March 2024 Report to Congress on Medicaid and CHIP
By MACPAC
Chapter 1 makes recommendations on how state Medicaid agencies can improve beneficiary engagement on MCACs and actions the federal government can take to aid states.
Chapter 1 examines the role of Medical Care Advisory Committees (MCACs) in supporting state Medicaid agency efforts to incorporate beneficiary voice into their programs. Beneficiaries can provide feedback to policymakers on the issues that affect their access and use of Medicaid-covered services. Federal rules mandate that every state Medicaid agency operate an MCAC that consists of beneficiaries or consumer group representatives. However, states seek additional guidance on strategies to improve beneficiary recruitment and engagement.
The chapter highlights the importance of beneficiary engagement, as well as an overview of the federal statute and regulations related to MCACs and recent proposed federal actions to implement changes to these regulations. Drawing on Commission discussions and findings from a 50-state policy document review and key stakeholder interviews, the chapter describes key findings and the challenges with recruitment of beneficiaries, particularly those representing historically marginalized communities, and barriers to meaningful beneficiary engagement. The chapter concludes with the rationale and implications for Commission recommendations.
The Commission voted in favor of three recommendations, which focus on how state Medicaid agencies can improve the beneficiary experience on MCACs and actions the federal government can take to aid states. The recommendations calls on the Centers for Medicare & Medicaid Services to issue federal guidance and technical assistance to states to address beneficiary recruitment and implementation challenges. The recommendations also urge state Medicaid agencies to strengthen efforts to recruit beneficiary members from historically marginalized communities, as well as to develop and implement policies that facilitate meaningful beneficiary engagement and reduce the burden on beneficiaries while participating in MCACs.
Chapter 2 focuses on the monitoring and oversight of denials and appeals in Medicaid managed care and makes recommendations to improve monitoring, oversight, and transparency of denials and appeals as well as the beneficiary experience with the appeals process.
Chapter 2 looks at the monitoring and oversight of denials and appeals in Medicaid managed care and the beneficiary experience with the appeals process. Beneficiaries appeal few denials, and program operators do not collect comprehensive information about denials in Medicaid managed care. Federal rules do not require states to collect and monitor data needed to assess access to care, monitor the clinical appropriateness of denials, or require that states publicly report information on plan denials and appeals outcomes.
This chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency; elaborates on state flexibilities within the current federal framework; and describes key challenges with the current structure. The Commission makes seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts.
Chapter 3 fulfills MACPAC’s annual, statutorily required report on Medicaid disproportionate share hospital allotments to states for payments to hospitals that serve a high proportion of Medicaid beneficiaries and other low-income patients.
Chapter 3 continues the Commission’s work on its annual report on Medicaid disproportionate share hospital (DSH) allotments to states. As in prior years, the Commission continues to find little meaningful relationship between state DSH allotments and the number of uninsured individuals; the amounts and sources of hospitals’ uncompensated care costs; and the number of hospitals with high levels of uncompensated care that also provide essential community services for low-income, uninsured, and vulnerable populations.
During the COVID-19 public health emergency, policy responses were effective in reducing the uninsured rate, enhancing hospital finances, and boosting DSH allotments. In recent years, some states have begun substituting other types of Medicaid payments for DSHs. In the Commission’s view, DSH policy should be assessed in the context of all other Medicaid payments to hospitals.
At the time of the chapter’s drafting, DSH allotment reductions were scheduled to take effect in fiscal year (FY) 2024. Congress has since delayed reductions until January 1, 2025. The amount of the reductions has remained the same ($8 billion) a year, which is about half of states’ unreduced allotment amounts. The report includes an analysis of the effects of these reductions in FY 2026, which is similar to the projected effects of the reductions currently scheduled for FY 2025.