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April 2023 Public Meeting

MACPAC’s April meeting began with a Commissioner discussion on recommendations for automatic adjustments to disproportionate share hospital (DSH) allotments for the June 2023 report to Congress. The Commission considered four recommendations on providing automatic adjustments to DSH allotments when there are changes in the federal medical assistance percentage.

On Friday, the Commission voted to approve a package of four recommendations related to:

  • Improving the relationship between total DSH funding and measures of need for DSH payments should allotment reductions go into effect;
  • Changing the basis of DSH allotments from federal funding to total funding;
  • Including DSH allotments in a countercyclical financing mechanism for Medicaid to preserve DSH funding when there is an economic recession; and
  • Removing the requirement for the Centers for Medicare & Medicaid Services (CMS) to compare DSH allotments to Medicaid spending so that allotments can be finalized in a timelier manner.

Next, the Commission reviewed a draft chapter for the June 2023 report to Congress on integrating care for people who are dually eligible for Medicaid and Medicare, and how different delivery mechanisms provide varying levels of integration. The chapter describes the tools that states have to integrate care, as well as beneficiary experiences in integrated care. The presentation concluded with next steps in the Commission’s work to advance integrated care for dually eligible beneficiaries.

The Commission then discussed a draft chapter for the June report to Congress on pre-release Medicaid services for adults leaving incarceration. The chapter draws on findings from an expert panel and extensive interviews with state Medicaid and corrections officials, as well as Commission discussions. The chapter describes state efforts to provide timely Medicaid coverage and care for adults leaving state prisons and local jails, including through Section 1115 demonstrations to provide Medicaid-covered services during incarceration. It concludes by providing key considerations for implementing pre-release Medicaid services, as well as future guidance and activities that CMS and other federal agencies can undertake to support states in those efforts.

Later, the Commission heard a panel discussion on dental benefits for adult Medicaid beneficiaries. After an overview from MACPAC staff on state Medicaid coverage for adults dental services, Brandon Bueche of the Louisiana Department of Health and Hospitals, Justin Gist of the Virginia Department of Medical Assistance Services, and Marko Vujicic of the Health Policy Institute at the American Dental Association, described approaches for providing dental coverage to certain high-need populations. Panelists also addressed state and federal policy levers that could increase access to dental care for Medicaid beneficiaries.

After this, MACPAC staff provided an update on unwinding the continuous coverage requirements in Medicaid that were in place during the COVID-19 public health emergency. Staff discussed beneficiary communication efforts and coordination with key stakeholders, including managed care organizations (MCOs), community-based organizations, and providers. The presentation concluded with a discussion of considerations related to the unwinding for individuals with disabilities and limited English proficiency.

To conclude the meeting on Thursday, the Commission examined a proposed rule on Medicaid DSH third-party payer policy. In February 2023, CMS published a notice of proposed rulemaking that implements statutory changes to DSH payments enacted in the Consolidated Appropriations Act, 2021 (CAA, P.L. 116-260) and makes additional technical changes to CMS’s oversight of DSH policy. This presentation summarized the proposed rule and proposed potential policy areas for the Commission to comment.

After a vote to approve DSH recommendations on Friday, staff presented a draft chapter on access to Medicaid home- and community-based services (HCBS). The chapter provides an overview of Medicaid coverage of HCBS and describes findings in two areas—access barriers for beneficiaries and state challenges in administering HCBS programs—mapped to MACPAC’s access framework. It concludes with areas for further work and next steps aimed at identifying policies that drive toward a more streamlined HCBS delivery system with increased access for beneficiaries and reduced administrative burden for states.

The meeting concluded with a staff presentation on findings from MACPAC’s ongoing examination of managed care denials and appeals. Medicaid MCOs manage and provide care to beneficiaries enrolled in their plan. This includes authorizing and paying for covered services, as well as denying or limiting services to ensure that only appropriate, medically necessary care is provided (42 CFR § 438.210). Beneficiaries have the right to appeal MCO coverage decisions. Federal rules require that states have monitoring systems in place to provide oversight of MCOs and their appeals systems.

This session discussed detailed interview findings that address whether denial and appeal processes ensure beneficiary access to covered and medically necessary care and how state and federal officials monitor the denial and appeals processes of Medicaid MCOs. Staff also solicited Commissioner feedback on areas where they may be interested in pursuing policy options.


  1. Recommendations for Automatic Adjustments to Disproportionate Share Hospital Allotments
  2. Integrating Care for Dually Eligible Beneficiaries: Different Delivery Mechanisms Provide Varying Levels of Integration
  3. Access to Medicaid Coverage and Care for Adults Leaving Incarceration
  4. Access to Covered Dental Benefits for Adult Medicaid Beneficiaries: Panel Discussion
  5. Unwinding Update: State Implementation and Coordination with Providers and Community Organizations
  6. Proposed Rule on Medicaid Disproportionate Share Hospital Third-Party Payer Policy
  7. Access to Home- and Community-Based Services
  8. Denials and Appeals in Managed Care: Interview Findings