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MACPAC September Meeting

• The Medicaid and CHIP Payment and Access Commission (MACPAC) met on September 21-22 to discuss topics including: denials and appeals in Medicaid managed care; Medicaid demographic data collection; unwinding the continuous coverage requirements; ex parte renewals and roundtable findings; hospital supplemental payment work plans; the proposed rule on nursing facility staffing and payment transparency; school-based behavioral health services for students enrolled in Medicaid; engaging beneficiaries through Medical Care Advisory Committees; and Medicare savings programs’ eligibility and enrollment (MACPAC, September 21-22). A summary of the discussion topics follows:
  • MACPAC conducted a study to determine whether the denial and appeals processes ensured access to care, were monitored appropriately, and if beneficiaries found the appeals process to be accessible. Currently, there is no federal requirement to collect and monitor data on denials, continuation of benefits, and appeal outcomes. There is also a lack of clinical audits to determine if a denial was clinically appropriate. In addition, there is insufficient public reporting with only 14 states publicly reporting the information and no federal requirement to do so. MACPAC presented four different policy options for CMS to pursue and recommended CMS to establish data reporting requirements, audit denials for clinical appropriateness, and publicly report on denials and appeals (including listing data on denials and appeals on the quality rating system website). The next steps in this process include Commissioner discussion and feedback.
  • In its March 2023 Report to Congress, MACPAC recommended updating the single streamlined application race and ethnicity questions to encourage more responses. The Commission also identified the need to expand the collection and reporting of other demographics such as sexual orientation and gender identity (SOGI), limited English proficiency (LEP), and disability data. The September 2023 presentation provided additional background on how state and federal agencies use the data, how they currently collect the data, and the data limitations. Medicaid demographic data can be used for many different purposes but can be broken down into two main categories: program administration and the identification and assessment of disparities. Current federal collection efforts are inconsistent and there are no federal minimum standards for collecting SOGI, LEP, and disability data. More inclusive data collection can help support health equity across federal and state programs. There will be more presentations in the coming months discussing results from stakeholder interviews and surveys.
  • MACPAC contracted with Mathematica to conduct a roundtable discussion during the summer of 2023 on the challenges and opportunities of ex parte renewals. Roundtable discussion attendees included CMS representatives, six state Medicaid agency representatives, policy experts, beneficiary advocates, and an IT systems vendor. In the September 2023 meeting, MACPAC shared the key findings from the discussion. There were four main takeaways that MACPAC presented: states need access to a variety of data sources to successfully conduct renewals; ex parte renewals can be challenging for some populations due to eligibility criteria being difficult to verify electronically; efforts are less likely to be hindered by technology limitations rather than limited resources and competing priorities; and, the level of integration between Medicaid eligibility systems and other HHS programs can help support efficiency in the renewal process. MACPAC staff intend to publish an issue brief on the findings of the roundtable in more detail in the coming weeks.
  • MACPAC reviewed its long-term work plan to examine Medicaid payments to hospitals. MACPAC reviewed the types of supplemental payments, the newly available data on these arrangements, and the provider payment framework. The Commission plans to compile a list of supplemental payment methods and identify payments that appear to advance similar goals. They also plan to link new non-DSH supplemental payments with hospital-level DSH data to facilitate a discussion on these payments. They also discussed some limitations in identifying all the potential impacts of physician supplemental payments. Over the next two years, MACPAC plans to release their findings on new supplemental payment analyses. At the December 2023 meeting, staff will report on a draft of the statutorily required DSH report.
  • Commissioners discussed the notice of proposed rulemaking on nursing facility staffing and payment transparency that establishes minimum staffing standards and requirements for states to report on Medicaid payments for certain Medicaid-covered services specific to nursing facilities and intermediate care facilities. Staff also reviewed MACPAC’s prior work on nursing facility staffing and payment transparency. The next steps for staff include incorporating feedback from the discussion for possible comments by the Commission.
  • As part of the continued focus on advancing health equity and beneficiary engagement, MACPAC staff explored the role of medical care advisory committees (MCACs) in assisting with these efforts. Staff provided an overview of the federal law related to MCACs and recent proposed federal actions to implement changes. They also discussed key findings about state approaches to MCAC beneficiary recruitment, meeting structure, and beneficiary engagement, and how CMS plans to address certain challenges in the proposed rule.
  • MACPAC discussed how schools provide Medicaid-covered health services, with a focus on behavioral health, to children and adolescents. The topic is increasingly important as communities seek to address an increase in behavioral health challenges among young individuals across the country. MACPAC presented background information related to school-based services, including financing, payment, billing, and claiming for these school-based services. Staff will present findings from stakeholder interviews at the Commission’s November meeting.
  • Commissioners held a session that provided a comprehensive overview of the Medicare Savings Program (MSPs), including benefits, eligibility criteria, and structure. The MSPs provide Medicaid assistance with Medicare premiums and cost sharing to individuals who are dually eligible. This MACPAC discussion detailed the individuals currently enrolled in these programs and provided a basis for informing future discussions on the potential policy options related to facilitating enrollment in the MSPs.

