Members of the Medicaid and CHIP Payment and Access Commission met publicly last week in Washington, D.C.

The following is MACPAC’s own summary of its meeting.

During MACPAC’s February 2025 meeting, staff presented four draft policy recommendations to address challenges related to transitions from pediatric to adult care for children and youth with special health care needs (CYSHCN). The draft recommendations reflect the Commission’s feedback from the December and January meetings.

The recommendations include requiring states to develop a strategy for transitions of care for CYSHCN, which includes developing an individualized transition of care plan and making the strategy publicly available; issuing guidance to states on existing authorities to cover transition of care related services for CYSHCN; requiring states to collect and report data on access to transition of care-related services as well as beneficiary and caregiver experiences with transitions; and requiring interagency agreements between state Medicaid and Title V agencies to specify the roles and responsibilities of the agencies in supporting CYSHCN transitions from pediatric to adult care.

Following this, staff presented analyses of hospital non-disproportionate share hospital (DSH) and state directed payments. Hospital spending is a strategic priority for MACPAC’s analytic work due to its substantial effect on overall Medicaid spending. Hospitals receive a complex array of Medicaid payments, including various types of supplemental payments, and payment mechanisms vary significantly across states. This session presented new information on supplemental payments, specifically non-DSH supplemental payments such as upper payment limit payments, and state directed payments. Overall, we found wide state variation in the use and targeting of non-DSH supplemental payments and directed payments. This session is part of our long-term work plan on hospital payment and financing.

The Commission then heard an overview of the self-directed home- and community-based services (HCBS) delivery model. The presentation began with a discussion of the required elements in self-direction and background on the model. Staff then presented on the roles of key actors in program administration. This presentation concluded with Commissioner discussion around the self-directed HCBS model and its key players.

In a related session, staff discussed interview findings on self-directed HCBS. The findings are organized into two sets of considerations: state design and state administration. Among state design considerations, staff identified the following flexibilities for states developing a self-direction program: the HCBS authorities available for self-direction, the populations served, the services offered, considerations for budget and employer authority, and the role of family caregivers. The findings on considerations for how states administer self-direction focused on variation and collaboration across state agencies, collaboration across entities to provide information and assistance supports, including the different roles they play, the role of FMS agencies, and quality reporting, monitoring, and oversight strategies.

Staff then presented themes from stakeholder interviews on improving access to medications for opioid use disorder. Given the ongoing drug-overdose crisis and Medicaid’s role in facilitating treatment, MACPAC has been engaged in research to understand access to and use of medications for opioid use disorder (MOUD) among Medicaid beneficiaries. In recent public meetings, the Commission has reviewed federal policies affecting access to MOUD and data on MOUD utilization based on an analysis of Medicaid claims.

Staff provided background information and discussed themes related to federal policies and funding, stigma, provider availability, and utilization management. While some of the issues discussed are specific to Medicaid, most affect access to MOUD more broadly and are beyond the program’s purview. The presentation ended with a discussion of next steps and additional work to examine the use of prior authorization for MOUD.

To conclude the day, the Commission heard a panel discussion on substance use disorder (SUD) section 1115 waivers. SUD is a significant public health issue that disproportionately affects the Medicaid program. Historically, Medicaid has provided limited coverage for residential SUD treatment due to federal rules prohibiting federal matching funds for services provided in institutions for mental disease. That policy has made it difficult for states to meet the need for residential treatment amid rising rates of opioid use disorder (OUD). In response, the Centers for Medicare & Medicaid Services (CMS) has encouraged states to pursue Section 1115 demonstrations that allow them to waive that restriction and address other gaps in the SUD treatment continuum.

To complement MACPAC’s ongoing work on improving access to OUD treatment, staff assembled an expert panel to share their insights and experiences. Medicaid directors from New Hampshire and West Virginia discussed their demonstration goals and implementation experiences, as well as areas where they have seen progress. A former CMS official and state technical assistance provider discussed CMS’s expectations for the demonstrations, including required state monitoring and evaluation activities, and areas where more information is needed to understand whether demonstrations are meeting their stated goals.

Panelists included:

        • Cynthia Beane, Bureau of Medical Services, West Virginia Department of Health and Human Services
        • Henry Lipman, Director, Division of Medicaid Services, New Hampshire Department of Health and Human Services
        • John O’Brien, National Advisor for Manatt Health

On Friday, the meeting began with a discussion of automation in prior authorization. In recent years, technology, including artificial intelligence, has been used to automate parts of the Medicaid prior authorization process. However, there is little information about how automation is used in Medicaid prior authorization and its effect on payers, providers, and Medicaid beneficiaries. To fill this gap in knowledge, staff completed a literature review on the role of automation in the Medicaid prior authorization process. During this session, MACPAC summarized the findings from this literature review, including automation tools that states and managed care organizations use today, existing evidence on the impact of automation on the prior authorization process, and federal and state oversight of automation in prior authorization.

Following this, staff presented on health care access for children in foster care. Staff conducted a systematic examination of federal requirements and state delivery methods of Medicaid benefits to children in foster care. During this session, staff presented background information on children in foster care, federal child welfare and Medicaid requirements, the role of state agencies and managed care plans in delivering health services, and selected policy issues that affect health care delivery and access for this population.

To conclude the meeting, staff shared findings from interviews with state and federal officials, national experts, advocates, and providers about appropriate access to residential treatment services for children and youth with behavioral health needs. Key themes that emerged from interviews related to data collection and sharing, admission and discharge processes, coverage and payment levers, and provider capacity.

Supporting the discussion were the following presentations:

  1. Transitions of Care for Children and Youth with Special Health Care Needs (CYSHCN): Draft Policy Recommendations
  2. Hospital Non-DSH Supplemental Payment and Directed Payment Targeting Analyses
  3. Overview of the Self-Directed Model
  4. Interview Findings on Self-Direction Program Design and Administration
  5. Improving Access to Medications for Opioid Use Disorder: Themes from Stakeholder Interviews
  6. Panel: Substance Use Disorder Section 1115 Demonstrations
  7. Automation in the Prior Authorization Process
  8. Health Care Access for Children in Foster Care
  9. Appropriate Access to Residential Services for Children and Youth with Behavioral Health Needs: Interview Findings

MACPAC 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 variety of issues affecting Medicaid and the State Children’s Health Insurance Program.  Its deliberations are highly influential among policymakers.  Find MACPAC’s web site here.