Members of the Medicaid and CHIP Payment and Access Commission met publicly last week in Washington, D.C.

The following is MACPAC’s own summary of its meeting.

The MACPAC December 2024 meeting began with a discussion on accountability in Medicaid managed care, which is the predominant delivery system in Medicaid. MACPAC will examine the tools the Centers for Medicare & Medicaid Services (CMS) and state Medicaid agencies use to manage managed care organizations’ (MCOs) performance and hold plans accountable to contractual obligations. Staff presented findings from MACPAC’s review of federal policy and a 40-state review of accountability tools as described in requests for proposals, MCO contracts, and MCO performance summaries available on state websites.

Next, staff presented policy options for improving the managed care external quality review (EQR) process. The proposed recommendations for MACPAC’s March 2025 report to Congress are intended to improve the transparency and usability of findings included in the EQR annual technical reports. The Commission discussed the potential recommendations, including the rationale for the recommendations and the implications for various stakeholders. Commissioners will vote on the recommendations during the January 2025 meeting.

After a break, the Commission considered policy options to address transitions of care for children and youth with special health care needs (CYSHCN). As CYSHCN reach adulthood, they need to transition from a pediatric to adult model of care. Findings from our work demonstrate that Medicaid-covered CYSHCN can experience challenges with this transition. During this month’s session, MACPAC presented four policy options for Commissioner consideration to address these findings.

Staff then presented for Commissioner consideration a CMS notice of proposed rulemaking that would mandate coverage of certain weight loss drugs for obesity under Medicare Advantage (MA) and Medicaid, add integration requirements for certain dual eligible special needs plans (D-SNPs), codify timelines for conducting health risk assessments and developing integrated care plans, and increase beneficiary awareness of certain cost-sharing assistance programs, among other things. Currently, D-SNPs are the primary vehicle for integrating care for people who are dually eligible for Medicare and Medicaid, and the Commission regularly reviews proposed rulemaking affecting the MA program.

To conclude the day, the Commission focused on self-directed services in Medicaid home- and community-based services (HCBS), which are designed to allow people with long-term services and supports (LTSS) needs to live in their homes or a home-like setting in the community.

MACPAC staff presented an overview of self-direction for HCBS. Commissioners then discussed areas of interest regarding self-directed HCBS and highlighted priority issues to address in subsequent stakeholder interviews with state and federal officials, third-party entities, and consumer advocates.

Following this, a panel of experts focused on the benefits, challenges, and design considerations associated with administering self-directed HCBS through Medicaid.

Panelists included:

    • Patricia Brennan, MSW, Director of the Office of Education on Self-Directed Services, Priority Waiting List, and Special Projects, New Jersey Division of Developmental Disabilities
    • Mark Sciegaj, Ph.D., MPH, Professor of Health Policy and Administration, Pennsylvania State University
    • Pamela Zotynia, Service Director of Participant Directed Services, Values Into Action, and Robert’s mother
    • Robert Zotynia, member of the Alliance for Citizen Directed Supports, and self-direction participant

On Friday, the Commission revisited the topic of provisional plans of care, which are service plans that states can use to expedite Medicaid eligibility determinations and enrollment for individuals in need of HCBS. In this session, staff returned with some additional information on state uptake of provisional plans of care, as well as with a policy option for CMS to issue guidance specifically on this topic. The Commission will vote on this recommendation during the January 2025 meeting.

Next, staff presented on differences in HCBS spending and utilization. While all states operate HCBS programs under various optional flexibilities in the Medicaid statute and provide services to a diverse population, there is limited research and data on how spending and utilization may vary across subpopulations of LTSS users. MACPAC is analyzing data for calendar years 2019 through 2021 to understand differences in HCBS spending and utilization. In this session, we presented key findings from this analysis.

The Commission then heard findings from a technical expert panel on Medicaid payment policies to support the HCBS workforce. HCBS workforce shortages affect the ability of Medicaid programs to serve people with long-term care needs in the home or community. Previous MACPAC meetings have addressed findings from federal and state interviews that explored strategies to ensure that HCBS payment rates are adequate to attract and retain a sufficient workforce. MACPAC convened a technical expert panel to better understand how Medicaid payment policies can be used to bolster the HCBS workforce. This session summarized the themes that emerged, which include the importance of comprehensive and aligned rate assumptions and consistent rate reviews.

To conclude the meeting, staff presented highlights from the 2024 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 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.

Supporting the discussion were the following presentations:

  1. State and Federal Tools for Ensuring Accountability of Medicaid Managed Care Organizations
  2. External Quality Review (EQR) Draft Recommendations
  3. Transitions of Care for Children and Youth with Special Health Care Needs (CYSHCN):  Policy Considerations and Options
  4. Potential Areas for Comment on CMS Proposed Rule on Medicare Advantage (MA) for CY2026
  5. Self-Directed Services in Medicaid Home- and Community-Based Services (HCBS)
  6. Panel:  Self-Direction for HCBS
  7. Timely Access to HCBS:  Policy Option on Provisional Plans of Care
  8. HCBS Spending and Utilization
  9. Findings from a Technical Expert Panel on Medicaid Payment Policies to Support the HCBS Workforce
  10. Highlights from the 2024 Edition of MACStats

MACPAC is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide variety of issues affecting Medicaid and the State Children’s Health Insurance Program.  Its deliberations are highly influential among policymakers and often have a significant effect on community safety-net hospitals and members of the Alliance of Safety-Net Hospitals.  Find MACPAC’s web site here.