The January 2024 meeting began with a discussion on denials and appeals in Medicaid managed care. MACPAC staff presented a draft chapter for the March 2024 report to Congress with seven recommendations aimed at improving the beneficiary experience with the appeals process and monitoring, oversight, and transparency of denials and appeals. The chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency, elaborates upon state flexibilities within the current federal framework, and describes key challenges with the current structure. The Commission voted in favor of the seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts.
Next, staff continued a discussion on the collection of primary language and limited English proficiency, sexual orientation and gender identity (SOGI), and disability data to help assess and address health disparities. Previous meetings have focused on considerations for collecting Medicaid language data and SOGI. This presentation focused on findings related to self-reported disability data collection. Our findings indicated that there is little consensus among stakeholders about the type of disability data that would be most useful and meaningful for purposes of measuring and addressing health disparities. Staff reviewed the federal priorities for collecting these data, how Medicaid disability data are currently collected, and key considerations for disability data collection.
Following up on the Commission’s December 2023 public meeting that introduced a discussion about the transparency of Medicaid financing, the Commission explored policy options for improving transparency of financing methods and amounts. Medicaid is jointly financed by states and the federal government, and states have flexibility to raise the non-federal share of Medicaid expenditures from multiple sources, including state general funds, health care-related taxes, and local government funds. The Commission considered the policy options using a framework that probed the usefulness, comprehensiveness, and administrative burden for states, providers, and the Centers for Medicare & Medicaid Services (CMS) in collecting new data.
Staff then presented key themes from our interviews with state Medicaid officials in five case study states, federal officials at CMS, and health plan representatives for Medicare Advantage dual eligible special needs plans (D-SNPs) operating in several of our case study states. To operate within a state, D-SNPs are required to hold a state Medicaid agency contract (SMAC). While federal law sets minimum requirements for what a SMAC must include, states have the authority to include additional requirements in their SMACs to further integration. Themes of the interviews included: contracting considerations, SMAC authorities, data and reporting requirements, monitoring and oversight processes, and performance improvement and enforcement.
After a break, the Commission turned its focus to the relationship between Medicaid physician payment rates and beneficiary access. Medicaid requires that payment for services must be consistent with the efficiency, economy, and quality of care and sufficient to enlist enough providers so that care and services are available to beneficiaries. MACPAC contracted with Mathematica to conduct a review of the literature and convene an expert roundtable. During the session, staff shared key themes from the roundtable and highlighted select areas that the Commission may examine in future work.
Next, the staff provided background information on how Medicaid policy differs for physician-administered drugs (PADs) compared to other drugs dispensed through a pharmacy. Many of the high-cost specialty drugs in the pipeline, such as cell and gene therapies, require physician administration. MACPAC provided information on some particular challenges related to managing PADs through the medical benefit. Finally, we summarized findings from our analysis on Medicaid utilization and spending on PADs using data from the Transformed Medicaid Statistical Information System.
To conclude the day, staff provided highlights from the Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid, which compiles information on individuals who were dually eligible for Medicare and Medicaid in calendar year (CY) 2021. The 2024 edition, which is jointly produced by MACPAC and the Medicare Payment Advisory Commission, presents key statistics about the dually eligible community’s demographics and characteristics, eligibility pathways and enrollment, service utilization and spending, and use of long-term services and supports.
After the Commission voted on recommendations to improve the denials and appeals process, staff presented on Medicare Savings Programs (MSPs), which provide Medicaid assistance with Medicare premiums and cost sharing to individuals who are dually eligible for Medicaid and Medicare. This session offered an up-to-date look at enrollment in these programs over a 12-year period from 2010 to 2021. We focus primarily on the Qualified Medicare Beneficiary Program and Specified Low-Income Beneficiary programs because together, they account for more than 90 percent of all MSP enrollees.
The meeting concluded with a panel discussion* on discussion on policies and activities related to the public health emergency by highlighting an important American Rescue Plan Act (ARPA) provision that provided states with new financial resources to invest in home- and community-based services (HCBS). MACPAC has been monitoring federal and state activities supporting the ARPA investment in HCBS.
Panelists included:
- Jennifer Bowdoin, Director of the Division of Community Systems Transformation, Centers for Medicare & Medicaid Services
- Alissa Halperin, Principal Consultant, Halperin Health Policy Solutions
- Bonnie Silva, Director of the Office of Community Living, Colorado Department of Health Care Policy & Financing
This panel focused on two central questions given state progress (or completion) in their investment activities: 1) how are states sustaining new or enhanced HCBS investments? 2) how are states, CMS, or third parties evaluating the effectiveness of HCBS investments?
*This panel did not include slides.
Presentations
- Denials and Appeals in Medicaid Managed Care
- Medicaid Self-Reported Disability Data Collection
- Policy Options for Improving the Transparency of Medicaid Financing
- State Medicaid Agency Contracts: Interviews with Key Stakeholders
- Findings from Expert Roundtable on Evaluating the Effects of Medicaid Payment Changes on Access to Physician Services
- Medicaid Coverage of Physician-administered Drugs
- Highlights from the Duals Data Book
- Medicare Savings Programs: Enrollment Trends