Some States Pause Disenrollments

• On September 21, CMS announced it is requiring 29 states and Washington, D.C. to pause redetermination terminations and restore coverage to approximately 500,000 Medicaid beneficiaries after finding that these states’ automatic renewal processes had an error that caused eligible beneficiaries, mostly children, to lose Medicaid or CHIP coverage. Washington, D.C., Maryland, Virginia, and West Virginia found that the error only affected children enrolled in their Medicaid and CHIP programs while seven other states found the error was affecting households with beneficiaries with different eligibility statuses. Pennsylvania and Nevada both reported the highest number of beneficiaries affected by the error at more than 100,000 beneficiaries. An additional thirteen states reported less than 10,000 beneficiaries affected by the issue. Delaware, Georgia, Idaho, Iowa, Kentucky, Minnesota, Nebraska, and Oregon are still reviewing their redetermination processes to verify which groups and the number of beneficiaries affected by the anomaly (Inside Health Policy, September 21; Modern Healthcare, September 21).

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Federal Legislation

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North Carolina Medicaid Expansion

• Medicaid expansion in North Carolina will soon be under way, as Governor Roy Cooper has announced he will allow the state budget bill to become law without his signature. This decision allows Medicaid to cover an additional 600,000 low-income adults who would likely not otherwise qualify for healthcare coverage. Governor Cooper signed a Medicaid expansion bill into law this past March, which required the enactment of a state budget before coverage could be implemented. Medicaid expansion has been one of the Governor’s top priorities since taking office in 2017. Meanwhile in Kansas, Governor Laura Kelly looks to increase support in her state for Medicaid expansion with a statewide tour, noting that this is her top priority for 2024. However, Kansas state legislators are critical of Governor Kelly’s efforts (Modern Healthcare, September 22; Health Payer Specialist, September 25).

Waivers

• Section 1115
  • Rhode Island
    • On September 12, 2023, Rhode Island submitted an amendment to the state’s existing 1115 Rhode Island Comprehensive Demonstration, Project Number 11-W-00242/1, to allow the provision of home and community-based personal care services in acute care hospital settings as authorized by state legislative action. The goal of this amendment is to improve participants’ immediate experience of short-term hospital stays, improve the transition of care back to the community, and to reduce the risk that a hospital stay will lead to institutionalization. The federal public comment period will be open from September 25, 2023, until October 25, 2023. Comments can be submitted here.
  • North Carolina
    • On September 11, 2023, North Carolina submitted an application to extend the substance use disorder (SUD) expenditure authority which is included in the state’s section 1115(a) demonstration known as the “North Carolina Medicaid Reform Demonstration.” This part of the demonstration authorizes federal matching funds for reimbursement of services delivered to beneficiaries residing in Institutions for Mental Diseases (IMD) with SUD. Currently, the SUD component of the waiver is set to expire on October 31, earlier than the other programs authorized under the demonstration. This application seeks the authority to extend the SUD program as approved with no additional changes for an additional five years. The federal public comment period will be open from September 26, 2023, through October 26, 2023. Comments can be submitted here.

