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MACPAC Looks at Medicaid DSH

Last week the Medicaid and CHIP Payment and Access Commission met in Washington, D.C. and one of the subjects on its agenda was Medicaid DSH.

The Affordable Care Act mandated major reductions of Medicaid disproportionate share (Medicaid DSH) allotments to states and those reductions have been delayed by Congress several times but are now scheduled to begin in FY 2020.

At the MACPAC meeting the commission’s staff presented three proposed recommendations that address Medicaid DSH allotments; these recommendations were based on a consensus reached by MACPAC commissioners at their October meeting.  Those recommendations are:

  1. Phase in Medicaid DSH reductions more gradually over a longer period of time.
  2. Apply reductions to unspent DSH funds first.
  3. Distribute reductions in a way that gradually improves the relationship between DSH allotments and the number of non-elderly, low-income individuals in a state.

Current regulations call for Medicaid DSH cuts to begin in FY 2020 and for DSH payments to decrease $4 billion a year in FY 2020, rising to $8 billion the following year.  It appears MACPAC may suggest slowing the pace of these cuts by starting with $2 billion in cuts in FY 2020 and then raising that amount $2 billion a year through 2023, when they would reach $8 billion a year.  MACPAC does not appear to prepared to suggest another delay in beginning the Medicaid DSH cuts.

As the third recommendation suggests, MACPAC is considering recommending a change in how DSH cuts are calculated on a state-by-state basis.  In particular, MACPAC appears to be focusing on how better to target cuts so that Medicaid DSH money continues to reach the hospitals that most need this money.  As a Medicaid expansion state, PEACH needs to pay particular attention to any such change in the methodology for determining how DSH cuts are allocated among the states.

MACPAC is expected to vote on these recommendations during its January 24-25 meetings.

All private safety-net hospitals participate in the Medicaid DSH program and rely heavily on these funds to serve the low-income communities in which they are located.  NAUH will monitor MACPAC’s upcoming deliberations, evaluate the potential impact of any MACPAC recommendations on NAUH members, and develop and implement an appropriate legislative strategy based on that analysis, if needed.

For a closer look at the draft MACPAC recommendations and the rationale underlying each, go here to see the presentations that guided last week’s MACPAC discussion about Medicaid DSH.

MACPAC: Let’s “hit the pause button” on Medicaid Work Requirements

The non-partisan legislative branch agency that advises Congress and the administration on Medicaid issues will ask the administration to delay approving any more state Medicaid work requirements.

That was the decision reached by the Medicaid and CHIP Payment and Access Commission when it met last week.

MACPAC warned that the work requirement currently being implemented in Arkansas, the first state to introduce such a requirement, is flawed and needs further work before moving forward.  The agency also believes the federal government should increase its oversight of new Medicaid work requirements before additional states begin implementing similar, already-approved Medicaid work requirements.

MACPAC plans to convey its concerns in a letter to Department of Health and Human Services Secretary Alex Azar.

Medicaid work requirements pose a potential challenge for private safety-net hospitals because they could leave meaningful numbers of low-income residents of the communities those hospitals serve without health insurance.

Learn more about MACPAC’s objections to the manner in which Medicaid work requirements are being introduced in this Bloomberg Law article.

 

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The October 2018 MACPAC meeting covered a range of front-line issues in Medicaid, leading off with an analysis of disproportionate share hospital (DSH) allotments on Thursday morning. Following the analysis, the Commission discussed options for March recommendations on how to structure DSH allotment reductions that are scheduled to begin in fiscal year 2020. The Commission later resumed the discussion it began in September on work and community engagement requirements, presenting new data from Arkansas on compliance and disenrollments, as well as information gathered since that meeting about Arkansas’s approach to implementation.

On Thursday afternoon, the Commission looked at the Department of Homeland Security’s proposed public charge regulations and their implications for Medicaid and the State Children’s Health Insurance Program (CHIP). A session responding to a congressional request to look at issues facing the Medicaid program in Puerto Rico was next on the agenda. A presentation from an ongoing project on how Medicaid drug coverage compares with Medicare Part D and commercial plans closed out the day.

On Friday, the Commission heard from Tom Betlach, director of the Arizona Health Care Cost Containment System, and Karen Kimsey, chief deputy at the Virginia Department of Medical Assistance Services, on their experiences integrating care for dually eligible beneficiaries.* At the final October session, the Commission reviewed the findings from a study of how six states carried out simplified Medicaid eligibility and enrollment established by the Patient Protection and Affordable Care Act (P.L. 111-148, as amended).

Supporting the discussion were the following presentations:

Because NAUH members serve so many Medicaid patients, MACPAC’s deliberations are especially relevant to them because its recommendations often find their way into future Medicaid and CHIP policies.

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 array of issues affecting Medicaid and the State Children’s Health Insurance Program.  Find its web site here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met recently in Washington, D.C. to review a number of Medicaid- and CHIP-related issues.

