes show that they're billing for 
services that were never rendered.
    Mr. Costello. Have you or will you be sharing your 
recommendations on usability with CMS to make sure that the 
data is in a workable manner for you to be able to audit?
    Ms. Grimm. We don't have any work specifically devoted to 
EVVS right now, but we do have a report looking at T-MSIS that 
is very close to completion that will point out issues related 
to complete list, accuracy, and timeliness.
    Mr. Costello. Thank you.
    Mr. Murphy. Thank you. I now recognize Ms. Brooks for 5 
minutes.
    Ms. Brooks. Thank you, Mr. Chairman. It was actually 2012 
to Mr. Collins' point earlier relying on data, but in 2012 it 
was when HHS Office of Inspector General released the portfolio 
highlighting waste, fraud, and abuse in the PCS program and to 
date, CMS has yet to implement four of the recommendations. And 
I'm not going to list all of them or read through all of them 
because I want to get to the questions, but they include 
reducing significant variation in the State PCS attendant 
qualifications and improving CMS' and States' ability to 
monitor billing and care quality.
    I can go into greater detail if you don't know which four, 
but you know which four. So rather than spend my time on that 
since it's been nearly 5 years since these recommendations for 
improving PCS were suggested and while I appreciate that CMS 
has adopted some of the recommendations, there are still these 
four.
    So Mr. Hill, why has CMS not adopted all of the HHS OIG 
recommendations after nearly 5 years? And do you disagree with 
any of the recommendations?
    Mr. Hill. So obviously the controls that the 
recommendations are articulating are controls we'd like to see 
States have in place.
    The question for me is, it's not--so there are four 
recommendations, but overarching all of them is CMS is showing 
a Federal standard and regulating here and requiring States and 
holding States accountable to those four standards. And it's 
that balance that we're trying to strike here as to whether or 
not we should regulate and create a Federal standard or whether 
or not we should be allowing States as they are now or 
requiring States to have more stringent standards at the State 
level. So it's not a disagreement necessarily with the fact 
that we ought to have standards for attendant qualifications. 
The question is should that be a Federal standard or should 
that be a standard that's left to the State with us ensuring 
that the State is following through on that and complying.
    Ms. Brooks. And while I understand that that's what the 
differences are, it's been 5 years since the recommendation 
came out and so what is the problem? Is there an internal 
deadline at this point for CMS to adopt these recommendations?
    Mr. Hill. So we issued a request for information last fall 
after a lot of conversation with the IG to gather more 
information on the question that I just articulated, in terms 
of Federal standards or not. We're going through that 
information and the data that we gathered as part of that RFI 
and we'll be considering that as we move forward in the 
regulatory agenda for Medicaid generally.
    I should just be very clear, there's not an internal 
deadline for when we have to have a reg out or not. We're going 
through those comments now.
    Ms. Brooks. Would you agree that a lot of people work best 
when there are deadlines?
    Mr. Hill. I do. I understand the point, yes.
    Ms. Brooks. So that might be something you might consider 
at this point after 5 years is setting a deadline?
    Mr. Hill. I will be sure to raise that. I can't set the 
deadlines. I'm a deadline follower, but I do report to the 
folks who set deadlines.
    Ms. Brooks. And you talked about the qualification issue, 
what about is that a similar problem with respect to the 
monitoring of the billing and care quality?
    Mr. Hill. The data and information on claims, all the 
controls that the IG has quite appropriately identified, we 
have to regulate if we were going to have to require a State to 
implement those.
    Ms. Brooks. Ms. Grimm, and so Mr. Hill has talked about 
have there been conversations between OIG and Mr. Hill and 
others at CMS regarding the length of time that's passed since 
you've issued these recommendations and have there been any 
reasons as to why you believe there's been a delay that we 
could maybe address in implementing the recommendations?
    Ms. Grimm. We have a number of processes in place for all 
of our unimplemented recommendations to follow up on the status 
of those recommendations. We have met beginning in November 
2015 with CMS leadership in person many times to talk about 
options and possible solutions.
    Ms. Brooks. So you're following your processes for 
following up on recommendations. What has been the primary 
reason for delay in moving forward since it's been years and 
you've been following your process since November of '15?
    Ms. Grimm. We certainly have provided a lot of technical 
assistance to CMS. I think that's a great question for my 
colleague, Mr. Hill.
    Ms. Brooks. Mr. Hill, so we'll bring it back to you.
    Mr. Hill. I fear I will not have a satisfactory answer for 
you to be able to say exactly why a reg hasn't been 
implemented. As you know, we sort of went through sort of a set 
of conversations last year. We've now had a transition. We have 
a new administration and we're beginning to think about what 
that agenda looks like.
    Ms. Brooks. I'll be anxious to see with respect to those 
that you work with at CMS that we've set an internal deadline 
and move forward on many of these recommendations. With that I 
yield back.
