The Bush administration, through the use of waivers, has given states flexibility in administering Medicaid, but has failed to adequately oversee these programs, according to a recent report by the Government Accounting Office (GAO). The use of Medicaid waivers, which exempt states from federal regulations and potentially enable them to tailor programs to meet state-specific needs, has grown significantly over the past decade. In particular, states have increasingly sought home and community-based services (HCBS) waivers in order to provide non-institutional long-term care for the elderly. The recent GAO report found, however, that the Centers for Medicare and Medicaid Services (CMS), which reviews and approves state requests for waivers, has allowed states to obtain waivers without first presenting a detailed plan for assessing quality of care. CMS itself has neglected to even develop guidance for states on acceptable quality assurance measures. The report also reveals that 228 HCBS waivers had been in place for three years or more as of June 2002. However, 42 of these waivers, serving 132,000 beneficiaries, had either never been reviewed by CMS regional offices as required or were renewed without review. Reviews were conducted for an additional 36 waivers, but reports summarizing the findings were never completed, “raising a question as to whether any weaknesses were identified and, if so, had been corrected,” according to GAO. Following the release of the report, Sens. Charles Grassley (R-IA) and John Breaux (D-LA), who requested the GAO investigation, wrote to Secretary of Health and Human Services Tommy Thompson, stating, “HHS has jurisdiction for protecting the health and welfare of each and every waiver beneficiary receiving services through these home and community-based waivers. Without improved guidance to the states and strengthened oversight activities such assurances will continue to be compromised. That is unacceptable.” The Senators requested a plan to address the oversight weaknesses by July 28.