MACPAC members heard presentations on and discussed the following issues:

Find outlines of these subjects and additional materials by clicking the links above and go here for a transcript of the two days of public meetings.

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 array of issues affecting Medicaid and the State Children’s Health Insurance Program.  While its recommendations are binding on neither the administration nor Congress, MACPAC’s work is highly influential and often finds its way into future Medicaid and CHIP policy.  Because private safety-net hospitals serve so many Medicaid and CHIP patients, they have an especially major stake in MACPAC deliberations and recommendations.

 

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission, a non-partisan legislative branch agency that advises Congress, the administration, and the states on Medicaid and CHIP issues, met publicly in Washington, D.C. last week.

The following is MACPAC’s own summary of its two days of meetings.

The April 2018 meeting began with session on social determinants of health. Panelists Jocelyn Guyer of Manatt Health Solutions, Arlene Ash of the University of Massachusetts Medical School, and Kevin Moore of UnitedHealthcare Community & State discussed state approaches to financing social interventions through Medicaid. In its second morning session, the Commission reviewed a draft chapter of the June 2018 Report to Congress on Medicaid and CHIP on the adequacy of the care delivery system for substance use disorders (SUDs) with a special focus on opioid use disorders.

In the afternoon, the Commission discussed the Centers for Medicare & Medicaid Services (CMS) March 2018 proposed rule changing the process by which states verify that Medicaid fee-for-service provider payment is sufficient to ensure access to care and agreed to submit comments to the agency. The first day of the meeting concluded with a review of the draft June chapter describing the status of managed long-term services and supports programs across the country. June chapters on Medicaid drug rebate policy and federal regulations governing confidentiality of SUD patient records were approved at the previous Commission meeting in March.

On Friday, the Commission heard from panelists Susan Barnidge, of the U.S. Government Accountability Office (GAO), and Judith Cash of CMS’s Center for Medicaid and CHIP Services, who discussed GAO’s report on Section 1115 demonstration evaluations and CMS’s efforts to improve the evaluation process. In the final session of the day, the Commission examined issues related to upper payment limit (UPL) hospital payments, which included findings from MACPAC’s recent review of state UPL demonstrations.

MACPAC members addressed a number of policy issues during the sessions using the following presentations to guide their discussion:

  1. State Approaches to Financing Social Interventions through Medicaid
  2. Draft Chapter: Access to Substance Use Disorder Treatment in Medicaid
  3. Proposed Rule on Exemptions to Monitoring Access in Fee for Service
  4. Draft Chapter: Managed Long-Term Services and Supports Programs
  5. Panel Discussion on Section 1115 Waiver Evaluations
  6. Uses and Oversight of Upper Payment Limit Supplemental Payments to Hospitals

MACPAC’s deliberations are especially important to private safety-net hospitals because they care for so many Medicaid and CHIP patients.

MACPAC Issues Annual Report, Recommendations to Congress

The Medicaid and CHIP Payment and Access Commission has published its annual report and recommendations to Congress.

MACPAC’s report addresses three primary areas:  Medicaid managed care, telehealth, and Medicaid disproportionate share payments (Medicaid DSH).

With 80 percent of Medicaid beneficiaries now enrolled in managed care plans, MACPAC offers three major recommendations for improving Medicaid managed care efforts:

  • permit states to require all of their Medicaid beneficiaries to enroll in a managed care plan
  • extend Medicaid managed care section 1915(b) waivers from two to five years
  • permit states to obtain waivers to waive freedom of choice and selective contracting restrictions

MACPAC notes the growing use of telehealth by state Medicaid programs and encourages states to continue this expansion while learning more from the efforts of one another to use telehealth effectively.

Finally, MACPAC notes that it

…continues to find little meaningful relationship across the country between DSH allotments and number of uninsured individuals, hospitals’ uncompensated care costs, and the number of hospitals providing essential community services that have high levels of uncompensated care. Total hospital charity care and bad debt continue to fall, especially in states that expanded Medicaid coverage, but Medicaid shortfall showed an uptick as a result of increased Medicaid enrollment. Now that Congress has delayed DSH allotment reductions for two years, the Commission will explore opportunities to improve the targeting of DSH payments in future reports.

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 array of issues affecting Medicaid and the CHIP program.

Medicaid DSH is very important to the nation’s private safety-net hospitals so NAUH will carefully monitor the response to MACPAC’s Medicaid DSH recommendations.

Learn more about MACPAC’s recommendations to Congress in its Report to Congress on Medicaid and CHIP, which can be found here.

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met last week in Washington, D.C. to discuss a variety of Medicaid and Children’s Health Insurance Program issues.

MACPAC, the non-partisan legislative branch agency that performs policy and data analysis and makes recommendations to Congress, the administration, and the states, addressed a number of issues during the meeting.  Among them it discussed Medicaid managed long-term services and supports (MLTSS) and voted to recommend that states be given the opportunity to seek permission to make Medicaid beneficiary enrollment in managed care plans mandatory through revisions of their state plan amendment rather than by seeking Medicaid waivers.

