MACPAC Recommendations

Updated as of March 2018

Recommendation

Date of recommendation

Status

Streamlining Medicaid Managed Care Authority
Congress should amend Section 1932(a)(2) to allow states to require all beneficiaries to enroll in Medicaid managed care programs under state plan authority.

March 2018

No action to date.
Congress should extend approval and renewal periods for all Section 1915(b) waivers from two to five years.

March 2018

No action to date.
Congress should revise Section 1915(c) waiver authority to permit Section 1915(c) waivers to waive freedom of choice and selective contracting.

March 2018

No action to date.
The Future of CHIP and Children’s Coverage
Congress should extend federal CHIP funding for a transition period that would maintain stable source of children’s coverage and provide time to develop and test approaches for a more coordinated and seamless system of comprehensive, affordable coverage for children.

January 2017

Enacted:

  • P.L. 115-120 renewed federal CHIP funding for FYs 2018–2023.
  • P.L. 115-123 renewed federal CHIP funding for FYs 2024–2027.
Congress should extend federal CHIP funding for five years, through fiscal year 2022, to give federal and state policymakers time to develop policies and to implement and test coverage approaches that promote seamlessness of coverage, affordability, and adequacy of covered benefits for low- and moderate-income children.

January 2017

  • P.L. 115-120 renewed federal CHIP funding for FYs 2018–2023.
  • P.L. 115-123 renewed federal CHIP funding for FYs 2024–2027.
In order to provide a stable source of children’s coverage while approaches and policies for a system of seamless children’s coverage are being developed and tested, and to align key dates in CHIP with the period of the program’s funding, Congress should extend the current CHIP maintenance of effort and the 23 percentage point increase in the federal CHIP matching rate, currently in effect through FY 2019, for three additional years, through fiscal year 2022.

January 2017

  • P.L. 115-120 extended the Medicaid and CHIP maintenance of effort requirements for children with family incomes below 300 percent FPL from FYs 2019–2023. It also provided an 11.5 percentage point increase to the enhanced CHIP matching rate in FY 2020.
  • P.L. 115-123 extended the Medicaid and CHIP maintenance of effort requirements for children with family incomes below 300 percent FPL from FYs 2014–2027.
To reduce complexity and to promote continuity of coverage for children, Congress should eliminate waiting periods for CHIP.

January 2017 (originally recommended in  March 2014)

No action to date.
In order to align premium policies in separate CHIP programs with premium policies in Medicaid, Congress should provide that children with family incomes below 150 percent FPL not be subject to CHIP premiums.

January 2017 (originally recommended in March 2014)

No action to date.
Congress should create and fund a children’s coverage demonstration grant program, including planning and implementation grants, to support state efforts to develop, test, and implement approaches to providing for CHIP-eligible children seamless health coverage that is as comprehensive and affordable as CHIP.

January 2017

No action to date.
Congress should permanently extend the authority for states to use Express Lane Eligibility for children in Medicaid and CHIP.

January 2017

(The Commission supported this policy in an April 2014 letter to the Secretary of HHS.)

  • P.L. 115-120 extended the Express Lane Eligibility option from FYs 2017–2023.
  • P.L. 115-123 extended the Express Lane Eligibility option from FYs 2024–2027.
The Secretary of the U.S. Department of Health and Human Services, in consultation with the Secretaries of the U.S. Department of Agriculture and the U.S. Department of Education should, not later than September 30, 2018, submit a report to Congress on the legislative and regulatory modifications needed to permit states to use Medicaid and CHIP eligibility determination information to determine eligibility for other designated programs serving children and families.

January 2017

No action to date.
Congress should extend funding for five years for grants to support outreach and enrollment of Medicaid and CHIP-eligible children, the Childhood Obesity Research Demonstration projects, and the Pediatric Quality Measures program, through fiscal year 2022.

January 2017

  • P.L. 115-120 extended funding for Medicaid and CHIP outreach and enrollment grants, Childhood Obesity Research Demonstrations, and the Pediatric Quality Measures Program through FY 2023.
Improving Data as the First Step to a More Targeted Disproportionate Share Hospital Policy
The Commission recommends that the Secretary of the U.S. Department of Health and Human Services collect and report hospital-specific data on all types of Medicaid payments for all hospitals that receive them.  In addition, the Secretary should collect and report data on the sources of non-federal share necessary to determine net Medicaid payment at the provider level.

March 2016

No action to date.
CHIP and the New Coverage Landscape
The Congress should extend federal CHIP funding for a transition period of two additional years during which time the key issues regarding the affordability and adequacy of children’s coverage can be addressed.

June 2014

  • Enacted in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10).
Examining the Policy Implications of Medicaid Non-Disproportionate Share Hospital Supplemental Payments
As a first step toward improving transparency and facilitating understanding of Medicaid payments, the Secretary should collect and make publicly available non-DSH (UPL) supplemental payment data at the provider level in a standard format that enables analysis.

March 2014

No action to date.
Issues in Pregnancy Coverage under Medicaid and Exchange Plans
To align coverage for pregnant women, Congress should require that states provide the same benefits to pregnant women who are eligible for Medicaid on the basis of their pregnancy that are furnished to women whose Medicaid eligibility is based on their status as parents of dependent children.

