December 2023 Public Meeting

MACPAC’s December 2023 meeting opened with a session that highlighted findings related to sexual orientation and gender identity (SOGI) data collection as part of the Commission’s focus on the collection of primary language and limited English proficiency, SOGI, and disability data for the purposes of assessing and addressing health disparities.

During this discussion, we reviewed the purpose of SOGI data and federal and state priorities for collecting these data, which includes an overview of the Centers for Medicare & Medicaid Services’ (CMS) update to the model Medicaid application for collecting SOGI data. We also looked at how SOGI data are currently collected and used as well as particular data collection considerations, such as data privacy.

Next, staff highlighted initial themes from expert interviews about the challenges related to improving the transparency of Medicaid financing. The Medicaid statute permits states to raise the non-federal share of Medicaid expenditures through multiple sources, including state general revenue, health care-related taxes, and contributions from local governments. However, data are limited on the extent to which states rely on funding sources other than state general revenue. MACPAC’s prior work on Medicaid financing includes past recommendations that CMS collect provider-level data on the non-federal share of payments to hospitals and nursing facilities to enable analyses of net Medicaid payments to providers. These recommendations have not been implemented.

Barriers to improving the transparency of Medicaid financing identified from interviews so far include unclear goals of additional transparency; incomplete information about state-level methods and amounts; multiple approaches that could be used to collect provider-level financing amounts; and, challenges using provider-level financing amounts to calculate net payments.

After this, MACPAC staff presented data on disproportionate share hospital (DSH) allotments. MACPAC continues to find that DSH allotments share no meaningful relationship with the measures of need that Congress asked us to consider. These include the 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. MACPAC estimates that FY 2024 DSH allotments will be reduced by 51 percent ($8 billion) on January 20, 2024 due to scheduled reductions that were implemented as part of the Further Continuing Appropriations and Other Extensions Act, 2024 (P.L. 118-22). MACPAC will continue to monitor congressional action on DSH allotments.

The Commission then reviewed a draft chapter for the March 2024 report to Congress with three recommendations on how state Medicaid agencies can improve the beneficiary experience on medical care advisory committees (MCACs) and actions the federal government can take to aid states. The chapter highlights the importance of beneficiary engagement, as well as an overview of the federal statute and regulations related to MCACs and recent proposed federal actions to implement changes to these regulations. The chapter describes key findings and the challenges with recruitment of beneficiaries, particularly those representing historically marginalized communities, and barriers to meaningful beneficiary engagement.

The Commission unanimously voted in favor of the recommendations for improved beneficiary engagement on MCACs. The recommendations call on CMS to issue guidance focused on specific state concerns related to implementation challenges. The recommendations also call on state Medicaid agencies to develop a plan to recruit beneficiary members from historically marginalized communities, as well as develop and implement policies that reduce beneficiary participation barriers.

Staff then updated the Commission on reporting requirements related to the unwinding of the continuous coverage requirements in Medicaid and an update on data to monitor state progress. The presentation included the most recently released data from CMS on renewal outcomes, changes in enrollment, transitions in coverage, and operational outcomes.

Next, the Commission discussed a notice of proposed rulemaking from CMS that would make technical changes to Medicare Advantage and Medicare Part D programs for contract year 2025, including for dual eligible special needs plans (D-SNPs). In 2023, more than 5 million dually eligible beneficiaries receive their Medicare benefits and sometimes their Medicaid benefits through D-SNPs. This presentation summarized provisions in the proposed rule that affect dually eligible beneficiaries and that overlap with the Commission’s work and areas for potential comment. The Commission plans to comment on the proposed rule.

To conclude Thursday’s meeting, MACPAC staff shared highlights from this year’s 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 data book contains statistics on Medicaid and CHIP enrollment and spending and key aspects of both programs, including federal matching rates, eligibility levels, and access to care measures, among others. This presentation highlighted some of the key facts and trends from the December 2023 publication.

On Friday, the meeting began with a discussion on Medicare-Medicaid plan (MMPs) transition monitoring. MMPs cover all Medicaid and Medicare benefits under a single entity through a three-way contract between CMS, the state, and the health plan. This three-way contract allows for fully integrated coverage for people who are dually eligible for Medicare and Medicaid. As of December 2023, beneficiaries were enrolled in MMPs across eight states: Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, and Texas. In May 2022, CMS finalized the rule that sunsets MMPs under the Financial Alignment Initiative by the end of 2025 and proposes that states transition MMP enrollees to integrated Medicare Advantage D-SNPs.

MACPAC has been monitoring this transition and provided our first update to Commissioners at the December 2022 meeting. Since then, MACPAC has regularly engaged state staff regarding their transition to integrated D-SNPs as well as their progress in completing transition activities within the two-year timeline that CMS established. This presentation discussed stakeholder outreach strategies from our most recent state interviews and concluded with next steps to continue monitoring progress as states move into the procurement phase of their transition.

The meeting ended with a panel discussion on MMP transitions and the future of integrated care for people who are dually eligible for Medicaid and Medicare services. These beneficiaries often experience fragmented care and poor health outcomes. Integrated products that coordinate care across both programs may help to address these challenges. In May 2022, CMS began to sunset one integrated care plan type, MMPs under the Financial Alignment Initiative demonstration, and encouraged demonstration states to transition enrollees to D-SNPs. Levels of integration vary across D-SNP types and recent federal rulemaking has continued to define requirements for and further integration in these plans.

MACPAC invited experts to participate in a moderated discussion on the MMP transition, considerations for states developing integrated D-SNPs, and the future of integrated care for this population.

Panelists included:

Tim Engelhardt, Director, Medicare-Medicaid Coordination Office, CMS
Michael Monson, Chief Executive Officer and President, Altarum
Michelle Herman Soper, Vice President of Public Policy, Commonwealth Care Alliance

Presentations