SPAs

• Payment SPAs
  • Arizona (AZ-23-0010, effective May 1, 2023): Updates the fee-for-service rate methodology for intensive outpatient alcohol and/or drug services.
  • Connecticut (CT-23-0011, effective April 1, 2023): Implements numerous updates to the payment methodology and rates for physician and clinic services.
  • Massachusetts (MA-23-0035, effective April 1, 2023): Updates the payment methods and standards to provide Clinical Quality Incentive (CQI) payments for privately-owned psychiatric hospitals and substance abuse treatment hospitals.
  • Massachusetts (MA-23-0037, effective May 1, 2023): Updates the payment methods and standards used to determine the rates for acute outpatient hospitals.
  • Massachusetts (MA-23-0038, effective June 30, 2023): Reauthorizes rate year 2023 supplemental payments for high-complexity care in privately-owned pediatric chronic disease and rehabilitation inpatient hospitals.
  • Massachusetts (MA-23-0036, effective May 1, 2023): Revises RY 2023 reimbursements for acute inpatient hospital services to include additional supplemental payments to qualifying providers with established criteria. In addition, provides clarifying technical changes to the Pay for Performance and Clinical Quality Incentive programs.
  • Massachusetts (MA-23-0039, effective April 1, 2023): Updates the methods and standards used to determine rates of payment to community health centers.
  • Massachusetts (MA-23-0040, effective May 12, 2023): Updates the professional dispensing fee when medications are delivered to an individual’s residence.
  • New York (NY-23-0084, effective April 1, 2023): Authorized 4% Cost of Living Adjustment (COLA) Adjustment for Medicaid Comprehensive Psychiatric Emergency Program (CPEP) extended observation bed (EOB) Services.
  • New York (NY-23-0086, effective April 1, 2023): Increases the operating cost component of hospital based Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) rates by 6.5%.
  • New York (NY-23-0090, effective April 1, 2023): Increases the CFTSS Children’s Medicaid rates by 4% for the Cost-of-Living Adjustment (COLA).
  • South Carolina (SC-23-0011, effective July 1, 2023): Establish reimbursement methodology for technical component/facility charges for Pediatric Inpatient Rehabilitation.
  • Texas (TX-23-0030, effective July 1, 2023): Updates the physicians and other practitioners fee schedules.
  • Washington (WA-23-0043, effective July 1, 2023): Increases the Nursing Facility and specialty services rates.
• Eligibility SPAs
  • Georgia (GA-23-0001, effective January 1, 2023): Adopts the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance-Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
  • Rhode Island (RI-23-0006, effective April 1, 2023): Confirms the eligibility requirements for the Medicare Savings Program eligibility groups.
• Services SPAs
  • Arkansas (AR-23-0005, effective March 11, 2021): Attestation of coverage of COVID-19 vaccines, testing, and treatment without cost limitations.
  • Kansas (KS-23-0030, effective July 1, 2023): Updates the coverage and limitations for the state’s Prescribed Drugs list.
  • Nebraska (NE-23-0007, effective July 1, 2023): Updates coverage and limitations for the state’s excluded drugs on the Prescribed Drugs list.
  • New Mexico (NM-23-0003, effective February 1, 2023): Provides for coverage and payment of all preventive services assigned a grade of A or B by the U.S. Preventive Services Task Force (USPSTF), and all approved vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and their administration.
  • New York (NY-21-0048, effective August 17, 2021): Establishes two eligible pediatric residential health care facilities to improve the quality of care for young adults with medical fragility.
  • Virginia (VA-21-0017, effective July 1, 2022): Allows payment of medical assistance services delivered to Medicaid-eligible students when the services qualify for reimbursement by the Virginia Medicaid program. Coverage is not dependent on whether the student has an individualized education program or if health care services are included in a student’s individualized education program. In addition, the amendment includes new transportation and personal care services language.

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