March 2014

  • A November 7, 2014 CMS letter to state health officials addressing pregnancy-related coverage in Medicaid did not affect states’ ability to limit the benefit package to pregnancy-related services.

The Secretaries of Health and Human Services and Treasury should specify that pregnancy-related Medicaid coverage does not constitute minimum essential coverage in cases involving women enrolled in qualified health plans.

(The Commission’s intent was to allow women already enrolled in exchange plans to retain that coverage when they become pregnant even if they became eligible for Medicaid thus reducing churning.)

March 2014

  • The November 2014 CMS letter to state health officials and concurrent guidance from the IRS allow a pregnant woman enrolled in an exchange plan to remain in that coverage, even if she is eligible for Medicaid, as long as she does not also enroll in Medicaid. However, the IRS guidance does not allow her to secure both sources of coverage if Medicaid is considered minimum essential coverage. (See MACPAC’s June 2016 Issue Brief)
Children’s Coverage under CHIP and Exchange Plans
In order to align premium policies in separate CHIP programs with premium policies in Medicaid, the Congress should provide that children with family incomes below 150 percent FPL not be subject to CHIP premiums. March 2014 No action to date.
To reduce complexity and to promote continuity of coverage for children, the Congress should eliminate waiting periods for CHIP. March 2014 No action to date.
Eligibility Issues in Medicaid and CHIP: Interactions with the ACA
In order to ensure that current eligibility options remain available to states in 2014, the Congress should, parallel to the existing Medicaid 12-month continuous eligibility option for children, create a similar statutory option for children enrolled in CHIP and adults enrolled in Medicaid. March 2013 No action to date.
The Congress should permanently fund current Transitional Medical Assistance (TMA)—required for six months, with state option for 12 months—while allowing states to opt out of TMA if they expand to the new adult group added under the Patient Protection and Affordable Care Act. March 2013
  • Enacted in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10). The law did not address whether to allow Medicaid expansion states to opt out of providing TMA.
Medicaid and Persons with Disabilities
The Secretary and the states should accelerate the development of program innovations that support high-quality, cost-effective care for persons with disabilities, particularly those with Medicaid-only coverage. Priority should be given to innovations that promote coordination of physical, behavioral, and community support services and the development of payment approaches that foster cost-effective service delivery. Best practices regarding these programs should be actively disseminated. March 2012 Examples of program innovations for persons with disabilities currently underway include:

  • Health homes. States are implementing health homes (created by the Patient Protection and Affordable Care Act [ACA, P.L. 111-148, as amended]) to integrate physical health, behavioral health, or long-term care services.
  • Innovation Accelerator Program. CMS provides states technical assistance on physical and behavioral health integration efforts.
  • Money Follows the Person Rebalancing Demonstration Grants. Help states rebalance their Medicaid long-term care systems by increasing use of home-  and community-based services (HCBS) and reducing use of institutionally-based services.
The Secretary, in partnership with the states, should update and improve quality assessment for Medicaid enrollees with disabilities. Quality measures should be specific, robust, and relevant for this population. Priority should be given to quality measures that assess the impact of current programs and new service delivery innovations on Medicaid enrollees with disabilities. March 2012 CMS has taken some steps to improve quality assessment for people with disabilities. For example:

  • Experience and functional tools.  CMS tested quality tools for community-based long-term services and supports. CMS developed a survey for consumer assessments of providers and systems providing home and community-based services. In 2016, the National Quality Forum endorsed 19 measures from the survey.
  • Financial alignment initiative. Requires states to collect data on core and state-defined quality measures, including some related to people with disabilities.
  • Star rating system. CMS is developing a star rating system for plans participating in the financial alignment initiative. This system will measure quality under both programs and will be a tool for beneficiaries to use to compare plans, similar to other CMS star ratings systems. CMS intends to include quality measures pertinent to individuals with disabilities.
Program Integrity in Medicaid
The Secretary should ensure that current program integrity efforts make efficient use of federal resources and do not place an undue burden on states or providers. In collaboration with the states, the Secretary should:

  • create feedback loops to simplify and streamline regulatory requirements;
  • determine which current federal program integrity activities are most effective; and
  • take steps to eliminate programs that are redundant, outdated, or not cost-effective.

To enhance the states’ abilities to detect and deter fraud and abuse, the Secretary should:

  • develop methods for better quantifying the effectiveness of program integrity activities;
  • assess analytic tools for detecting and deterring fraud and abuse and promote the use of those tools that are most effective;
  • improve dissemination of best practices in program integrity; and
  • enhance program integrity training programs to provide additional distance learning opportunities and additional courses that address program integrity in managed care.
March 2012 CMS has taken a number of steps to address many of the elements of these two recommendations including:

  • temporarily replacing the eligibility components of the Payment Error Rate Measurement and Medicaid Eligibility Quality Control programs with a pilot program;
  • developing a revised eligibility review approach to reduce the burden for states;
  •  shifting the focus of the National Medicaid Audit Program from independent audits collaborative state audits;
  • suspended collection of a redundant  program integrity dataset;
  • using already available data to support federal audits;
  • launching a workgroup to identify best practices and provide input to strengthen program oversight;
  • providing a secure online platform for states to exchange best practices and documents on program integrity;
  • publishing guidelines to promote best practices; and
  • creating a new program integrity curriculum, professional program of study, and distance learning webinars