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November 2023 Public Meeting

To kick off MACPAC’s November meeting, the Commission continued its work on denials and appeals in Medicaid managed care with a review of findings from beneficiary focus groups. Medicaid managed care organizations (MCOs) manage and provide care to beneficiaries enrolled in their plans. 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 described key challenges with the current requirements for the appeals process and explored policy options to address these challenges.

The Commission then considered Medicaid demographic data on primary language and limited English proficiency (LEP) information, how these data can be used to ensure language access and measure health disparities, and modes for collecting language information from Medicaid-covered individuals.  MACPAC is examining the collection of primary language and LEP, sexual orientation and gender identity, and disability data for the purposes of assessing and addressing health disparities. The presentation concluded with considerations for Medicaid language data collection and next steps.

After a break, the Commission continued its discussion on how the unwinding of the continuous coverage requirement in Medicaid is proceeding. MACPAC convened a panel discussion focused on the approaches and adjustments states have made over the course of the unwinding.

Panelists included:

Amir Bassiri, Deputy Commissioner of the Office of Health Insurance Programs and New York State Medicaid Director;

Stephanie Myers, State Affairs Director, Medicaid Health Plans of America; and

Cora Steinmetz, Medicaid Director, Indiana Family and Social Services Administration.

Panelists discussed how states are using data to inform their efforts and outreach strategies, including engaging managed care plans in such efforts.

Next, MACPAC staff examined the role of medical care advisory committees (MCACs) in supporting state Medicaid agency efforts to incorporate the beneficiary voice into their programs. Federal rules require each state Medicaid agency to establish an MCAC that includes beneficiaries or consumer group representatives. MACPAC contracted with RTI International to examine how states use MCACs to engage beneficiaries, particularly those from historically marginalized communities, to inform programs, policies, and operations.

This presentation provided an overview of the federal statute and regulations related to MCACs and recent proposed federal actions to implement changes to these regulations. Staff shared findings and challenges with beneficiary engagement on MCACs, including policy options on how state Medicaid agencies can improve the beneficiary experience on MCACs and actions the federal government can take to help states.

To end the day, MACPAC staff shared key findings from interviews on school-based behavioral health services for students. Schools are an important setting for providing health services to children and adolescents covered by Medicaid, particularly as communities seek to address an increase in behavioral health challenges among young people. As part of the Commission’s efforts to understand how children and adolescents access behavioral health care, MACPAC conducted stakeholder interviews to examine how states and schools are providing behavioral health services to students with Medicaid and considerations for doing so.

While MACPAC set out to understand the experience of schools and states in providing school-based behavioral health services, many of the findings are relevant to school-based services generally. This session also highlighted select policy issues that the Commission may examine in future work.

On Friday, the meeting began with a discussion around opportunities to streamline administrative complexity around home- and community-based (HCBS) services. The session focused on comparing federal requirements across the various Section 1915 authorities that states use to operate HCBS programs. Staff also presented results from 17 interviews with policy experts, states, and federal officials on state experiences adhering to five administrative requirements. Staff shared interviewees’ feedback on requirements, as well as opportunities to streamline or otherwise address challenges associated with complying with the requirements.

Next, staff presented on Medicaid payment policies for HCBS, which are used to support HCBS workers, including direct care workers, direct support professionals, and independent providers. Staff presented initial findings from a review of state payment policies and interviews with national experts. The presentation identifies five policy issues for further examination in future work:

  1. The data used to develop fee-for-service (FFS) rate setting;
  2. Budget constraints that affect a state’s ability to finance HCBS rates at levels recommended during the rate-setting process;
  3. The use of self-directed services and managed care to pay rates that may differ from FFS;
  4. Policies to regulate the share of HCBS payments agencies spend on HCBS worker wages; and
  5. Non-financial policies to increase HCBS worker recruitment and retention.

To conclude MACPAC’s November meeting, staff presented on the use of state Medicaid agency contracts (SMACs) to better integrate care and improve quality for people who are dually eligible for Medicaid and Medicare. This session provided background on Medicare Advantage dual eligible special needs plans (D-SNPs) and the contracts they must hold to operate within a state, as well as contracting strategies that states may use in their SMACs to further integrate care above federal requirements. Staff presented results from a contract review of SMACs that identified how states are leveraging their contracts to require greater integration in coverage alignment, care coordination, member materials and experience, data sharing, as well as requiring D-SNPs to work toward reducing health disparities and improving quality.


  1. Improving the Managed Care Appeals Process
  2. Medicaid Primary Language and Limited English Proficiency Data Collection
  3. Unwinding the Continuous Coverage Requirement in Medicaid: State and Managed Care Plan Strategies
  4. Medical Care Advisory Committees and Beneficiary Engagement
  5. School-Based Behavioral Health Services: Findings from Stakeholder Interviews
  6. Medicaid Home- and Community-Based Services: Comparing Requirements for States
  7. Medicaid Payment Policies to Support the Home- and Community-Based Services Workforce
  8. Optimizing Contracts with Medicare Advantage Dual Eligible Special Needs Plans: State Medicaid Agency Contracts