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September 2023 Public Meeting

The September 2023 meeting kicked off with a staff presentation on policy options for monitoring and oversight of denials and appeals in Medicaid managed care. Medicaid managed care organizations (MCOs) manage and provide care to beneficiaries enrolled in their plans. MCOs authorize and pay for covered services, as well as deny or limit services to ensure that only appropriate, medically necessary care is provided. 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 discussed key challenges with the current requirements for monitoring and oversight of managed care denials and appeals and explored corresponding policy options to address these challenges.

In MACPAC’s March 2023 Report to Congress, the Commission recommended updating the model single, streamlined application with race and ethnicity questions and developing model training materials to encourage responses. In addition to these recommendations, the Commission identified a need for additional work related to the collection and reporting of additional demographic data. MACPAC will build on this body of work and focus on the collection of limited English proficiency, sexual orientation and gender identity, and disability data. The next presentation provided background on how the Centers for Medicare & Medicaid Services (CMS) and state Medicaid programs use demographic data, how these data are currently collected as part of federal administrative and survey data collection efforts, and the limitations with each of these data sources.

After a break, the Commission heard from an expert panel on the unwinding of the continuous coverage requirement in Medicaid. CMS has issued additional guidance and released the first few months of data as states have been processing renewals and disenrolling individuals. This panel session provided an update on progress and the challenges states and beneficiaries are facing, as well as the oversight efforts on the part of CMS.

Panelists included:

  • Kate McEvoy, Executive Director, National Association of Medicaid Directors
  • Allison Orris, Senior Fellow, Center on Budget and Policy Priorities
  • Daniel Tsai, Deputy Administrator and Director, Center for Medicaid and CHIP Services, CMS

Next, the Commission turned its focus to ex parte renewals in Medicaid, a requirement for states to first attempt to confirm that a beneficiary is eligible for Medicaid using data available to the agency without requiring information from the individual. These renewals have drawn renewed interest as states prepared for the unwinding of the continuous coverage requirement in Medicaid. To understand the barriers to successful ex parte renewals and opportunities to improve them, MACPAC contracted with Mathematica to conduct a roundtable discussion with subject matter experts. During this session, staff shared key findings from the roundtable.

The Commission then reviewed MACPAC’s long-term work plan to examine all types of Medicaid payments to hospitals. The work plan is based on the Commission’s framework for evaluating how Medicaid hospital payments relate to statutory requirements of economy, efficiency, quality, and access. The presentation covered hospital payment and financing with respect to hospital payment methods and goals; characterizing payment hospital targeting; and overall hospital payment rates.

The day ended with a discussion of a CMS notice of proposed rulemaking on nursing facility staffing and payment transparency and establishes minimum staffing standards for long-term care facilities to ensure safe and quality care. The notice also requires states to report the percent of Medicaid payments for certain Medicaid-covered institutional services specific to nursing facilities and intermediate care facilities for individuals with intellectual disabilities that are spent on compensation for direct care workers and support staff. During this session, the Commission reviewed MACPAC’s prior work on nursing facility staffing and payment transparency. The next steps for staff include incorporating feedback from the discussion for possible comment by the Commission.

On Friday, the meeting began with a presentation on how schools provide health services to children and adolescents covered by Medicaid, particularly as communities seek to address an increase in behavioral health challenges among young people. This presentation provided background information on school-based services, described key concepts related to financing and payment, and discussed select factors affecting billing and claiming for school-based services.

Next, the Commission examined the role of medical care advisory committees (MCACs) in supporting beneficiary engagement. Federal rules require each state Medicaid agency to establish an MCAC that consists of beneficiaries or consumer group representatives, but there is little federal guidance on state engagement of beneficiaries through MCACs. MACPAC contracted with RTI International to examine how states use MCACs to engage beneficiaries 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. It included key findings about state approaches to MCAC beneficiary recruitment, meeting structure, and beneficiary engagement, as well as how CMS plans to address certain challenges in an already-released proposed rule.

To close the meeting, the Commission looked at Medicare Savings Programs (MSPs), which provide Medicaid assistance with Medicare premiums and cost sharing to individuals who are dually eligible for Medicaid and Medicare. Recent regulatory changes to streamline MSP eligibility and facilitate enrollment into these programs have led to a renewed awareness of MSPs among policymakers.

This session provided Commissioners with a comprehensive overview of MSPs, including their benefits, eligibility criteria, and structure. Additionally, it presented a detailed description of the individuals who are currently enrolled in these programs, providing a foundation to inform future Commissioner discussions of potential policy options related to facilitating enrollment in the MSPs.


  1. Denials and Appeals in Medicaid Managed Care
  2. Medicaid Demographic Data Collection
  3. Panel Discussion: Unwinding the Continuous Coverage Requirement
  4. Ex Parte Roundtable
  5. Hospital Supplemental Payment Work Plan
  6. Review of Proposed Rule on Nursing Facility Staffing and Payment Transparency
  7. School-Based Behavioral Health Services for Students Enrolled in Medicaid
  8. Engaging Beneficiaries through Medical Care Advisory Committees (MCACs)
  9. Medicare Savings Programs: Eligibility and Enrollment