ACIP Panel Vote Causes Continued Confusion on Vaccines

On September 19, the Advisory Committee on Immunization Practices (ACIP) voted to recommend COVID-19 vaccination based on “individual decision making” for those six months and older. Individual decision making is not solely up to the person receiving the vaccine, but will be a shared clinical decision among physicians, nurses, and pharmacists to ensure proper coverage of vaccines via the marketplace or state and federal health insurance programs. Implications of this shift to individual-based decision making remain unclear (Inside Health Policy, September 19; HHS, September 19).

Continuing Resolutions Stall in Congress Ahead of October 1 Deadline

The Senate adjourned for a week-long recess on Friday, September 19 without passing a continuing resolution (CR). Lawmakers were unable to approve a House-passed Republican CR, nor an alternative provided by Democrats. Generally, Republicans are seeking to pass a “clean” CR for seven weeks, setting up negotiations for policy at the end of the year, while Democrats are demanding that the CR contains important policy action now, including an extension of the health insurance subsidies that are set to expire at the end of the year. Without any concessions, it appears that the federal government may be on the verge of a shutdown starting October 1. However, some Republican lawmakers have indicated that the enhanced premium subsidies are important to them as well. Eleven House Republicans signed a different CR that would have extended the enhanced subsidies for one year and Senator Murkowski voted against the Republican CR that landed in the Senate, one of only two members of her party to do so. Democratic lawmakers also sought to reverse Medicaid cuts that were enacted through H.R.1 this summer, but were unsuccessful (Politico, September 22; Inside Health Policy, September 19).

MACPAC September 2025 Meeting

On September 18 and 19, the Medicaid and CHIP Payment and Access Commission (MACPAC) convened for its September meeting to discuss the following topics:

• Summary of P.L. 119-21, An Act to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14
  • On September 18, MACPAC reviewed Public Law 119-21, the 2025 Budget Reconciliation Act, which was signed into law on July 4, 2025. The law contains several provisions that affect Medicaid and the State Children’s Health Insurance Program (CHIP), and the session provided an overview of these Medicaid- and CHIP-related changes.
• Background on Work and Community Engagement Requirements in Medicaid
  • On September 18, 2025, MACPAC presented background on the new work and community engagement requirements introduced in Public Law 119-21, the 2025 Budget Reconciliation Act. For the first time, federal law will require states to condition Medicaid eligibility for certain applicants and beneficiaries on participation in qualifying activities, such as work or community service. The session provided an overview of this new provision and reviewed the history of similar requirements that some states tested under Section 1115 demonstration waivers, highlighting the lessons learned from those earlier state experiences.
• Panel on Work and Community Engagement Requirements in Medicaid
  • Following a session providing background information on Medicaid work requirements, MACPAC held a panel where experts discussed considerations for implementing the new community engagement requirements. An expert on the panel urged states to begin preparing for the requirements immediately due to the scale of the task, despite limited federal guidance. Panelists noted that there are significant barriers to implementation, like overhauling data systems, further defining exemptions like “medically frail,” and collaborating with other stakeholders, both in the community and in other state agencies (Healthcare Dive, September 22).
• Medicaid Payment Policies to Support the Home- and Community-Based Services Workforce
  • In this session, MACPAC staff presented a draft recommendation for the final March 2026 Report to Congress on ways to promote and expand the home- and community-based services (HCBS) workforce. The draft language recommends that the Secretary of DHHS should direct CMS to require states to submit a biannual report on hourly wages paid to HCBS workers who provide personal care, home health aide, homemaker, and habilitation services. Based on previous work on this topic and stakeholder interviews, wage data was found to be a key tool to create appropriate payment rates that in turn promote a sufficient workforce.