The commission also heard presentations on and discussed:

  • the integration of substance use disorder treatment with other Medicaid-covered services
  • residential substance abuse treatment and the exclusion of institutions for mental disease from treatment options
  • stakeholder experiences with MLTSS
  • Medicaid hospital payments
  • Medicaid managed care
  • the “Money Follows the Person” demonstration program
  • appeals for the dually eligible

MACPAC’s deliberations are important to private safety-net hospitals because those hospitals serve so many Medicaid patients.  While MACPAC’s recommendations are binding on neither the administration nor Congress, it is a respected source of insight and ideas and its recommendations often find their way into future regulations, legislation, and policy.

Go here for a summary of the meeting and links to the presentations used for these subjects.

MACPAC Meets

The non-partisan legislative branch agency that advises Congress, the administration, and the states on Medicaid and CHIP-related issues met recently in Washington, D.C.

The following is the Medicaid and CHIP Payment and Access Commission’s own summary of its meeting.

The December 2017 meeting of the Medicaid and CHIP Payment and Access Commission began with a brief update on the State Children’s Health Insurance Program (CHIP). Although federal funding for the CHIP expired at the end of September, legislation to renew funding was still pending in Congress. The Commission then heard from a panel discussing state tools to manage drug utilization and spending in Medicaid. Panelists included Renee Williams, director of clinical pharmacy services for TennCare; Doug Brown, Magellan Rx Management’s vice president for Medicaid drug rebate management; and John Coster, director of the Center for Medicaid and CHIP Services Division of Pharmacy at the Centers for Medicare & Medicaid Services. At the final morning session, Commissioners reviewed a draft March 2018 report chapter on streamlining Medicaid managed care authorities. The Commission voted to approve recommendations to Congress, but deferred action on a third recommendation for further discussion at its upcoming January 2018 meeting.

In the afternoon, MACPAC staff previewed highlights from the December 2017 MACStats: Medicaid and CHIP Data Book. MACStats pulls together Medicaid and CHIP data from multiple sources that often can be difficult to find. The collection is published annually and individual tables are updated throughout the year. The Commission then reviewed the draft March report chapter on telemedicine in Medicaid, and later in the day the Commission returned to the topic of prescription drugs, to explore potential recommendations on the Medicaid drug rebate program.

The final December sessions covered MACPAC’s annual analysis of disproportionate share hospital payments (a required element of its March reports), and findings from interviews with four states to better understand how they are implementing Section 1115 Medicaid-expansion waivers.

The following presentations, many with supporting documents, were offered during the MACPAC meeting:

  1. State Strategies for Managing Prescription Drug Spending
  2. Review of March Report Chapter: Streamlining Managed Care Authorities
  3. Highlights from MACStats
  4. Review of March Report Chapter: Telemedicine in Medicaid
  5. Potential Recommendations on Medicaid Outpatient Drug Rebates
  6. Review of Draft March Report Chapter: Analyzing Disproportionate Share Hospital Allotments to States
  7. Implementation of Section 1115 Medicaid Expansion Waivers: Findings from Structured Interviews in Four States

MACPAC Meets

The Medicaid and CHIP Payment and Access Commission met recently in Washington, D.C.

Among the issues MACPAC commissioners discussed during their two-day meeting were:

  • delivery system reform incentive payment programs
  • Medicaid enrollment and renewal processes
  • managed care oversight
  • monitoring and evaluating section 11115 demonstration waivers
  • Medicaid coverage of telemedicine services

MACPAC advises the administration, Congress, and the states on Medicaid and CHIP issues.  It is a non-partisan agency of the legislative branch of government.

Go here to find background information on these and other subjects as well as links to the presentations that MACPAC staff made to the commissioners during the meetings.

MACPAC Meets

Last week the Medicaid and CHIP Payment and Access Commission met in Washington, D.C.  The agency performs policy and data analysis and offers recommendations to Congress, the Department of Health and Human Services, and the states.

During two days of meetings, MACPAC commissioners received the following presentations:

  • Federal CHIP Funding Update: When Will States Exhaust Their Allotments?
  • Review of June Report Chapter: Program Integrity in Medicaid Managed Care
  • Review of June Report Chapter: Medicaid and the Opioid Epidemic
  • Medicare Savings Program: Eligible But Not Enrolled
  • Medicaid Reform: Implications of Proposed Legislation
  • Preliminary Findings From Evaluations of Medicaid Expansions Under Section 1115 Waivers
  • Potential Effects of Medicaid Financing Reforms on Other Health and Social Programs
  • Review of June Report Chapter: Analysis of Mandatory and Optional Populations and Benefits
  • Managed Long-Term Services and Supports: Network Adequacy for Home and Community-Based Services
  • Update on MACPAC Work on Value-Based Payment and Delivery System Reform

For links to all of these publications and a transcript of the two-day meeting go here, to the MACPAC web site.