The January 2025 MACPAC meeting began with a discussion on a draft chapter on timely access to home- and community-based services (HCBS), which will be included in the March 2025 report to Congress. States have a number of ways in which they can expedite Medicaid eligibility determinations and enrollment for individuals whose income is not determined using modified adjusted gross income (MAGI) and who need HCBS. In particular, the chapter focuses on the use of presumptive eligibility and expedited eligibility flexibilities for non-MAGI populations, as well as provisional plans of care. It provides background on these topics, as well as the findings from our stakeholder interviews, environmental scan, and review of Section 1915(c) HCBS waivers. It concludes with a recommendation to the Secretary of the U.S. Department of Health and Human Services to direct the Centers for Medicare & Medicaid Services to issue guidance on how states can use provisional plans of care, including policy and operational considerations, under Section 1915(c), Section 1915(i), Section 1915(k), and Section 1115 of the Social Security Act. On Friday, the Commission voted to approve the recommendation.
Next, staff summarized the findings and presented payment principles and a policy option to support the HCBS workforce. HCBS workforce shortages reduce Medicaid’s ability to serve people with long-term care needs in the home or community. Although some factors that affect the HCBS workforce are outside of Medicaid’s purview, many states are exploring ways to use Medicaid rate setting to expand the HCBS workforce and reduce worker turnover. In previous MACPAC meetings, we discussed findings from a compendium of HCBS authorities, federal and state interviews, and a technical expert panel that explored strategies to ensure that HCBS payment rates are adequate to attract and retain a sufficient workforce.
The Commission then focused on the use of medications for opioid use disorder (MOUD) among Medicaid beneficiaries. Medicaid plays an important role in facilitating access to treatment for the estimated 1.9 million beneficiaries with opioid use disorder (OUD). Federal law requires state Medicaid programs to cover all three forms of MOUD: methadone, buprenorphine, and extended-release injectable naltrexone. These medications are the standard of care for OUD, yet they remain underused. Staff presented national and state-level estimates of MOUD use, highlighted variations in the receipt of MOUD among beneficiaries by demographic and health-related characteristics, and discussed how the MOUD benefit mandate affected MOUD use in states that did not previously cover methadone.
After a break, the Commission heard from an expert panel about policies and considerations to ensure that Medicaid-enrolled children and youth with serious behavioral health conditions are able to access effective, medically necessary treatment services in residential settings. Panelists discussed the opportunities and challenges states, providers, and beneficiaries face in designing, implementing, and sustaining residential treatment services, as well pre-admission and post-discharge services.
Panelists include:
- Gary Blau, PhD, Executive Director Emeritus at The Hackett Center and Senior Fellow for Children’s Mental Health at the Meadows Mental Health Policy Academy
- Maureen Corcoran, MBA, MSN, Director, Ohio Department of Medicaid
- Steve Girelli, PhD, President and CEO of Klingberg Family Centers
- Ivy-Marie Washington, Project Associate, Youth and Transition Services, American Public Human Services Association
Following up on the Commission’s discussion at the December 2024 public meeting on proposed recommendations for improving the managed care external quality review (EQR) process, staff then presented a draft chapter and three recommendations for MACPAC’s March 2025 report to Congress. The recommendations are intended to shift the focus of EQR activities from process and compliance to meaningful outcomes and actionable data, and to improve the usability of that data through reporting standardization and transparency. On Friday, the Commission voted to approve the recommendations
To end the day, the Commission reviewed a draft chapter on Medicaid Section 1915 authorities for HCBS for the March 2025 report to Congress. The chapter includes an analysis of federal administrative requirements and opportunities to reduce the administrative burden for states. MACPAC has engaged in work over the past two years to identify opportunities to alleviate some of that burden. The chapter describes our key findings on administrative complexity across HCBS authorities including opportunities to streamline and a discussion of the rationale for our recommendation. The chapter concludes with a recommendation to the Secretary of the U.S. Department of Health and Human Services to increase the renewal period for HCBS programs operating under Section 1915(c) waivers and Section 1915(i) state plan amendments from 5 years to 10 years. On Friday, the Commission voted to approve the recommendation.
After the Commission voted on recommendations to Congress on Friday, MACPAC staff presented revised policy options to address challenges related to transitions from pediatric to adult care for children and youth with special health care needs (CYSHCN). Staff initially presented policy options at the December 2024 public meeting. The policy options focus on requiring states to develop a strategy for transitions of care for CYSHCN, which includes developing an individualized transition of care plan and making the strategy publicly available; issuing guidance to states on existing authorities to cover transition of care related services for CYSHCN; requiring states to collect and report data on access to transition of care related services as well as beneficiary and caregiver experiences with transitions; and requiring interagency agreements to specify the roles and responsibilities of state Medicaid and Title V agencies in supporting CYSHCN transition from pediatric to adult care.
To conclude the meeting, staff discussed key findings from interviews on the Program of All-Inclusive Care for the Elderly (PACE), which is a provider-led model that provides fully integrated care to frail adults ages 55 and older with nursing-facility level of care needs while allowing them to remain in the community. In the September public meeting, staff provided the Commission with an overview of the PACE model, including information on the regulatory framework design elements, enrollment and spending data, and outcome evaluations. MACPAC staff described key findings from a series of interviews with state and federal PACE stakeholders that provided insight into the operation of the PACE model.
