News

MACPAC April 2024 Meeting Highlights

• Medicaid Demographic Data Collection
  • MACPAC staff discussed the need to update and improve upon Medicaid demographic data collection by including data such as primary language and limited English proficiency (LEP), sexual orientation and gender identity (SOGI), and disability. This type of data can aid in providing meaningful information about certain marginalized groups. Staff also spoke on considerations for data quality, such as self-reported data, the ability to update information over time, standardization of questions, ensuring that collection methods are representative of the Medicaid population and that there are both federal and state policies in place to ensure data privacy.
• Improving the Transparency of Medicaid and CHIP Financing
  • This session followed up on the Commission’s December 2023 Public Meeting discussion. Staff presented ways to enhance transparency regarding the financing of the non-federal share of Medicaid and CHIP. During the session, staff shared a preliminary chapter and proposed two recommendations aimed at gathering and disclosing data on financing method sources and state and provider-level financing amounts. The proposed recommendations for Congress require states to submit an annual, comprehensive report on Medicaid financing methods and amounts as well as that Congress amend the Social Security Act to align CHIP financing transparency requirements with Medicaid.
  • Click here for an exclusive summarized breakdown provided by our Sellers Dorsey experts.
• Optimizing State Medicaid Agency Contracts
  • The Commission developed a draft chapter focusing on state Medicaid agency contracts (SMACs) for Medicare Advantage dual eligible special needs plans (D-SNPs). The draft chapter is based on a year-long review which included stakeholder interviews and analysis of contract provisions and administration. Findings highlighted in the chapter include challenges faced by states in overseeing their SMACs, which mirrors broader issues that previous Commission recommendations on integrated care for duals sought to address. The chapter offers two recommendations intended to provide an introduction for optimizing and overseeing SMACs and explaining the potential benefits of integrated care for beneficiaries. The Commission proposes that states use their contracting authority to require that MA D-SNPs regularly submit care coordination and MA encounter data for monitoring, oversight, and quality assurance purposes. The Commission also proposes CMS update guidance that supports states in their development of a strategy to integrate care tailored to each unique health coverage landscape and advance state policy goals.
• Timely Access to Home- and Community-Based Services: Environmental Scan Results
  • During this session MACPAC staff discussed key findings from a scan of existing policies affecting timely access to home- and community-based services (HCBS). Additionally, staff informed the public on their next steps, including holding stakeholder interviews and holding meetings later this year surrounding eligibility, level of care (LOC) determinations, and person-centered planning.
  • Some preliminary findings are as follows:
    • 9 states use presumptive eligibility for non-MAGI populations.
    • 6 states currently use, or plan to use, expedited eligibility for non-MAGI populations.
    • 32 states have time limits on how long assessors have to complete functional assessments, ranging from 2-45 days.
    • 17 states have time limits on LOC approvals, ranging from 5-30 days.
    • 47 states and DC reported their LOC methods, 47 states and DC offer in-person, 19 have over the phone or virtual options, and 32 allow for recorded reviews.
    • Most states require an individual to have a person-centered service plan (PCSP) before they receive HCBS, within 30-45 days of enrollment.
    • 17 states, across 41 waiver programs, allow provisional plans for Section 1915(c) waiver services to expedite the process.
    • 33 states allow e-signatures for person-centered specialty plans (PCSPs).
• Update on Hospital Supplemental Payment Analyses
  • This session follows up on the September 2023 meeting regarding the long-term plan for examining payments to hospitals. MACPAC staff discussed their review of the Consolidated Appropriations Act of 2021, specifically within the bounds of the usage of supplemental policy principles and analysis of non-DSH supplemental payment data. Staff also discussed next steps, including meeting with a panel of experts to discuss the possibility of creating a payment index to evaluate both total base and supplemental payments, in relation to external benchmarks (MACPAC, April 11; MACPAC, April 12).
  • Click here for an exclusive summarized breakdown provided by our Sellers Dorsey experts.

Alzheimer’s Disease Drug Expected to Surpass Initial Medicare Spending Estimates

• CMS anticipates a significant increase in spending on the Alzheimer’s disease drug, Leqembi, compared to the drugmaker’s initial estimates for the upcoming year. According to a CMS document obtained by Stat, spending per member per month on Leqembi is projected to rise from $1.67 in 2024 to $4.67 in 2025. This translates to approximately $550M in spending for traditional Medicare in 2024 and an estimated $3.5B across all Medicare programs in 2025. This anticipated substantial surge in spending on the drug is prompting a discussion on Medicare’s willingness to pay for similar products. Leqembi was fully approved by the FDA in July 2023, exempting the drug from CMS’ restrictive coverage determination on this class of drugs (Fierce Healthcare, April 11).

Federal Legislation

Senate Finance Committee Holds Hearing about Medicare Physician Payment Reforms

• On April 11, the Senate Finance Committee convened to discuss Medicare physician payment reforms and ideas on how they can best boost care for older adults with chronic illnesses. Committee members shared their thoughts and ideas for legislative reforms to tackle this issue (Inside Health Policy, April 11).

Federal Studies and Reports

Mental Health Care Provider Shortages Among Medicare and Medicaid in OIG Report

• HHS’ Office of the Inspector General (OIG) released a report at the end of March that detailed shortages of mental health care providers in Medicare and Medicaid. Though these programs serve more than 40% of the country’s population, the report found that there were fewer than five active mental health providers for every 1,000 enrollees in 2021. The report analyzed 20 counties in 10 states, choosing one urban and one rural county from each state. On average, the rural counties had less than half the number of active providers compared to urban counties across all government programs. Despite these low numbers, Medicare and Medicaid enrollees are likely to be living with a mental health need, 1 in 4 for Medicare and 1 in 3 for Medicaid. Additionally, 1 in 5 Medicaid enrollees have a substance use disorder. The OIG recommends that CMS take the following steps to increase access to behavioral health services: increase payments to providers, expand the provider types that can serve enrollees, strengthen network adequacy standards in managed care, and lower administrative requirements (NPR, April 3 and OIG, March 29).