Congressional advisory panel makes recommendations on community engagement in Medicaid, automation in prior authorization, managed care accountability, appropriate access to residential treatment services, youth with special health care needs, and the Program of All-Inclusive Care for the Elderly
The Medicaid and CHIP Payment and Access Commission (MACPAC) released its June 2026 Report to Congress on Medicaid and CHIP today, with recommendations on community engagement (CE) requirements in Medicaid, automation in prior authorization (PA), Medicaid managed care accountability, appropriate access to residential treatment services for Medicaid-enrolled youth, transitions to adult Medicaid coverage for children and youth with special health care needs (CYSHCN), and the Program of All-Inclusive Care for the Elderly (PACE). The report also includes a chapter on provider enrollment in Medicaid.
“This report offers federal and state policymakers valuable recommendations and insights that are designed to help Medicaid function better for the people it serves while maintaining the integrity and efficiency of the program,” MACPAC Chair Verlon Johnson said.
Chapter 1 contains a recommendation to create a transparent plan for monitoring and evaluating CE requirements in Medicaid. Under the 2025 Budget Reconciliation Act, states will be required to make Medicaid eligibility for certain applicants and existing beneficiaries contingent on their participation in qualifying CE activities. The chapter outlines the need for timely guidance and technical assistance to states; steps to reduce coverage losses; the need for efficiency when procuring, updating, and operating state information technology systems; and the use of timely monitoring and evaluation data to inform policy and operations. MACPAC’s research highlights the need to monitor eligibility and enrollment changes following implementation of the CE requirement.
Chapter 2 focuses on automation in Medicaid PA and makes recommendations to strengthen oversight, and increase disclosure and transparency of managed care plans’ use of automation in PA. MACPAC has looked at how payers and providers are increasingly incorporating technology, including artificial intelligence, to automate parts of the Medicaid PA process. Automated systems that use algorithms or AI to conduct portions of the PA process have the potential to reduce burdens associated with PA and promote appropriate, cost-effective care. However, automated PA processes present potential risks to beneficiaries, states, providers, and health plans, and there is limited transparency into how these tools make decisions. In addition, there is little federal guidance on these tools, and state guidance varies.
Chapter 3 offers recommendations to improve managed care plan accountability. Managed care is the predominant Medicaid delivery system in most states. Although the Centers for Medicare & Medicaid Services and states have made efforts to strengthen oversight of managed care programs, little is known about the accountability tools state Medicaid agencies use to ensure managed care plans comply with contract requirements and meet performance expectations. The recommendations seek to improve the usability of managed care performance data and provide states with additional guidance and tools to more effectively assess and oversee plan performance.
Chapter 4 looks at appropriate access to residential treatment services for youth who are enrolled in Medicaid. Federal law requires that services (e.g., behavioral health) be provided to youth with disabilities. Some youth with intense treatment needs or those who pose a safety risk to themselves or their families and cannot be served in the community require access to residential treatment. For children whose needs cannot be met in the community, it is important that residential treatment options be available when they are needed. However, difficulty finding real-time information on facility and bed availability and specialized care can hinder access to residential services. In addition, there is no single federal data source on the use of residential treatment, including on out-of-state facilities. The Commission makes recommendations aimed at improving appropriate access to residential behavioral health treatment for Medicaid-enrolled children and youth.
Chapter 5 contains recommendations to ease the transition to adult Medicaid coverage for CYSHCN. Medicaid-covered CYSHCN often navigate multiple, sometimes overlapping, transitions as they reach adulthood. In addition to transitioning from child to adult Medicaid eligibility, they may simultaneously undergo the Supplemental Security Income (SSI) age-18 redetermination and transition from child-only to adult 1915(c) home- and community-based waivers. Key challenges with the transition to adult Medicaid coverage include insufficient time to prepare and respond to Medicaid redetermination notices, lack of clarity about changes to SSI and how it affects Medicaid eligibility, and inconsistent support with the Medicaid redetermination and other simultaneous transitions.
Chapter 6 focuses on PACE, which provides integrated care to adults age 55 and older who meet nursing facility level-of-care criteria and can live safely in the community. Findings from MACPAC’s June 2025 report to Congress identified questions related to transparency in state and federal oversight of PACE compliance and quality. MACPAC’s research found overlap and lack of coordination in federal and state audit activities and limited availability of information on PACE program quality and performance. The Commission makes recommendations aimed at improving coordination on audits, making existing PACE performance information publicly available, and developing a standard national quality measure set for PACE organizations.
Chapter 7 looks at Medicaid provider enrollment and managed care credentialing, which is designed to ensure that Medicaid enrollees receive care from qualified providers. In addition, these processes are intended to prevent the enrollment of providers who have criminal records related to federal health programs or who have engaged in fraud, waste, or abuse. The chapter provides an overview of federal requirements for provider enrollment and credentialing in Medicaid, the approaches taken by three states, and challenges for states and providers. It includes insights into barriers faced by certain provider types or challenges related to specific parts of the enrollment and credentialing processes as well as the effects on provider participation, state administrative burden, and program integrity.
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ABOUT MACPAC
The Medicaid and CHIP Payment and Access Commission is a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP). For more information, please visit: www.macpac.gov.