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March 2022 Public Meeting

The March 2022 meeting began with a follow-up discussion on directed payments in managed care. This presentation reviewed a package of five proposed recommendations related to:

  • improving the transparency of existing directed payment approval documents, rate certifications, and evaluations;
  • collecting new provider-level data on directed payment spending;
  • further clarifying directed payment goals and their relationship to network adequacy requirements;
  • providing guidance for more meaningful, multi-year assessments of directed payments; and
  • improving the coordination of reviews of directed payments and managed care rate setting.

The Commission is expected to vote on these recommendations at its April 2022 meeting.

The Commission then continued its discussion on how greater adoption of health information technology could facilitate clinical integration for behavioral health. Prior Commission meetings discussed barriers to adopting electronic health records (EHR), including financing and available products that support behavioral health providers. This presentation had two recommendations for the Commission to discuss: (1) creation of voluntary standards for behavioral health-focused EHRs, and (2) Medicaid mechanisms to finance EHR adoption among behavioral health providers. The Commission will vote on these recommendations in the April 2022 meeting.

After a break, the Commission discussed the general framework for the upcoming chapter in the June 2022 report to Congress on advancing health equity in Medicaid. This is the next step in the Commission’s ongoing work to examine how it can best contribute to combating institutional racism and addressing racial disparities in health care and health outcomes. Specifically, the Commission discussed the key themes and potential Medicaid policy levers to advance health equity and improve health outcomes for racial and ethnic minorities. In addition, the chapter will provide context for understanding racial disparities and inequities, Medicaid’s role in advancing health equity, and explore what it means to use a health equity lens in analyzing both problems and solutions.

Next, the Commission discussed recommendations to require states to develop an integrated care strategy for people who are dually eligible for Medicaid and Medicare. Integrating care for the 12.3 million Americans who were dually eligible for Medicaid and Medicare in 2020 has the potential to improve care and reduce federal and state spending. However, only about 1 million full-benefit dually eligible beneficiaries were enrolled in integrated care models in 2020. States are at different stages of integrating coverage for dually eligible beneficiaries and face a number of barriers to moving forward, including limited resources and lack of Medicare expertise.

Staff presented a draft chapter for the June report to Congress with a recommendation to require all states to develop a strategy to integrate coverage. The strategy should include the following components –integration approach, eligibility and benefits covered, enrollment strategy, beneficiary protections, data analytics, and quality measurement- and be structured to promote health equity. The recommendation includes federal financing to support states in developing the strategy. The Commission subsequently voted on the recommendation on Friday and it was unanimously approved with slight wording changes from the draft presented on Thursday.

Staff then presented on policy issues related to managed care rate setting, actuarial soundness, and implications for efficiency, access, and value in Medicaid. Capitation rates influence many factors important to successful managed care programs. To learn more about the extent to which federal standards support meaningful development and review of capitation rates, MACPAC conducted an extensive examination of the Medicaid actuarial soundness standard. MACPAC found that federal guidance provides states with substantial flexibility to control cost growth, increase efficiency, and manage plan profits. Federal oversight focuses on whether rates provide for all reasonable, appropriate, and attainable costs but does not explicitly examine whether rates represent the most efficient use of Medicaid funds or provide for adequate quality of care or access to care. These findings suggest potential areas for future Commission recommendations.

To close the day, staff presented findings from an expert roundtable about whether existing risk mitigation and rate-setting tools are sufficient to deal with external shocks, such as COVID-19. Capitation payment rates are established prospectively and remain in effect for the duration of the rating period. This can create challenges for states, managed care plans, and providers if there is an unexpected shock to the system that changes utilization and costs drastically from the assumptions used to calculate the capitation rates. States can use risk mitigation strategies to limit the financial risk for both the state and participating plans. The roundtable discussion was focused on identifying the distinctive features of certain system shocks that go beyond normal risk, how the existing risk mitigation tools can be applied to deal with these shocks, and whether there was a need for additional tools or process improvements.

On Friday, staff presented considerations in redesigning the home-and community-based services (HCBS) benefit in Medicaid.  Over the past several years, the Commission has focused on rebalancing long-term services and supports (LTSS) Medicaid spending on LTSS from institutional services to HCBS. Under the statute, states must cover institutional care, but coverage of HCBS is optional. In addition, the combination of state plan authorities and waivers used to provide HCBS has resulted in a complex system design for both beneficiaries and states.

In December 2021, MACPAC convened a roundtable of federal and state officials as well as key stakeholders to consider the design of a core benefit that would streamline access to and address the incentive for HCBS rather than institutional care, and to think through design elements. This presentation focused on tradeoffs and considerations for designing a core HCBS benefit. It included takeaways from the roundtable, core HCBS benefit design considerations, as well as key issues for Commission discussion.

To close out the March meeting, the Commission discussed recommendations for the June report to Congress on access to vaccines for adults enrolled in Medicaid. The Commission considered draft policy recommendations to improve vaccine coverage and access for adults in Medicaid. These draft recommendations aimed to address the key challenges to vaccine access described in the March report to Congress.

This presentation included five draft policy recommendations to improve vaccine access, and uptake among adults in Medicaid: (1) mandate vaccine coverage in Medicaid; (2) implement vaccine payment regulations; (3) encourage the use of pharmacies and other providers; (4) improve vaccine education and outreach; (5) improve immunization information systems.  The Commission will vote on recommendations at its April meeting.


  1. Directed Payments in Managed Care: Decisions on Recommendations for the June Report to Congress
  2. Improving the Uptake of Electronic Health Records by Behavioral Health Providers: Decisions on Recommendations for the June Report to Congress
  3. Leveraging Medicaid Policies to Promote Health Equity
  4. Requiring States to Develop an Integrated Care Strategy for Dually Eligible Beneficiaries: Review of Draft Chapter and Recommendation for the June Report
  5. Managed Care Rate Setting and Actuarial Soundness: Federal Oversight and Implications for Efficiency, Access, and Value in Medicaid
  6. Risk Mitigation and Rate Setting: Report on Discussion at Expert Roundtable
  7. Considerations in Redesigning the Home-and Community-based Services Benefit
  8. Access to Vaccines for Adults Enrolled in Medicaid: Decisions on Recommendations for the June Report to Congress