On September 18 and 19, 2025, the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) held a virtual public meeting. Sessions included:
- Summary of P.L. 119-21, An Act to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14;
- Background on Work and Community Engagement Requirements in Medicaid;
- Panel on Work and Community Engagement Requirements in Medicaid;
- Implementation of Increased Federal Medical Assistance Percentage for HCBS under the American Rescue Plan Act: Key Takeaways;
- Medicare-Medicaid Plan Transition.
The full agenda for the meeting and the presentations for the sessions are available here.
MACPAC DIVES INTO THE ONE BIG BEAUTIFUL BILL ACT
In this session, MACPAC staff provided a detailed summary of changes to Medicaid and the State Children’s Health Insurance Program (CHIP) following the recent passage of Public Law (P.L.) 119-21, An Act to Provide for Reconciliation Pursuant to Title II of H. Con. Res. (A concurrent resolution originating in the House of Representatives) 14, referred to as the One Big Beautiful Bill Act (OBBBA). The presentation focused on four categories: eligibility and enrollment, financing, services and payment, and other provisions.
Eligibility and Enrollment
- Updated Redetermination Policies: Beginning in January 2027, states will now be required to make redeterminations every six months instead of annually for the Medicaid expansion under the Affordable Care Act of 2010 (the expansion).
- Reduced Alien Medicaid Eligibility: As of October 1, 2026, federal funding supporting coverage of qualified aliens through Medicaid and CHIP will be limited to lawful permanent residents, certain Cuban and Haitian immigrants, and individuals lawfully residing in the United States under the Compact of Free Association. All other qualified aliens will only be eligible for emergency Medicaid, with some exceptions for children and pregnant women who are residing in the country legally.
- New Work and Community Engagement Requirements: As of January 1, 2027, individuals in the Medicaid expansion will be required to engage in work, an educational program, community service, or a combination of these three for a minimum of 80 hours per month. Individuals can also satisfy the requirement by earning a monthly income equal to or above the state’s applicable minimum wage multiplied by 80 hours. Certain groups are exempt from these requirements, states can offer limited short-term “hardship” exceptions, and states can receive additional flexibility in implementing requirements through a “good-faith effort” waiver from the Secretary.
- Reduced Retroactive Care Applicability: OBBBA reduces the maximum Medicaid and CHIP retroactive coverage states can provide to only one month prior to the application month for the expansion population, or two months for all other Medicaid and CHIP participants.
- Other Eligibility and Enrollment Changes: Staff also highlighted additional changes to reduce duplicate enrollment in multiple states, a requirement for states to review the Death Master File to disenroll deceased enrollees and providers, and a 10-year moratorium on two eligibility rules from 2023 and 2024.
Financing
- Changes to the Expansion Population Federal Matching Percentage (FMAP) for Emergency Medicaid: Beginning in October 2026, federal matching funds for emergency Medicaid for individuals who would be eligible for Medicaid if not for their immigration status will now be determined based on the state’s regular FMAP percentage, not their expansion FMAP rate.
- Reduced Expansion Incentives: OBBBA removes the five-percentage-point increase to a state’s regular FMAP for two years if it chooses to expand Medicaid after March 2021. This incentive was established in the American Rescue Plan Act of 2021 in response to the COVID-19 Public Health Emergency (PHE) and would apply to any state that chooses to expand Medicaid after December 31, 2025.
- New Provider Tax Limits: The legislation also implemented significant changes to provider taxes, reducing the hold harmless threshold from six to zero percent for any provider taxes not in effect at the date of enactment (July 4, 2025). Existing provider tax rates are grandfathered, with the hold harmless rate set to phase down (for expansion states only) beginning in October 2027 from 5.5 percent to 3.5 percent in Fiscal Year (FY) 2032. Several types of facilities are notably exempt from these requirements, including nursing and intermediate care facilities. At the date of enactment, CMS will also apply updated standards regarding what constitutes uniformity in determining whether a provider tax is “generally redistributive”. This change is meaningful given that states can apply for a waiver to the hold harmless threshold if the tax is deemed “generally redistributive.”
- Other Financing Changes: Staff also highlighted new requirements for Section 1115 demonstration waivers to be budget neutral, changes to how erroneous excess payments are handled, and new restrictions on federal payments to prohibited entities.
