January 2023 Public Meeting

During the January 2023 meeting, MACPAC voted to approve a series of recommendations to improve Medicaid race and ethnicity data collecting and reporting, improve the transparency of nursing facility payment data, and allow states the option to restrict coverage of a drug based on coverage with evidence (CED) requirements under a Medicare National Coverage Determination (NCD). The recommendations will be published in the March 2023 Report to Congress on Medicaid and CHIP.

The meeting began with a Commission discussion of recommendations on improving Medicaid race and ethnicity data collection and reporting. In this session, staff presented a draft chapter for the March 2023 report to Congress with two recommendations for improving the collection of these data. The Commission voted to approve the recommendations.

The Commission then discussed two potential recommendations to improve the transparency of nursing facility payment data. In this session, staff presented a draft chapter for the March 2023 report to Congress with two recommendations. The recommendations call for improved transparency of Medicaid payments and costs, as well as regular state rate studies to assess whether payment policies are consistent with statutory goals. The Commission approved the recommendations.

Next, the Commission discussed a draft chapter and recommendation to allow states to follow a Medicare NCD or CED requirements to evaluate whether a service or prescription drug is reasonable and necessary. Under certain circumstances, the Centers for Medicare & Medicaid Services (CMS) can link coverage of an item or service to participation in an approved clinical study or to the collection of additional clinical data, which is referred to as a CED. The presentation provided the rationale for making the recommendations and potential implications on different stakeholders.

The Commission approved a recommendation that calls on Congress to allow states to follow the CED requirements included in a Medicare NCD. They also approved a recommendation to require managed care plans to follow the state’s coverage decision regarding drugs based on CED requirements implemented under a Medicare NCD.

After a break for public comment, staff provided an overview of Medicaid home- and community-based services (HCBS), focusing on the range of Medicaid HCBS authorities states use to make services available. Staff also presented results from 18 stakeholder interviews with federal and state officials, beneficiary advocates representing a range of HCBS populations, and national experts on barriers that beneficiaries face accessing services, including disparities by HCBS subpopulations, and the challenges states face in administering HCBS programs.

The Commission heard a panel discussion on states’ early experiences with The American Rescue Plan Act of 2021 (ARPA, P.L. 117-2), which provided a temporary increase in the federal medical assistance percentage (FMAP) for state Medicaid programs to support the infrastructure for HCBS. It increased the FMAP by 10 percent for the one-year period from April 1, 2021 through March 31, 2022. States had to submit spending plans to CMS for approval on how they would spend this new money.

This panel provided an overview of state spending plans and initial implementation efforts. The panel also
discussed sustainability of initiatives and the federal policy levers that might enable states to use ARPA funds to improve state HCBS systems and beneficiary access. Panelists included Kevin Bagley, director, Medicaid & long-term care, Nebraska Department of Health and Human Services; Camille Infussi Dobson, deputy executive director, ADvancing States; Heidi Hamilton, acting director of the disability services division, Minnesota Department of Human Services; and Elizabeth Matney, state Medicaid director, Iowa Department of Health and Human Services.

After a break, the Commission heard three presentations addressing oversight and accountability of managed care. Given that managed care has become the dominant delivery approach in Medicaid, the Commission is interested in examining how states and the federal government are using available oversight tools to hold plans accountable. The sessions provided an overview of the quality oversight process, the role of external quality review, and a new project examining denials and appeals in Medicaid managed care.

The day ended with a staff presentation on key statistics regarding people who are dually eligible for Medicare and Medicaid. The Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid, which is jointly produced by MACPAC and the Medicare Payment Advisory Commission (MedPAC), will be published in February 2023 and features trends in population composition, spending, and service use between calendar years (CY) 2018 and 2020. Among the key trends reported in CY 2020, the shift toward managed care enrollment for dually eligible beneficiaries and their elevated use of institutional long-term services and supports offer insights into the care and coverage of this vulnerable population.

After the Commission voted on recommendations Friday, staff provided an overview of three recent proposed rules related to MACPAC’s work and possible areas for comment. They are:

The 2024 notice of benefit and payment parameters for health insurance exchanges, which includes provisions related to transitions between Medicaid, the State Children’s Health Insurance Program (CHIP), and exchange coverage;
A CMS notice of proposed rulemaking that would make technical changes to the Medicare Advantage and Medicare Part D programs for contract year 2024, including dual-eligible special needs plans (SNPs); and
An HHS notice of proposed rulemaking that would make changes to substance use disorder patient privacy protections under 42 CFR Part 2 (Part 2), which implements provisions of the Coronavirus Aid, Relief, and Economic Security Act (CARES) and further aligns Part 2 with the privacy protections under the Health Insurance Portability and Accountability Act (HIPAA).

To conclude MACPAC’s January meeting, the Commission heard from states on unwinding the continuous coverage requirement in Medicaid. During the past year, the Commission has had discussions about unwinding the continuous coverage provisions in Medicaid once the COVID-19 Public Health Emergency (PHE) ends. In particular, the Commission is focused on the potential risk of eligible individuals inappropriately losing coverage as states resume redeterminations, as well as state administrative and system capacity to handle redeterminations. The Consolidated Appropriations Act of 2023 (CAA, P.L. 117-328) delinks the end of the continuous coverage requirement from PHE and phases down the enhanced federal matching rate to states over the remainder of 2023. The CAA also places specific redetermination processing and data reporting requirements on states.

A state panel provided an update on how states are now thinking about the unwinding of the continuous coverage requirement in light of the passage of the CAA. Panelists included: Traylor Rains, state Medicaid director, Oklahoma Health Care Authority; Sandie Ruybalid, deputy administrator, Nevada Division of Health Care Financing and Policy; and Chris Underwood, chief administrative officer, Colorado Department of Health Care Policy and Financing.

Presentations