An official website of the United States Government -

December 2021 Public Meeting

The December 2021 MACPAC meeting kicked off with a presentation on directed payments in Medicaid, which allow states to require managed care plans to pay providers according to specified rates and methods. To examine how states are using this option, MACPAC contracted with Mathematica to review available information on approved directed payments and to interview state officials and stakeholders in five states (California, Florida, Massachusetts, Ohio, and Utah).

This presentation reviewed themes that emerged about the relationship between fee-for-service supplemental payments and directed payments, as well as the large share of Medicaid payments that directed payments represent for certain providers. It also examined the substantial growth in directed payments, noting also that the effects of directed payments on quality and access are unclear in many cases. Finally, staff discussed oversight challenges. The presentation concluded with a discussion of potential policy approaches for Commissioner consideration, including potential recommendations that would bring more transparency to directed payments and whether to create an upper limit.

Next, staff presented policy options for a congressionally mandated study on the Money Follows the Person (MFP) demonstration. MFP funds may be used to transition beneficiaries from institutions into specific settings, a much more limited definition than permitted for Medicaid home-and community-based services (HCBS) more generally. Congress directed MACPAC to consider whether the criteria should be harmonized. This presentation outlined two policy options for the Commission’s consideration as it prepares the mandated report. It first describes the rationale for maintaining the existing MFP residence criteria. It then provides a rationale for aligning the MFP criteria with the HCBS settings rule. The Commission plans to publish the final report as part of its March 2021 report to Congress.

Later, the Commission heard from experts who discussed the roles and responsibilities of the Centers for Medicare & Medicaid Services (CMS), and states in designing and implementing an improved system for monitoring Medicaid beneficiaries’ access to care. Under the current approach, there are different requirements for ensuring access across delivery systems, and the responsibilities and expectations of states and plans in monitoring access are not clearly established. Karen LLanos, director of the Medicaid Innovation Accelerator Program at the Center for Medicaid and CHIP Services; Elizabeth Lukanen, deputy director at the State Health Access Data Assistance Center at the University of Minnesota; Abigail Coursolle, senior attorney with the National Health Law Program; and Jennifer McGuigan Babcock, senior vice president for Medicaid policy at the Association for Community Affiliated Plans, discussed strategies for engaging beneficiaries, plans, and other stakeholders.

After a break, Commission staff presented highlights from 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. This presentation highlighted some of the key facts and trends from the December 2021 publication, including the use of data from the Transformed Medicaid Statistical Information System.

The day concluded with a discussion on how greater adoption of health information technology could facilitate clinical integration for those with behavioral health conditions.  Staff presented three policy options that address: (1) the quality of behavioral health focused electronic health records (EHRs), (2) Medicaid mechanisms to finance behavioral health connections to health information exchanges, and (3) testing behavioral health EHR incentive payments through the Center for Medicare and Medicaid Innovation.

On Friday, the day began with a panel discussion on the definition of health equity, what it means to apply a health equity lens, and the types of Medicaid policy levers that could be used to advance racial health equity and improve health outcomes. Cara James, president and CEO of Grantmakers In Health, provided an overview of federal Medicaid policy levers for addressing disparities and health equity. Patrick Piggott, associate director of investigations at North Carolina Medicaid, offered a state perspective on Medicaid strategies to address health equity. Monica Trevino, director of the Center for Social Enterprise at Michigan Public Health Institute, described how to engage Medicaid beneficiaries in policymaking.

Following a discussion and break, staff reviewed state policy approaches to ensure adequate staffing of nurses and nurse aides in nursing facilities, with a particular focus on how Medicaid payment policy can be used to address these concerns. Specifically, the presentation examined state minimum staffing standards that exceed federal requirements and Medicaid payment methods that incentivize facilities to spend more of their revenue on staff wages The presentation reviewed prior research about the effects of such policies and the wide state variation in staffing rates by state. The presentation ended with a discussion of how nursing facility staffing has changed during the COVID-19 pandemic and potential areas for future Commission work.

The meeting concluded with the Commission continuing its discussion regarding needed improvements in the approach to access monitoring. During this session, the Commission considered the goals of access monitoring, key elements of an effective access monitoring system, the role of stakeholders in designing and implementing these systems, and other design considerations. In January 2022, staff will provide additional detail about what a more robust access monitoring system would look like based on Commission feedback. The Commission may consider recommendations on access monitoring as part of its June report to Congress.


  1. Transparency and Oversight of Directed Payments in Medicaid Managed Care
  2. Mandated Report on Money Follows the Person Qualified Residence Criteria: Policy Options
  3. Designing and Implementing an Approach to Monitoring Access to Care among Medicaid Beneficiaries
  4. Highlights from the 2021 Edition of MACStats
  5. Options to Strengthen Integration of Behavioral Health Services through Health Information Technology
  6. Applying a Health Equity Lens to Medicaid
  7. State Policy Levers to Address Nursing Facility Staffing Issues
  8. Next Steps on Access Monitoring