NEWS

MACPAC holds January 2024 Public Meeting

• The Medicaid and CHIP Payment and Access Commission (MACPAC) met on January 24-25 to discuss the following topics:
  • Denials and appeals in Medicaid managed care – MACPAC staff presented the draft chapter for the March 2024 report to Congress with seven recommendations intended to improve the beneficiary experience with the appeals process generally along with the monitoring, oversight, and transparency of denials and appeals. The Commission voted in favor of all seven recommendations.
  • Self-reported disability data collection in Medicaid populations – MACPAC staff discussed findings related to self-reported disability data collection. The Commission reviewed federal priorities for collecting data, how Medicaid disability data are currently collected, and essential considerations for disability data collection.
  • Policy options for improving the transparency of Medicaid financing –- The Commission reviewed policy options for improving transparency of financing methods and amounts. Since Medicaid is jointly financed by states and the federal government, MACPAC considered the policy options using a framework that explored the usefulness, comprehensiveness, and administrative burden for states, providers, and CMS in collecting new data.
  • Interviews with key stakeholders about state Medicaid agency contracts – MACPAC staff reviewed important themes from interviews with state Medicaid officials in five case study states, federal officials at CMS, and health plan representatives for Medicare Advantage dual eligible special needs plans (D-SNPs).
  • Evaluating effectiveness of Medicaid payment changes on access to physician services – MACPAC staff discussed the relationship between Medicaid physician payment rates and beneficiary access. MACPAC partnered with Mathematica to conduct a review of the literature between 2013 and 2023. Mathematica also convened an expert roundtable and MACPAC staff shared themes from the roundtable and focused on certain areas that MACPAC may examine in the future.
  • Medicaid coverage of physician-administered drugs (PADs) – MACPAC staff discussed challenges related to managing PADs through the medical benefit and summarized findings from their analysis on Medicaid utilization and spending on PADs using data from the Transformed Medicaid Statistical Information System.
  • Highlights from the duals data book – MACPAC staff reviewed the Beneficiaries Dually Eligible for Medicare and Medicaid data book, which includes information on individuals who were dually eligible for Medicare and Medicaid in 2021. This edition includes information about the dually eligible community’s demographics and characteristics, eligibility pathways and enrollment, service utilization and spending, and use of long-term services and supports.
  • Enrollment trends in Medicare savings programs (MSPs) – MACPAC staff provided enrollment information from 2010 through 2021 and focused mainly on the Qualified Medicare Beneficiary (QMB) and Specified Low-Income Beneficiary (SLIB) programs since they account for more than 90% of MSP enrollees. (MACPAC, January 24-25).

Cell and Gene Therapy Model will Focus on Sickle Cell Disease

• The Biden Administration has announced that sickle cell disease (SCD) will be the top priority of the Cell and Gene Therapy (CGT) Access Model which aims to improve health outcomes, increase access to CGT care, and lower healthcare costs for vulnerable populations. This model will begin in January 2025 and may expand to include other types of CGTs. CMS plans to negotiate outcomes-based agreements (OBAs) with manufacturers to tie pricing with positive health outcomes for people with SCD under Medicaid. Around 50-60% of people with SCD are Medicaid beneficiaries. Participating states will have the opportunity to enter into an agreement with manufacturers based on the previously negotiated terms from CMS to offer the agreed-upon standard access policy in exchange for rebates. States can choose to participate in the model between January 2025 and January 2026. Additionally, CMS plans to offer extra funding to states that increase equitable access to CGTs and promote comprehensive care for Medicaid beneficiaries with SCD receiving gene therapy (CMCS, January 30).

$50 Million to Provide Essential School-Based Health Services to Children

• On January 24, CMS announced $50 million in grant funding for states to connect millions more children to mental and physical health services while at school. The funding will provide 20 states with up to $2.5 million each to help implement, enhance, and expand the use of school-based health services through Medicaid and the Children’s Health Insurance Program (CHIP). HHS Secretary, Xavier Becerra, and Department of Education Secretary, Miguel Cardona, issued a letter to governors, highlighting that the funding will make it easier to support schools in providing critical physical and mental health services. Sixteen states currently cover school-based health services provided to children covered by Medicaid or CHIP outside of special education needs demonstrated in an Individualized Education Program (IEP) or an Individual Family Service Plan (IFSP). These states are Arizona, California, Colorado, Connecticut, Georgia, Illinois, Indiana, Kentucky, Louisiana, Massachusetts, Michigan, Nevada, New Mexico, North Carolina, Oregon, and Virginia. A minimum of 10 awards will be provided to states that do not yet cover school-based health services (Medicaid.gov, January 24).

Enrollment in ACA Hits Record High

• Enrollment in Affordable Care Act (ACA) plans has officially reached beyond 21 million this year, crossing the 20 million line for the first time since the ACA began in 2014. When signups closed on January 16, 21.3 million people (about the population of New York) had enrolled in marketplace plans. Four states and the District of Columbia allow enrollment to remain open through January 31. Florida outpaced other states with over 4.2 million residents signed up for ACA coverage, followed by Texas with almost 3.5 million and California with 1.7 million (Health Payer Specialist, January 26).

Health Resources and Services Administration Announces New Enhancing Maternal Health Initiative

• On January 25, the Health Resources and Services Administration (HRSA) announced a year-long Enhancing Maternal Health Initiative aimed at facilitating partnerships for maternal health. The announcement came at a White House event held on Maternal Health Awareness Day, which highlighted HHS initiatives that improve maternal and infant health outcomes. The Biden administration has been emphasizing its work on maternal and reproductive health ahead of the 2024 presidential election. The initiative will bring together HRSA grantees from high-need states to collaborate on projects directed at making maternal health progress. These states include Alabama, Arizona, Georgia, Illinois, Kentucky, Maryland, Michigan, Missouri, Montana, North Carolina, Oregon, and the District of Columbia (Inside Health Policy, January 26).

Nursing Home Residents Continue to be a Population Vulnerable to COVID-19

• As COVID-19 cases dwindle, nursing home residents continue to be a population vulnerable to the virus, with fewer than 4 in 10 of these individuals receiving the latest vaccine. Over the course of the pandemic, over 170,000 nursing home residents passed away. Katie Smith Sloan, the president of LeadingAge, wrote a letter to the HHS Secretary, Xavier Becerra, highlighting the low vaccination rate issue and requesting additional federal assistance. Becerra stated that facilities need to continue to offer residents the shots, but stopped short of promising additional aid (Politico Pro, January 26).

HHS Aims to Maintain Low-Cost Access to COVID Oral Antivirals

• HHS has reminded provider groups that patients should not pay the full out-of-pocket cost for oral antivirals that treat COVID-19, such as Paxlovid, during the transition of the antivirals to the commercial market. HHS, Pfizer, and other groups such as the American Nurses Association and the American Academy of Family Physicians discussed the transition during a virtual meeting held on January 22. Pfizer signed an agreement with HHS to allow free Paxlovid access for Medicare and Medicaid patients until the end of 2024 and until the end of 2028 for uninsured patients. On January 4, CMS released guidance for Medicare Part D programs to cover these medicines and anticipates that plans may allow enrollees to access Paxlovid for free through the Pfizer-HHS agreement (Inside Health Policy, January 23).