December 2022 Public Meeting

The December 2022 MACPAC meeting began with a Commission discussion on two potential recommendations for improving Medicaid race and ethnicity data reporting. As part of its commitment to prioritizing health equity in all of its work, the Commission is focused on how to improve Medicaid race and ethnicity data collection and reporting. In October, staff presented findings from a literature review and key stakeholder interviews, as well as possible approaches for improving the collection and reporting of these data. In this presentation, staff reviewed the state data collection and reporting processes, data quality priorities, and barriers to improvement. Staff also presented two potential recommendations for the Commission’s consideration, with the goal of making recommendations in MACPAC’s March report to Congress. The Commission will vote on these recommendations in January 2023.

Next, the Commission discussed two potential recommendations to improve the transparency of nursing facility payment data. The Commission has undertaken long-term work to examine the extent to which Medicaid nursing facility payment policies are consistent with the statutory goals of efficiency, economy, quality, and access. Staff reviewed the outline for a proposed report chapter that would synthesize these findings and outline policy principles for states to consider when setting nursing facility rates and methods. The presentation concluded with a discussion of two potential recommendations on improving the transparency of nursing facility payment data and updating existing requirements for states to conduct regular rate studies, which the Commission will vote on in January 2023.

After this, MACPAC staff presented our statutorily required report on Medicaid disproportionate share hospital (DSH) allotments. MACPAC estimates that the American Rescue Plan Act of 2021 increased fiscal year (FY) 2023 federal allotments by 10.9 percent ($1.5 billion). We also estimate that FY 2024 DSH allotments will be reduced by 54 percent ($8 billion) on October 1, 2023 due to scheduled reductions that were implemented as part of the Consolidated Appropriations Act, 2021. MACPAC continues to find that DSH allotments share no meaningful relationship to the different measures of need that the Commission is statutorily required to report, which includes changes in the number of uninsured individuals, amounts and sources of hospital uncompensated care, and hospitals with high levels of uncompensated care that also provide access to essential community services.

After a break, the Commission examined transitions in coverage between Medicaid and other insurance affordability programs, focusing on policy issues that affect the ability of beneficiaries who are losing Medicaid eligibility to smoothly transition to other insurance affordability programs, including the State Children’s Health Insurance Program (CHIP), the Basic Health Program, and subsidized exchange coverage. This assessment follows up on MACPAC’s previous work examining transitions between coverage sources before the COVID-19 pandemic and is also part of the Commission’s ongoing discussion about how states and the federal government are preparing for the unwinding of the continuous coverage provisions in Medicaid related to the COVID-19 Public Health Emergency (PHE). The presentation concluded by reviewing federal- and state-level efforts to monitor these transitions during the unwinding of the PHE.

Next, the Commission discussed new developments in Medicaid waivers. The Centers for Medicare & Medicaid Services (CMS) has recently approved several large-scale Section 1115 demonstration waivers that allow states to test the efficacy of new approaches to delivering Medicaid services and improving population health. These include changes to eligibility rules, benefit coverage, and measures to address the social determinants of health and health-related social needs. These waivers also incorporate modifications to prior CMS policies on waiver financing, provider payment, and budget neutrality. This presentation provided an overview of the key policy changes.

The Commission then continued its work on managed care rate setting with a look at in-lieu-of services (ILOS) and value-added benefits. ILOS are medically appropriate, cost-effective alternatives to approved state plan services, while value-added benefits typically are non-medical services funded by health plans’ administrative dollars. CMS has indicated that it will release proposed regulations addressing access, ILOS, directed payments, and other managed care topics in 2023. This presentation provided an overview of our findings on how ILOS and value-added benefits are treated in rate setting and raised potential areas for the Commission’s consideration that could be addressed in a future comment letter.

Staff then provided an update on the transition of Medicare-Medicaid plans to integrated Medicare Advantage dual eligible special needs plans (D-SNPs), progress to date, and challenges that states face. CMS in May 2022 finalized a rule that sunsets an existing integrated care model, the Medicare-Medicaid plans (MMPs) under the Financial Alignment Initiative, with a potential transition of MMP enrollees to integrated Medicare Advantage D-SNPs by 2025. The Commission had previously highlighted contracting strategies available to states to integrate care through D-SNPs, and commented on this rule when it was first proposed.

Next, the Commission considered a recommendation that would allow state Medicaid programs the option to follow a Medicare national coverage determination (NCD). Under Medicare Part B, CMS has the authority to make an NCD on whether a service or prescription drug is reasonable and necessary. Under certain circumstances, CMS can link coverage of an item or service to participation in an approved clinical study or to the collection of additional clinical data. This policy is referred to as coverage with evidence development (CED). Because of the requirements of the Medicaid Drug Rebate Program, state Medicaid programs do not have similar authority to restrict drug coverage or require the collection of additional data in the same way as Medicare. The presentation included a draft recommendation to make a statutory change that gives states the option to follow a Medicare NCD, including any CED requirements. The presentation provided the rationale for making this recommendation and potential implications for different stakeholders. The Commission will vote on recommendations in January 2023.

To end the day, staff highlighted some of the key facts and trends from the December 2022 edition of the MACStats: Medicaid and CHIP Data Book, which compiles the most current data available on Medicaid and the State Children’s Health Insurance Program (CHIP) into a single, end-of-year publication. The 2022 publication includes new survey tables and additional data that offer richer insights into Medicaid beneficiaries and their access to and experience with care.

Friday’s meeting began with a panel discussion on the role of Medicaid in improving outcomes from adults leaving incarceration. Panelists included DeAnna Hoskins, president and CEO of JustLeadershipUSA; David Ryan, senior policy to the sheriff in Middlesex County, Mass.; Jami Snyder, director of Arizona’s Health Care Cost Containment System; and Vikki Wachino, executive director for the Health and Reentry Project and principal, Viaduct Consulting. Panelists discussed the importance of Medicaid coverage for adults leaving incarceration, as well as the challenges to providing and accessing health care services once people reenter the community.

To conclude the meeting, the Commission discussed a congressional request for information (RFI) on improving care for people who are dually eligible for Medicare and Medicaid. The RFI sees stakeholder input on a series of questions related to integrating care for people who are dually eligible for these programs. Staff summarized MACPAC’s prior work in this area and identified potential areas for comment. These included requiring state strategies to integrate care, state capacity to integrate care, and considerations for a unified program. Comments are due January 13, 2023.

Presentations