October 2024 Public Meeting

The October 2024 MACPAC meeting began with an overview of medications for opioid use disorder (MOUD) and the federal policies affecting access to these medications. The COVID-19 pandemic and continued increase in overdose-related deaths prompted a number of federal policy changes intended to increase access to MOUD. Staff discussed next steps for the Commission’s work in this area, including future presentations on MOUD coverage and utilization based on an analysis of Medicaid claims data. Staff will also present findings from stakeholder interviews on the effects of recent policy changes and barriers to accessing MOUD.

Next, staff presented on provisional plans of care that states can use to expedite Medicaid eligibility determinations and enrollment for individuals in need of home- and community-based services (HCBS). MACPAC staff shared findings from a review of waivers containing language on provisional plans of care, as well as findings from interviews with state and federal officials, and other national experts. Interviews indicated that provisional plans of care are rarely used, but when they are, it is most often for emergency situations.

The Commission then heard from an expert panel on policies and considerations for state Medicaid and the State Children’s Health Insurance Program (CHIP) multi-year continuous eligibility (CE) approaches, which are designed to mitigate churn. Churn occurs when individuals disenroll and re-enroll in health coverage within a short period of time, leading to disruptions in coverage. A few states have received Centers for Medicare & Medicaid Services (CMS) approval to implement Section 1115 demonstration programs to provide multi-year CE for children age 0 to 6 years, and several others have demonstration requests pending approval. Panelists described lessons learned about CE during the public health emergency, policy and programmatic considerations for designing and implementing multi-year CE policies, and factors that will be important in monitoring and evaluating the demonstrations.

Panelists included:

Cindy Mann, JD, partner at Manatt Health
Emma Sandoe, PhD, MPH, Medicaid director with the Oregon Health Authority
Laura Barrie Smith, PhD, senior research associate in the Health Policy Center at the Urban Institute

To conclude the day, staff presented on appropriate access to children’s residential services as part of MACPAC’s ongoing focus on children’s behavioral health. Medicaid supports a wide range of behavioral health services for children including residential treatment programs. MACPAC is examining how Medicaid ensures that children and youth with serious behavioral health conditions appropriately access intensive services in residential settings if needed.

Staff reviewed a sample of publicly available state and federal reports that describe common barriers to appropriate access to residential services for youth with behavioral health needs. These reports note common challenges in serving youth with certain demographic, clinical, and functional characteristics, as well as difficulty accessing residential care and HCBS when ready to leave the residential setting.

On Friday, staff presented policy options for the external quality review (EQR) process as part of MACPAC’s work on strengthening managed care oversight and accountability. The 2024 Medicaid managed care rule requires the EQR annual technical report include any outcomes data and results from quantitative assessments of performance improvement plans, performance measures, and network adequacy. The Commission discussed the findings from the prior work in light of the 2024 Medicaid managed care rule. Specifically, the Commission examined whether there were additional areas for improvement not addressed by the rule regarding how EQR could be structured to use outcomes data and improve the usability of EQR findings by CMS, states, and other stakeholders. This session described key challenges with the current requirements for the EQR process and explored policy options to address these challenges.

Next, staff provided background information about children and youth with special health care needs (CYSHCN) and their transitions of care, including survey data findings from MACPAC’s recently published Access in Brief on CYSHCN, and findings from stakeholder interviews and beneficiary focus groups. As CYSHCN reach adulthood, they need to transition from child to adult coverage and health care, which can be challenging for beneficiaries and their families. MACPAC’s work examined policy on state transitions of care and beneficiary experiences when transitioning from pediatric to adult care. During our previous session in March, we presented findings from our federal and state policy scan and literature review.

The meeting concluded with a staff presentation on an updated analysis of directed payments and recent regulatory updates to the directed payment policy framework. In 2016, CMS updated the regulations for Medicaid managed care and created a new option called directed payments for states, allowing them to direct managed care organizations to pay providers according to specific rates or methods. Since their initial implementation, directed payment arrangements have grown rapidly in both utilization and spending amounts.

In our prior work, MACPAC reviewed directed payment arrangements approved up to February 2023 and made recommendations for improving the transparency and oversight of directed payments in Chapter 2 of MACPAC’s June 2022 Report to Congress on Medicaid and CHIP. To build off this, MACPAC updated an issue brief that discusses the history of directed payment policy, highlights changes made in the 2024 managed care rule, and examines the use of directed payments based on MACPAC’s review of directed payments approved between February 1, 2023, and August 1, 2024.

Presentations: