The September 2022 Medicaid and CHIP Payment and Access Commission meeting began with a presentation that provided background for MACPAC’s work on the collection and reporting of race and ethnicity data. In MACPAC’s June 2022 report, the Commission addressed Medicaid approaches for promoting health equity and addressing racial disparities, which included improving state Medicaid administrative race and ethnicity data. Staff described the need for high-quality and standardized data, provided an overview of federal data collection standards, addressed how those standards are applied by state Medicaid programs, and reviewed MACPAC’s earlier assessment of the availability and quality of Medicaid race and ethnicity data.
Next, as part of the Commission’s ongoing discussions about unwinding the continuous coverage provisions in Medicaid related to the public health emergency (PHE), a panel session focused on state operationalization of unwinding activities. This included the process for conducting redeterminations at the end of the PHE and challenges states face; how the stakeholder community has been engaged in the planning process and their role going forward; and state approaches for monitoring progress.
Panelists included:
- Jami Snyder, Director, Arizona Health Care Cost Containment System
- Carl Feldman, Executive Policy Specialist, Pennsylvania Department of Human Services
- Jodi Ray, Director and Principal Investigator, Florida Covering Kids & Families
After a break, the Commission reviewed prior MACPAC findings around federal managed care rate setting requirements and oversight procedures. Based on that work, commissioners identified a number of policy areas that could be developed into potential policy options. Since that time, the Centers for Medicare & Medicaid Services (CMS) announced that it intends to publish proposed rulemaking in early 2023 that will address several of the same areas, such as treatment of in-lieu-of services and directed payments. This presentation provided an overview of our prior findings and described additional research that can help inform discussion of policy areas for the Commission’s consideration, including areas that could be addressed in future public comment.
Next, MACPAC staff shared preliminary analyses of Medicaid nursing facility payments relative to costs based on feedback from a technical expert panel that MACPAC convened in February 2022. Although limited data are available nationally, we found that Medicaid payments varied widely by state and facility in 2019. After accounting for supplemental payments, some facilities received payments in excess of costs, but complete data on supplemental payments are not yet available for all states. The presentation also examined the relationship between Medicaid payment rates and nurse staffing levels. The presentation concluded by discussing potential payment principles to guide future analyses of Medicaid nursing facility payment policies. Additionally, it looked at potential policy options, which the Commission will consider at future meetings to help support the adoption of these principles, such as improved data at the federal level and support for states to conduct their own, more detailed analyses of Medicaid payments relative to costs.
The Commission then heard a discussion on Medicaid disproportionate share hospital (DSH) payments. 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 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 background information on previous congressional efforts to increase federal DSH allotments during economic recessions, and summarized countercyclical DSH policy issues gathered from interviews with states and hospitals during the COVID-19 pandemic. The Commission will consider policy options on countercyclical DSH payments at future meetings.
To close the day, staff introduced a potential policy option to allow states to implement coverage criteria based on a Medicare national coverage determination, including any coverage with evidence development (CED) requirements. Using the recent approval of Aduhelm, a drug to treat Alzheimer’s disease as an example of how the policy could be applied, staff started by presenting on the potential implications of Alzheimer’s disease treatments on Medicaid. The presentation provided an overview of coverage under Medicaid and Medicare Part B, including Medicare’s coverage with evidence development policy. Next, staff summarized the approval of Aduhelm and the subsequent Medicare coverage decision. The presentation also included an analysis of the number of Medicaid beneficiaries with Alzheimer’s disease and the potential costs of treatment for non-dually eligible Medicaid beneficiaries and beneficiaries dually eligible for Medicare and Medicaid.
On Friday, the meeting began with a review of a proposed rule on core set reporting in Medicaid and the State Children’s Health Insurance Program (CHIP) and a request for information on long-term services and supports by minority members of the House Energy and Commerce Committee. In the first presentation, staff summarized key provisions of the August 22nd proposed rule implementing mandatory core set reporting in Medicaid and CHIP. Reporting on the core sets is currently voluntary, but Congress required it for the child core set and the adult core set behavioral health measures beginning in fiscal year 2024. The proposed rule also would implement mandatory health home core set reporting. Staff highlighted potential areas for MACPAC comment. Comments on the proposed rule are due October 21.
The second presentation focused on the House Energy and Commerce Committee’s July 27th request for information, which asks a series of questions about what can be done to remove barriers to meaningful community living for people with disabilities. Potential areas for MACPAC comment focused on access to long-term services and supports, including information on home- and community-based services (HCBS) waiver waiting lists, barriers states’ face in increasing access to HCBS, and estate recovery. The RFI asks for feedback on MACPAC’s 2021 recommendation to make estate recovery in Medicaid optional. Comments are due September 26.
The meeting concluded with a panel discussion with representatives from the District of Columbia, Maine, and Washington that have varying approaches to improving care for people who are dually eligible for Medicaid and Medicaid. This panel advances the conversation about integrated care options and is part of a larger MACPAC effort to identify available policy levers that state Medicaid programs could use to design an integrated care strategy and advance integration.
Panelists included:
- Kelli Emans, Integration Manager, Home and Community Services Division, Washington Aging and Long-Term Support Administration
- Katherine Rogers, Director, Long-Term Care Administration, District of Columbia Department of Health Care Finance
- Olivia Alford, Director, Delivery System Reform, Office of MaineCare Services
Presentations
- Background on Medicaid Race and Ethnicity Data Collection and Reporting
- State Strategies and Stakeholder Engagement for Unwinding the Public Health Emergency Continuous Coverage Requirement
- Improving Rate Setting and Risk Mitigation in Medicaid Managed Care
- Principles for Assessing Medicaid Nursing Facility Payments Relative to Costs
- Countercyclical Disproportionate Share Hospital Policies
- Medicaid Coverage of Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
- Review of Proposed Rule on Core Set Reporting and Congressional Request for Information on Long-term Services and Supports
- Panel on Integrating Care for Dually Eligible Beneficiaries in Medicaid Fee-for Service