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March 2023 Public Meeting

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The March 2023 MACPAC meeting began with a staff presentation on potential recommendations for countercyclical disproportionate share hospital (DSH) allotments. Medicaid DSH payments offset hospital uncompensated care costs for Medicaid-enrolled and uninsured patients. During economic recessions, Medicaid enrollment and the number of people who are uninsured increases.

During the October 2022 MACPAC meeting, Commissioners agreed that a countercyclical policy should be implemented during future economic recessions, and asked for additional analyses of the effects of making this policy permanent. This presentation looked at the state and federal effects of implementing this policy only during economic recessions versus also implementing this policy during periods of normal economic growth. The Commission will vote on recommendations to Congress during the April 2023 meeting.

Next, the Commission examined key implementation considerations for states looking to offer pre-release Medicaid services to justice-involved adults. The presentation included an overview of California’s recently approved Section 1115 demonstration to provide a set of pre-release services to certain individuals leaving incarceration. Staff also highlighted key takeaways regarding implementation considerations based on MACPAC’s analytic work to date.

The Commission then heard an update on unwinding the continuous coverage requirements in Medicaid. At the beginning of the COVID-19 pandemic, Congress enacted legislation that provided states with enhanced federal funding if they maintained coverage for most individuals receiving Medicaid. The Consolidated Appropriations Act (CAA) of 2023 ended the continuous coverage provision and established requirements for states to receive an enhanced match during the remainder of 2023. This session provided a review of the CAA provisions as well as the subsequent CMS guidance that described additional policy and operational instructions to states. MACPAC conducted interviews with a number of national organizations representing state and beneficiary interests to identify potential implementation issues.

After a break, staff presented findings from focus groups about the experience of beneficiaries who are eligible for Medicare and Medicaid and who receive coverage through integrated care arrangements. Integrating care for beneficiaries who are dually enrolled in Medicaid and Medicare is an ongoing area of interest for the Commission. Combined, Medicaid and Medicare cover a broad range of health care services, but the division of coverage between the two programs can result in fragmented care. Focus group participants were largely satisfied with their integrated coverage. However, a number of participants noted challenges when it came to accessing services such as behavioral health, home-and community-based services, and transportation.

Next, the Commission heard from a panel of three states that use alternative approaches to contracting with full-risk managed care organizations (MCOs). State Medicaid programs can design delivery systems to provide services to beneficiaries that best fit their needs. Some states select fee-for-service delivery systems, where the state agency pays providers directly for each covered service a beneficiary receives. Other states choose managed care approaches like full-risk capitation using an MCO.

Panelists included:

  • William Halsey, LCSW, MBA, Deputy Director of Medicaid and Division of Health Services, Connecticut Department of Social Services
  • Juliet Charron, MPH, Medicaid Division Administrator, Idaho Department of Health and Welfare
  • Ashley Berliner, MPA, Director of Healthcare Policy and Planning, Vermont Agency of Human Services

The panelists provided an overview of their state’s delivery system approach, as well as their perspective on how this approach has affected quality and outcomes for beneficiaries.

The Commission then continued its work examining how states and the federal government are using available oversight tools such as external quality review (EQR) in Medicaid managed care. EQR is one of the few statutory tools that the federal government and states have to engage in oversight of Medicaid managed care, and is also one part of an interrelated set of compliance and quality requirements that apply to Medicaid and State Children’s Health Insurance Program managed care. Staff presented findings from interviews with states on how states structure their approaches to EQR, how states use EQR findings to hold plans accountable and improve care for beneficiaries, and how the Centers for Medicare & Medicaid Services (CMS) engages in oversight of the EQR process.

To conclude the meeting, staff provided an overview of a recent proposed rule on disclosures of nursing facility ownership that would require nursing facilities to report whether private equity firms or real estate investment trusts have an ownership stake in the facility. This change is generally consistent with the Commission’s recommendation that CMS collect and report more data on nursing facility ownership in a standard format that enables analysis. The Commission discussed potential areas for comment.


  1. Additional Analyses of Potential Recommendations for Countercyclical Disproportionate Share Hospital Allotments
  2. Considerations for Providing Pre-Release Medicaid Services to Adults Leaving Incarceration
  3. Update on Unwinding the Continuous Coverage Requirements and Other Flexibilities
  4. Focus Group Findings: Experiences of Full-Benefit Dually Eligible Beneficiaries in Integrated Care Models
  5. Panel on State Flexibilities to Coordinate Care in the Absence of Full-Risk Capitation
  6. Managed Care External Quality Review: Study Findings
  7. CMS Proposed Rule on Disclosures of Nursing Facility Ownership