Services and Payment
- Moratorium on the Nursing Facility Staffing Rule: The legislation established a 10-year moratorium (through September 30, 2034) on the Minimum Staffing Standards for Long-Term Care Facilities promulgated under the Biden administration, though the mandate has been the subject of extensive litigation and was recently struck down in federal court.
- New Home Equity Limits for Long-Term Services and Supports (LTSS) Eligibility: Beginning in 2028, the home equity limit to determine eligibility for LTSS will be capped at $1 million for homes that are not zoned for agricultural use.
- New Cost Sharing Requirements for Medicaid Expansion Populations: OBBBA establishes new requirements for states to impose cost-sharing requirements on Medicaid expansion populations beginning on October 1, 2028. Cost sharing must be greater than $0 but no more than $35 per item or service, with an aggregate cap of five percent of family income per year. Certain services, including primary care, are also exempt from this requirement.
- New Caps on State Directed Payments (SDPs): New requirements establish a cap on SDPs of 100 percent of published Medicare rates for expansion states, or 110 percent for non-expansion states. To ease this transition, states will have limited grandfathering periods for existing SDPs.
- Other Services and Payment Changes: Staff also highlighted adjustments to Home and Community-Based Services, with a new standalone 1915(c) waiver option for individuals who need less than an institutional level of care.
Other
- Updated Eligibility Requirements for Premium Tax Credits: New requirements disallow the premium tax credit for lawfully present individuals with incomes below 100 percent of the Federal Poverty level for five years after being granted this status.
- Establishment of the Rural Health Transformation Program (RHTP): OBBBA established a $50 billion RHTP, which will distribute up to $10 billion per year through FY2030. Funds are available to states for specified activities that promote rural health, following an application process managed by CMS.
Commissioner Discussion
Commissioners asked wide-ranging questions on several OBBBA provisions. One commissioner asked whether these new provisions would supersede existing waivers for continuous Medicaid eligibility, and a staff member responded that they do. One commissioner wondered how the SDP cap would be applied to services that Medicare/Medicaid typically do not reimburse, including services for pregnant women and children. Staff responded that they plan to investigate this further, but highlighted that Medicare has published rates even if they rarely reimburse for these services. Staff also planned to follow up on questions from commissioners regarding whether refugees and asylees would be affected by OBBBA, if FMAP changes would activate any state-level trigger laws that would repeal the expansion, and whether states could unexpand and then re-expand Medicaid to take advantage of differences in provider tax and SDP provisions. To close the session, one commissioner also requested that MACPAC focus on how these provisions will affect access to care.
MACPAC PROVIDES BACKGROUND ON WORK AND COMMUNITY ENGAGEMENT REQUIREMENTS
In the first session of a two-part series this meeting, MACPAC commissioners discussed the upcoming work and community engagement requirements under Medicaid. This session presented relevant background information, including Arkansas and Georgia’s experiences with work requirements, and walked through the specifics of work and community engagement requirements established in OBBBA.
In 2018, CMS encouraged states to implement work and community engagement requirements under Section 1115 waivers. While thirteen states were approved for these demonstrations, only Arkansas and Georgia fully implemented work and community engagement requirements. Both states experienced (or were projected to experience) substantial coverage losses.
Arkansas’s Arkansas Works demonstration began in June 2018 but was halted in March 2019 due to a federal court ruling. While short-lived, Arkansas remains the only state where work and community engagement requirements disenrolled beneficiaries who failed to meet program requirements. Applicable beneficiaries in Arkansas were required to fulfill 80 hours per month of qualifying activities, which included employment, education, or health-related courses. The program also included exemptions for beneficiaries who were medically frail, pregnant, or the primary caregiver for a family member. Reporting on the program highlighted a lack of beneficiary awareness of the requirements and substantial administrative barriers, particularly issues with the portal where beneficiaries were required to upload proof of their hours. In January of 2025, Arkansas proposed (but has yet to receive approval for) a modified work requirements program with data matching and no beneficiary self-reporting.
In Georgia, Governor Brian Kemp spearheaded the Georgia Pathways program, implementing work and community engagement requirements under a Section 1115 waiver in July 2023. Georgia Pathways increased coverage for qualifying adults up to one hundred percent of the Federal Poverty Level (FPL) and like Arkansas Works, required eighty hours per month of qualifying activities like employment, community service, or education. While the program was meant to expand coverage without expanding Medicaid under the ACA, enrollment was lower than anticipated. The state has also recently received an extension for the program, adding new qualifying activities, such as caregiving for a child under the age of six, that would count toward the eighty-hour requirement. The updated Georgia Pathways also received approval to shift to annual reporting, reducing the burden on enrollees.