• Background on Behavioral Health in Medicaid and CHIP
  • In this session, MACPAC staff explored Medicaid’s coverage of behavioral health services. Currently, nearly one-third of adults with mental health disorders and one-fifth of adults with a substance use disorder are covered under Medicaid. While the federal government has oversight into making certain services mandatory or optional, there is no standardized definition of behavioral health services, leaving coverage of certain services up to state discretion. Coverage of these services varies on age, exclusions, and avenues. States can utilize state plan authorities, Section 1115 demonstrations, CCBHC demonstrations, Section 1915(b), or 1915(c) waivers for the administration of behavioral health services. Currently, 42 states and DC offer these services via Medicaid managed care, while the remaining 8 do so through fee for service arrangements. MACPAC commissioners briefly looked back on their prior 2015 prior analysis before previewing their forthcoming analysis using 2023 Transformed Medicaid Statistical Information System (T-MSIS) data and will report on their findings in future meetings and publication.
• Children and Youth with Special Health Care Needs Coverage Transitions: Federal and State Policy Scan Findings
  • In this session, MACPAC staff presented on the second phase of their project that focuses on children and youth with special healthcare needs (CYSHCN) transitioning to adult Medicaid coverage. In the current landscape, nearly half of CYSHCN individuals are covered by Medicaid or a mix of insurances. Possible challenges include SSI eligibility redeterminations at age 18, which may cause disruptions in care, as well as possible difficulties in transitions between child and adult state HCBS waiver processes. Commissioners emphasized the vital role that transition planning has on beneficiaries enrolled in age-limited 1915(c) HCBS waivers, as this supports continuity of care. MACPAC commissioners plan to study this topic further through quantitative analyses and stakeholder interviews
• Access to Care for Medicaid-enrolled Youth in Foster Care
  • MACPAC staff presented the draft chapter on Medicaid coverage and access for children and youth enrolled in foster care. Staff noted that children and youth in foster care have multiple pathways to Medicaid coverage and are entitled to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services. However, MACPAC found that these children are more likely to have chronic conditions or mental health needs while also being less likely to have consistent healthcare utilization. Some children may fall behind on screenings or miss them entirely. Utilizing stakeholder interviews, staff indicated that collaboration and coordination between Medicaid and child welfare agencies were key to improving care for foster children, but difficult to achieve in a consistent manner. Staff described other challenges but also noted that specialty managed care plans reduced the administrative burden on state agencies and allowed for specialized quality improvement activities.
• Background on Medicaid for Justice-Involved Youth
  • This session focused on providing background information for justice-involved youth (JIY) and their access to Medicaid. Staff noted that while this population shares some similarities with justice-involved adults, the needs of JIY can differ significantly. Research has indicated that access to Medicaid services upon release can reduce recidivism. On average, JIY are more likely to be male, ages 15 and above, and have unmet physical and mental health needs. Youth of color, low income, or LGBTQ youth are overrepresented in the JIY population. Unlike adults in the carceral system, JIY still need to continue their education and may need parental consent for certain processes and decision-making, and half are jointly involved with the child welfare system. The SUPPORT Act specified that states should suspend coverage of eligible youth who are incarcerated instead of terminating eligibility. The Consolidated Appropriations Act of 2023 required certain Medicaid benefits for JIY, effective January 2025. MACPAC staff will interview states and present their findings at the next meeting.
• Implementation of Increased Federal Medical Assistance Percentage for Home- and Community-Based Services under the American Rescue Plan Act: Key Takeaways
  • MACPAC staff presented findings on the implementation of the temporary FMAP increase for home- and community-based services (HCBS) under the American Rescue Plan Act of 2021 (ARPA, P.L. 117-2). ARPA provided $37.1B in one-time federal funding for states to reinvest in HCBS, but states faced a compressed timeline for using the funds. The session offered a legislative overview of ARPA, including the timelines and federal guidance attached to the funding, and highlighted MACPAC’s monitoring of state experiences. Key takeaways focused on how states managed the timing of expenditures, evaluated programs supported by the funds, and considered strategies for sustaining HCBS improvements once the temporary funding ends.
• Medicare-Medicaid Plan Transition
  • MACPAC staff provided an update on the transition from the Medicare-Medicaid Plan (MMP) model to integrated dual-eligible special needs plans (D-SNPs) following CMS’s decision to end the Financial Alignment Initiative (FAI) by the end of 2025. The FAI, launched to better align Medicare and Medicaid financing and services for dually eligible beneficiaries, had primarily operated through the capitated MMP model. States with MMPs were required to submit plans for moving enrollees into D-SNPs, which are Medicare Advantage products tailored to dual-eligible populations and designed to coordinate Medicaid benefits. Building on their earlier framework focused on stakeholder engagement, procurement, IT system changes, and enrollment, MACPAC staff reported on state progress in these areas, including outreach to beneficiaries, adjustments to IT infrastructure, and procurement processes. The presentation emphasized the Commission’s ongoing monitoring of how states manage the operational and beneficiary impacts of this transition.

