October 2022 Public Meeting

The Commission kicked off the October meeting with a presentation on federal and state considerations for how to improve Medicaid race and ethnicity data collection and reporting. In September 2022, staff provided background on race and ethnicity data collection and reporting standards, a summary of MACPAC’s earlier assessment of Medicaid administrative race and ethnicity data quality, and an overview of the challenges with data collection and processing. In this presentation, staff shared federal and state considerations for collecting and analyzing race and ethnicity data based on findings from a literature review and key stakeholder interviews. Staff also presented possible approaches for improving the state collection and processing of these data.

Next, MACPAC examined state approaches to improving access to Medicaid coverage and care for adults leaving incarceration. This session provided background information on justice-involved adults and the role of Medicaid when individuals are released back into the community and described demographic characteristics, health status, and access to care among adults with justice-involvement. Staff also highlighted state approaches for facilitating Medicaid coverage and access to care for adults upon release based on interviews with state Medicaid and corrections agency officials in 16 states. These approaches include Section 1115 demonstration proposals to waive the inmate exclusion to cover pre-release Medicaid services.

The Commission then heard a presentation on how the Centers for Medicare & Medicaid Services (CMS) and states are preparing to monitor the unwinding of the continuous coverage provisions in Medicaid once the COVID-19 public health emergency ends given concerns over the administrative and operational complexity of unwinding the continuous coverage provisions and the potential for inappropriate loss of coverage for Medicaid beneficiaries. The presentation focused on the available data to monitor the unwinding. Staff provided details on the federal monitoring requirements, information on state monitoring plans, where available, and other data possible data sources.

Following this, the Commission discussed a proposed CMS rule on changes to Medicaid eligibility, enrollment, and renewal processes and possible areas for comment. CMS published a notice of proposed rulemaking (NPRM) that makes changes to Medicaid application, enrollment, and renewal processes. The NPRM addresses many different eligibility policies, including enrollment in the Medicare Savings Programs, certain requirements for individuals’ submitting eligibility information, state treatment of returned mail, and transitions in coverage between Medicaid and separate State Children’s Health Insurance Program (CHIP). This session provided an overview of the changes in the proposed rule and relevant MACPAC work that can serve as the basis for comments.

Next, the Commission continued its work on Medicaid managed care rate setting by facilitating a discussion on how access is considered in federal guidance, actuarial soundness standards, and the rate setting process. CMS has indicated that it will release proposed regulations addressing access, including access in managed care settings, in 2023. During a prior meeting, staff reviewed potential policy areas that the Commission could discuss that would serve as the basis for comments when proposed regulations are released. This presentation provided an overview of our prior findings specific to the treatment of access in rate setting and raised potential areas for the Commission’s consideration that could be addressed in a future comment letter.

Staff then presented new data on recent trends in Medicaid spending and rebates for prescription drugs between fiscal years (FY) 2018 to 2021. In FY 2021, Medicaid spent approximately $80.6 billion on outpatient prescription drug and collected $42.5 billion in rebates, bringing net drug spending to $38.1 billon. Net spending for outpatient prescription drugs accounted for about 5.3 percent of Medicaid benefit spending. This continues the trend since 2018 of large increases in net drug spending following several years of low growth. This spending increase may reflect a number of factors, including the introduction of new, high-cost specialty drugs.

Publicly available data on drug rebates are only available in aggregate at the state level. In 2021, Congress gave MACPAC access to the price benchmarks used to calculate Medicaid rebates and the actual rebate amounts for individual drugs. This new information helps the Commission to better understand the effect of drug rebates at a more granular level. These new analyses included how rebates differ for brand and generic drugs, and the distribution of the rebates across the basic and inflationary rebate components.

To close the day, the Commission heard a panel discussion on streamlining the delivery of home -and community-based services (HCBS). The panelists included Henry Claypool, a visiting scientist with Community Living Policy Center at Brandeis, and Katie Evans Moss, chief of TennCare’s Long Term Services and Supports. They discussed the challenges for Medicaid beneficiaries in accessing HCBS, how states and the federal government could help address access barriers, and ways to simplify the administrative complexity surrounding Medicaid HCBS. The panel concluded with a discussion of key considerations for policymakers to increase access to HCBS and reduce administrative complexity.

On Friday, the day began with a brief overview of Medicaid financial eligibility criteria for people with LTSS needs. Staff focused on individuals who are eligible for Medicaid through the special income level pathway because they are subject to post-eligibility treatment of income rules that permit them to retain a portion of their income in the form of a maintenance needs allowance. Staff also presented an analysis of the resources of community-based adults age 65 and older with incomes no greater than 400 percent of the federal poverty guideline, and their household spending relative to maintenance needs allowances.

Next, MACPAC examined potential policy recommendations on disproportionate share hospital payments during economic crises. Medicaid disproportionate share hospital (DSH) payments offset hospital uncompensated care costs for Medicaid-enrolled and uninsured patients. During economic recessions, Medicaid enrollment and the number of people who are uninsured increases. During the 2020 economic recession, Congress implemented countercyclical Medicaid policy by temporarily increasing the federal medical assistance percentage (FMAP) for Medicaid spending. However, doing so had the effect of lowering total DSH funds available to states to pay for uncompensated care. This presentation provided two policy options that would increase federal support to states by tying DSH allotments to future economic recessions or to any change in a state’s FMAP. Under these set of policy options, increases in the FMAP would lead to greater federal support for DSH instead of decreasing total DSH funding.

The meeting ended with the Commission considering a CMS request for information (RFI), “Make Your Voice Heard: Promoting Efficiency and Equity within CMS Programs.” The RFI seeks stakeholder comments in four areas across all CMS programs relating to access, understanding provider experiences, advancing health equity, and the effect of COVID-19 PHE waivers and flexibilities. The Commission anticipates drawing upon prior work, commenting on the topics pertaining to health equity, data transparency, access, and the PHE.

Presentations