New Requirements Under OBBBA
The OBBBA establishes new statutory work and community engagement requirements that will apply to all states beginning in 2026. States that qualify for a “good faith” exemption waiver from the Secretary will have until 2029. $200 million will be distributed to the states for fiscal year (FY) 2026 with another $200 million designated to CMS in FY 2026. Under these work and community engagement requirements, non-pregnant, non-dually eligible Medicaid beneficiaries aged nineteen to sixty-four, who would otherwise qualify for coverage under the adult expansion group, must engage in and document eighty hours of work, education and/or community service. The average monthly income for the previous six months will be assessed for seasonal workers. States will verify these hours at least every six months and must use existing data wherever possible. Those who are deemed medically frail, former foster care youths, those recently incarcerated, and several other statuses will exempt beneficiaries from having to meet those eighty hours. States also have the option to offer exemptions for “short-term hardship” such as living in a county with a high unemployment rate or being recently hospitalized. Non-compliant beneficiaries will be notified and given thirty days to comply with the work and community engagement requirements. Statute cedes the defining of certain standards and procedures to the Health and Human Services (HHS) secretary. MACPAC anticipates HHS further defining qualifying exemptions prior to the rollout of the final rule.
Commissioner Discussion
After the presentation, commissioner discussion began with several questions about the details and definitions of the work requirements. Commissioners and MACPAC staff identified several areas where more clarity and guidance is needed from CMS, including on the time frame for the post-partum exception, how “medically frail” will be defined given the current statutory text, and whether CMS intends to use an open Application Programming Interface (API) for agencies and hospital systems to communicate with one another about work requirements. Commissioners emphasized the need for data sharing, with one noting that a hospitalized beneficiary qualifying for the temporary hardship exemption is unlikely to complete the necessary paperwork while hospitalized. Several commissioners suggested that this program would benefit from the lessons that states learned from Medicaid unwinding after the pandemic. Additionally, many commissioners agreed that MACPAC should conduct a robust evaluation of the work and community engagement requirements to assess its impact.
MACPAC PANEL LOOKS TO THE FUTURE OF OBBBA-ESTABLISHED WORK AND COMMUNITY ENGAGEMENT REQUIREMENTS
Panelists:
- Melisa Byrd: Senior Deputy Director and Medicaid Director, District of Columbia Department of Health Care Finance; President of the Board of Directors, National Association of State Medicaid Directors
- Jessica Kahn: Partner, McKinsey & Company
- Jennifer Strohecker: Integrated Healthcare Division and Medicaid Director, Utah Department of Health and Human Services
- Deanna Williams: Enrollment Assister, Georgians for a Healthy Future
Following the background session on work and community engagement requirements, panelists from several states and policy organizations discussed their planning efforts, operational challenges, and lessons learned related to implementing community engagement (CE) requirements. The discussion focused on the current Medicaid Information Technology (IT) landscape, strategies for minimizing administrative burden, and considerations for effective communication and outreach—particularly for populations facing barriers to access.
Ms. Kahn described the current Medicaid IT landscape and how it impacts implementation of community engagement (CE) requirements. She noted that most states are integrated with Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) systems, and in some cases, eligibility determinations are made through the federal exchange. The vendor landscape has also evolved significantly since Arkansas implemented work requirements. For example, today, states have access to standalone software modules that can integrate with existing eligibility systems via Application Programming Interfaces (APIs). This reduces reliance on existing vendors and gives states more flexible, cost-effective options. She highlighted Louisiana’s pilot of CMS’s income verification as a service, which requires consumer consent and communicates directly with payroll providers to automatically supply employment data. States are also exploring a range of strategies to verify beneficiary volunteering information.
Ms. Strohecker emphasized that Utah is designing its CE efforts with a strong focus on the lived experiences of Medicaid members, especially those facing significant barriers such as homelessness, limited English proficiency, and low health literacy. Drawing on lessons learned from the Medicaid unwinding process, she underscored the importance of early and frequent communication, and the need to minimize administrative burden for both beneficiaries and caseworkers.
Utah is in the first phase of CE project planning. Planning efforts are centered on evaluating policies, reducing administrative complexity, and leveraging Utah’s status as an integrated state to align CE with existing eligibility systems across programs. Ms. Strohecker noted the importance of tailoring outreach and support differently for those new to Medicaid versus those renewing coverage, with the overarching goal of preventing eligible individuals from falling through the cracks.