    Mr. Murphy. The gentlelady yields back. And I now recognize 
Mr. Carter for 5 minutes.
    Mr. Carter. Thank you, Mr. Chairman, and I thank all of you 
for being here. You know, I think we've established the fact 
that the personal care services are extremely important. Before 
I became a member of Congress, I was a practicing pharmacist, 
so I had some experience with this, particularly in the way of 
medication management and drug therapy. I was also a consultant 
pharmacist, as well as being a community pharmacist. And one of 
the primary reasons that people are admitted to a nursing home 
or to a personal care home is medication management. It's one 
thing that we have to be careful of.
    Representative Walberg alluded to some of the abuse and 
certainly I have witnessed some of the abuse that can take 
place with that, but I've also witnessed a lot of the benefit 
that it can have. And the benefit of allowing someone to stay 
in their home and not having to be institutionalized, it's a 
great benefit to them personally and it saves money for a lot 
of us, but obviously, there is a lot of room in that particular 
scenario for abuse and for fraud. And it's difficult. I get it. 
I understand it's difficult to identify that and hopefully our 
healthcare professionals such as pharmacists are helping us 
with that. And whenever they might see a trend or a tendency 
there where medication goes missing or someone is not getting 
their medication, maybe a physician can identify why is your 
blood pressure going up, you know? Are you getting your blood 
pressure medication or something and why is your pain level 
going up? Perhaps they're not getting it like they're supposed 
to. But nevertheless, I agree it is a good program, but it is a 
program that obviously we wouldn't have you here today if we 
weren't looking into the fraud, the waste, and the abuse that 
exists in the program.
    I want to start by very quickly talking just about the 
self-directed Medicaid service models because as I understand 
it a lot of the fraud that's involving the personal care 
services is conspiracy, if you will, between the PCS and the 
beneficiary.
    Tell me, Mr. Hill, what has CMS done to combat that? What 
can you do and what's been beneficial and what's worked?
    Mr. Hill. So self-direction--I think, particularly for 
those of us, myself included, who have sort of spent a lot of 
time thinking about the medical model and how we do insurance 
and provide services, self-direction is sort of the most out-
of-the-envelope way to think about how people are getting 
services. You know, having a beneficiary pick and understand 
and have a lot more control over who's coming into their home 
and how that service is being delivered is a challenge. 
Sometimes, as we've identified a family member or a friend, so 
there is a range of things that we've done to help, not just 
beneficiaries, but States and agencies who are sometimes 
involved in that model to build in practices and policies to 
mitigate against abuse.
    We've talked about training. We've talked about compliance 
work with the folks who are doing the service work. Some 
States--and many States--have requirements for enrollment and 
background checks, all of the things that we've talked about 
work in self-direction as well as they're going to work in 
agency. But again, because the beneficiary will be at the 
center of that planning, at the center of identifying who is 
coming into their home, the self-directed model is one that 
provides, presents unique challenges.
    Mr. Carter. Ms. Grimm, let me ask you, it's my 
understanding that most of the fraud is proven through by 
showing--most of the fraud is by people who have come and 
actually testified and through referrals from individuals who 
have turned them in, if you will. How can Health and Human 
Services do a better job with that? Is there anything? How can 
we incentivize people to report these types of abuse or fraud?
     Ms. Grimm. I appreciate your question. I think yes, it is 
true that a lot of the fraud that we see is in self-directed 
models. They've shored up a number of different requirements 
for self-directed so that things like the flow of cash isn't as 
easily sort of shared with others. So CMS has taken steps in 
that regard. But it would be easier, consistent with our 
recommendations for us to know who we're doing business with. 
Right now, we don't know the identities and the dates and the 
types of services being provided at the attendant level. So 
that's something that I think is critically needed for 
oversight.
    Mr. Carter. Great. Well, my time is about up. But again, I 
want to stress that I've seen the benefits of this program. The 
benefits are good. But I hope that we can do something to 
address some of the problems that we have because I've also 
seen the fraud that exists in there and it does exist. And 
trying to get those bad actors out is difficult, but we need to 
get them out. Thank you very much and I yield back.
    Mr. Murphy. The gentleman yields back. I want to thank our 
panel here. This has been very enlightening for us, and I want 
to follow up on my friend and colleague's recommendation that 
we bring the States in. We would look forward to hearing from 
you if you have suggestions of what States that might be, so we 
can hear about what's working, what's not working. And in the 
meantime, please let us know if there's other things we need to 
pay attention to.
    I thank all of the witnesses and all the Members who 
participated in today's hearing. I will remind Members they 
have 10 business days to submit questions for the record, and I 
ask that the witnesses give us timely responses to those and 
respond promptly to those questions. And with that, this 
subcommittee is adjourned.
    [Whereupon, at 12:04 p.m., the subcommittee was adjourned.)
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