CMS Finalizes Rule to Improve Provider Directories in Medicare Advantage

CMS finalized the Medicare and Medicaid Programs Contract Year 2026 rule (CMS 4208-F2) on September 19. The final rule requires Medicare Advantage (MA) plans to submit provider directories to CMS in 2026. The agency plans to incorporate this information into its Medicare Plan Finder portal, with the ultimate goal of creating a national provider directory. Through these new requirements, CMS aims to increase access to important plan information and improve the ability of enrollees and caregivers to compare health plans. Following the final rule, CMS will issue operational guidance on how MA plans should prepare the provider directory data to meet federal requirements. MA plans must also update their provider directory data within 30 days after they becomes aware of any changes (Modern Healthcare, September 18; American Hospital Association, September 19).

Projected Financial Impact of Medicaid Work Requirements on U.S. Hospitals

A Commonwealth Fund analysis estimates that Medicaid work requirements, if implemented nationwide by 2027, would place additional financial pressure on hospitals in expansion states. The study projects that operating margins could decline by roughly 12% to 14% as more people lose coverage and hospitals face higher levels of uncompensated care. Safety net and rural hospitals are expected to be most affected, with safety net facilities facing margin reductions of up to 30% and rural hospitals, many already at risk of closure, seeing losses that could further limit services. The report highlights that these financial strains may reduce access to care in some communities and shift costs onto privately insured patients. While proponents of the policy view work requirements as a way to limit public spending, hospital groups and other stakeholders caution that the changes could destabilize the healthcare system (Fierce Healthcare, September 19).

GAO Report on 1115 Waiver Budget Neutrality

On September 16, the GAO issued a report on budget neutrality in states’ 1115 waivers. GAO began conducting its audit in 2024 at the request of Congress. GAO began conducting its audit of state’s Medicaid Section 1115 waivers and related budget neutrality policies in 2024. The report focuses on CMS policy changes in 2021—when CMS began requiring states to use more recent spending data to calculate spending limits—and 2022, when CMS began allowing weighted average, higher President Budget’s trend rate, and spending limits to include certain hypothetical costs. GAO contends that allowing for consideration of hypothetical costs (which facilitated states’ coverage of health-related social needs (HRSN) services and pre-release coverage for justice-involved populations), inappropriately caused significant growth in spending. While CMS has since rescinded its guidance around HRSN, waivers for pre-release services appear to still be approvable. The report recommends CMS “revise the agency’s section 1115 budget neutrality policy to stop treating costs for populations or services that could not have otherwise been covered under existing Medicaid authorities as hypothetical when setting demonstration spending limits. Instead, CMS should require the costs of those populations or services to be offset by other reductions in demonstration spending.” In its response, CMS notes it will take the GAO’s recommendation under consideration as it looks to issue rules implementing the OBBBA provisions on 1115 waiver budget neutrality by January 1, 2027 (General Accountability Office, September 16).

GAO Releases Report on GA’s Administrative Spending for Work Requirements

On September 18, GAO released a report detailing the amount and type of administrative spending incurred by Georgia’s Pathways to Coverage demonstration from Fiscal Year 2021 through the second quarter of Fiscal Year 2025. The GAO report notes that the Pathways program had a substantial administrative cost of over $54M, with 87.6% being spent by the federal government. No administrative costs were factored into the budget neutrality assessment during the process. Additionally, the GAO found evidence that CMS may have approved administrative costs at the enhanced matching rate of 90% that are not typically allowable. Georgia was approved to receive a 90% federal matching rate for monitoring reports, media strategy, and branding. Georgia officials noted that the high administrative costs may have resulted from the program having to pause while in the court system and restarting in July 2023. The GAO recommends that CMS begin to factor administrative costs into budget neutrality assessments and strengthen oversight into administrative spending, as recommended in a 2019 report. CMS has not agreed with the GAO’s recommendations on administrative spending related to 1115 waivers to date and has not implemented any changes (GAO.gov, September 18).