Ms. Byrd highlighted the differences across state requirements and noted that DC is still in the early stages of planning. She echoed comments on integration and discussed the importance of aligning and partnering across state-level agencies.
As Georgia is the only state currently with work requirements, Ms. Williams was asked about the beneficiary experience and common challenges. Her response focused primarily on technological challenges including system crashes and data loss, the lack of a mobile-friendly site which presents an added challenge for those in rural areas, and issues with uploading documentation that have led to some wrongful denials. (Georgia has recently updated their system and Ms. Williams touted many of these challenges have since been resolved). One strength was integration with employer API systems that verified eligible work without the beneficiary needing to upload documents, although verification remains a challenge for those who are self-employed.
Regarding changes states will need to make on the IT front, Ms. Kahn described two categories: 1) changes that existing vendors can make, such as adding new questions, new notice language, and business requirements to the portal, and 2) new functionalities and integrating new data sources, among other customized changes based on state policy changes. For example, if the state chooses to allow exemptions through self-attestations or claims data verification. Key considerations for states when determining an IT solution include IT costs, data costs, and workforce implications.
Ms. Kahn, Ms. Strohecker and Ms. Byrd were asked what guidance they needed from CMS to move forward with system changes, and how CMS can work with states to make these changes less costly. Ms. Byrd talked about the importance of training and balancing the workflow burden for caseworkers as the eligibility system is set up. She highlighted the value of open dialogue across states and with CMS, and the importance of obtaining a roadmap from CMS on which areas the federal government will provide further guidance versus which areas are subject to state interpretation. Another area highlighted was the value of releasing funding for state-level implementation as early as possible so it can be accounted for in the state budgeting process. Ms. Kahn emphasized that no state should be waiting for CMS guidance to be doing IT planning, because most CMS guidance is business-focused and can be updated later, but data infrastructure needs to be designed and created now. Ms. Strohecker reiterated these comments and asked for CMS clarification on who can be considered “medically frail”.
Ms. Williams was asked about best practices from Georgia on the most efficient outreach strategies. She highlighted the importance of partnering with trusted community organizations such as Federally Qualified Health Centers (FQHCs), food banks, religious organizations or groups that beneficiaries have existing relationships with for care coordination and application support. She also discussed the importance of repeated communication across multiple streams (text, email, and mail in person) utilizing clear language and translated into multiple languages.
Commissioner Questions
Commissioners followed the informational part of the session with a lengthy and wide-ranging question-and-answer session with MACPAC staff that focused on the specifics of implementing CE requirements. One commissioner asked where states would most benefit from near-term CMS support. Both Ms. Byrd and Ms. Strohecker highlighted the value in CMS signaling where greater clarification is expected, versus what areas states will have flexibility. Specifically, they cited when self-attestation could be used, and flexibility on what would happen for someone who would no longer be able to work if they stopped receiving their medicine (e.g., insulin). Another commissioner asked how states account for people in non-accredited training programs, such as workforce training. Ms. Williams provided an example from Georgia, where on-the-job training is paid and the employer can verify. Another commissioner asked about the most common reasons people are found ineligible in Georgia. Ms. Williams highlighted system errors and a failure to meet the hourly requirements, particularly for those with gig jobs, restaurant and retail workers, or anyone with inconsistent hours. One commissioner raised the issue of data privacy and the extent to which data sharing was allowed between government agencies, while respecting privacy concerns. One panelist described it as technically feasible but dependent on interoperability and appropriate Memorandums of Understanding (MOUs) between agencies and state API systems. Ms. Byrd discussed challenges around claims data lag and how to leverage real-time data while maintaining privacy. Another commissioner asked about the cost of the implementation. Both DC and Utah have in-house eligibility systems, which reduce costs, but highlighted that their final expenditure will ultimately depend on how much additional work must be done to complete the necessary upgrades. Another commissioner asked what happens if the impact is worse than expected and highlighted examples of low enrollment and accelerated disenrollment in Georgia and Arkansas, particularly how information will be aggregated at CMS. Ms. Byrd responded from the association’s perspective and spoke about the strength of the association in spotting issues and raising them to CMS’s attention. However, this is more anecdotal, and there is no formal reporting at this point.
