April 2025 Public Meeting

MACPAC’s April meeting kicked off with a two-part presentation on Medicaid key statistics, trends, and financing. MACPAC highlighted trends in enrollment, spending, and utilization based on the most recent and complete data available. Overall, we found that Medicaid provides health coverage to many low-income groups, including families, seniors, and people with disabilities, and while Medicaid spending has grown it has remained lower than private insurance and Medicare.

MACPAC staff also provided a refresher on Medicaid payments and financing, including background information on the non-federal share of Medicaid financing. The presentation focused on how states may use permissible sources of financing, such as provider taxes and intergovernmental transfers, to fund a large portion of the non-federal share of supplemental and directed payments that can be used to target specific policy goals.

The Commission then continued its discussion on transitions from pediatric to adult care for Medicaid-covered children and youth with special health care needs (CYSHCN). MACPAC staff presented a draft chapter for the June 2025 report to Congress with four recommendations aimed at addressing challenges with transitioning to adult care and improving beneficiary experience.

On Friday, the Commission voted unanimously in favor of the four recommendations to address challenges with CYSHCN transitions from pediatric to adult care. The recommendations would: (1) require states to develop a strategy for transitions of care for CYSHCN, which includes developing an individualized transition of care plan and making the strategy publicly available; (2) release federal guidance to states on existing authorities to cover transition of care related services for CYSHCN; (3) require states to collect and report data on access to transition of care related services as well as beneficiary and caregiver experiences with transitions; and (4) require interagency agreements between state Medicaid and Title V agencies to specify the roles and responsibilities of the agencies in supporting CYSHCN transitions from pediatric to adult care.

Staff then presented on level of care determinations and person-centered planning processes for individuals in need of home- and community-based services (HCBS). The presentation included background on these two topics, as well as preliminary findings from interviews with state officials. The session concluded with next steps.

Next, staff presented a draft chapter for the June 2025 report to Congress describing findings from the Commission’s analytic work on access to medications for opioid use disorder (MOUD) in Medicaid. The chapter includes a discussion of recent federal policies and funding that have affected access to MOUD, an overview of MOUD coverage and estimates of use, and barriers to MOUD as identified through the Commission’s work. The Commission plans to further investigate the use of utilization management practices and how they affect Medicaid beneficiaries’ receipt of timely and effective care.

After this, staff provided the Commission with an overview of the draft chapter for the June report to Congress on the Program of All-Inclusive Care for the Elderly (PACE), a provider-led model that provides fully integrated care to adults ages 55 and older with nursing-facility level of care needs while allowing them to remain in the community. The chapter begins with background on PACE, which is currently available in 33 states and the District of Columbia, and highlights findings on the model’s design and administration. The chapter concludes with plans for the Commission to further examine the design and administration of the PACE model.

Commissioners then heard an overview of a draft chapter for the June report to Congress on self-direction for Medicaid HCBS. The chapter begins with a discussion of the required elements in self-direction and the key stakeholders in program administration. The chapter continues by reviewing state design considerations, including Medicaid HCBS authorities, populations served, services provided, and flexibilities for beneficiaries. Next, it describes state administrative considerations, including information and assistance supports, approaches to financial management services, and quality reporting, monitoring, and oversight. Looking ahead, the Commission plans to continue exploring the self-direction model as a coverage option that gives beneficiaries more autonomy over their care than traditional HCBS and may help to alleviate the HCBS workforce shortage.

After a break, the Commission heard a panel discussion on the use of technology, including artificial intelligence, to automate parts of the Medicaid prior authorization process. Panelists included:

Sanmi Koyejo, PhD, associate professor, Stanford University Department of Computer Science and Principal Investigator, Stanford Trustworthy AI Research

Heather McComas, PharmD, director, Administrative Simplification Initiatives, American Medical Association

Wayne Turner, JD, senior attorney, National Health Law Program

On Friday, the Commission examined how HCBS workforce shortages reduce Medicaid’s ability to serve people with long-term care needs in the home or community. Although some factors that affect the HCBS workforce are outside of Medicaid’s purview, many states are exploring ways to use Medicaid rate setting to expand the HCBS workforce and reduce worker turnover. In previous MACPAC public meetings, staff discussed findings from a compendium of HCBS authorities, federal and state interviews, and a technical expert panel that explored strategies to ensure that HCBS payment rates are adequate to attract and retain a sufficient workforce. During this session, staff presented a revised policy option to promote the HCBS workforce for Commissioner consideration.

Staff then presented themes from an analysis of policies, approaches, and experiences serving children in foster care in seven states, and stakeholder interviews. Four themes emerged from the study: collaboration and coordination between child-serving systems, including data sharing, delivery of Early and Periodic Screening, Diagnostic, and Treatment benefits, behavioral health needs, and specialty managed care plans.

Next, staff presented a draft chapter describing findings from the Commission’s analytic work on appropriate access to residential behavioral health treatment services for children with Medicaid coverage. The draft chapter provided an overview of Medicaid coverage for residential treatment services, how children are referred to residential treatment, what is known about the use of residential treatment, the use of out-of-state placement, access considerations related to the continuum of care, and barriers to appropriate residential treatment.

To conclude the meeting, staff provided Commissioners with updates on the status of procurement with Medicaid managed care plans affiliated with integrated Dual Eligible Special Needs Plans (D-SNPs), necessary information technology (IT) systems changes, and the development of enrollment processes for transitioning Medicare-Medicaid Plan (MMP) enrollees to integrated D-SNPs.

The Commission expressed an interest in monitoring the transition from the MMPs to D-SNPs, and in its June 2023 report to Congress presented a framework for doing so. The framework focused on four key elements: stakeholder engagement, procurement, IT system changes, and enrollment. Since that framework was published, staff have continued to monitor transition efforts across participating MMP states, and in December 2023, staff presented Commissioners with key findings on stakeholder engagement efforts related to the transition.

Presentations:

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