The discussion concluded with a commissioner asking about what recommendations Georgia has for other states. Ms. Williams noted that it has not been as successful as they would have liked, but recommended good technology, a mobile-friendly website, well-trained outreach workers, and sufficient case workers.
Commissioner Reactions
Commissioners also discussed the panel and subsequent question-and-answer session, offering concerns, caution, and recommending future MACPAC research opportunities. One commissioner pondered the cost-benefit analysis of getting people employed, the cost to the state, the uncompensated care costs to the hospital if people are not on Medicaid, and the cost of the lack of prevention. Another commissioner spoke about how the bill was described as a saver, but that it is based on significant disenrollment. However, 7 out of 10 Medicaid recipients are working or are expected to be eligible for an exemption. Therefore, they argued that the premise of significant savings is based on disenrollment of eligible people. They also voiced concerns about the lack of empirical data on wrongful disenrollments and the subsequent health impacts. Commissioners highlighted this as an area where MACPAC could pursue further research. A third commissioner reiterated the problem of a lack of evaluation and the role of MACPAC. This commissioner also discussed longstanding CMS guidance on data tools and the cost of each state creating a customized system, rather than having a national strategy and CMS base that states can implement and then customize. Another commissioner commented on the challenge of having sufficient technical expertise to evaluate IT vendors effectively and the burdensome procurement requirements and process. One commissioner focused on three challenges: the tech build, the legal barriers between agencies and the beneficiary’s consent. One example of this is the privacy concerns surrounding the sharing of inpatient treatment information. To close the discussion, another commissioner emphasized the importance of adding monitoring and evaluation, as well as understanding the cumulative effects of changes implemented in OBBBA, particularly the impact of this work on other state priorities.
MACPAC’S FINDINGS ON STATE IMPLEMENTATION OF TEMPORARY FEDERAL MEDICAL ASSISTANCE PERCENTAGE (FMAP) FOR HOME- AND COMMUNITY-BASED SERVICES (HCBS) UNDER THE AMERICAN RESCUE PLAN ACT (ARPA, P.L. 117-2)
In response to the COVID-19 public health emergency (PHE), Section 9817 of the American Rescue Plan Act of 2021 (ARPA, Public Law (P.L.) 117-2) provided a temporary 10 percentage point increase in the federal medical assistance percentage (FMAP) for state Medicaid home- and community-based services (HCBS) expenditures between April 1, 2021, and March 31, 2022. This temporary increase was intended to generate reinvestment funds to help states improve their HCBS programs. States qualified for the additional funds if they used the federal dollars to “supplement, not supplant,” existing state HCBS funding and if they implemented activities to enhance, expand, or strengthen Medicaid HCBS. The FMAP increase is estimated to have generated $37 billion in additional state and federal funds for state-driven HCBS reinvestment activities.
Section 9817 did not specify how CMS should implement the law, nor did it establish state requirements for funding operations, timelines, or reporting. The Centers for Medicare & Medicaid Services (CMS) issued guidance through two State Medicaid Director (SMD) letters (on May 13, 2021 and June 3, 2022 respectively) that outlined requirements like acceptable usage of ARPA funds, state requirements, spending parameters, and reporting timelines The guidance also established maintenance of effort (MOE) rules requiring states to: 1) maintain existing eligibility standards, methodologies, and procedures; 2) preserve covered HCBS; and 3) sustain HCBS provider payments. States were also required to submit spending plans and narrative updates, along with quarterly and semi-annual reports. CMS extended the original spending deadline twice: first from March 31, 2024 to March 31, 2025, and later to September 30, 2026 for about half of states.
CMS analysis found that as of the quarter ending December 31, 2023, more than 1,400 activities were proposed across all 50 states and DC, with the most common activities including workforce recruitment and retention ($26.3 billion planned spending), workforce training ($3.9 billion), quality improvement ($2.7 billion), reducing or eliminating HCBS waiting lists ($1.7 billion), and developing cross-system partnerships ($1.7 billion).
As part of its monitoring activities, MACPAC conducted interviews with CMS officials, states, and other stakeholders; reviewed federal, state, and organizational documentation; and convened panels in January 2023 and January 2024. These efforts informed MACPAC’s assessment of state experiences, which focused on three main areas in the session: timing challenges, limited evaluation requirements, and sustainability concerns.
MACPAC Analysis – Implementation Challenges and Lessons Learned
Timing: The Commission’s analysis found that both states and CMS faced significant timing challenges during implementation. States only had about 2.5 months after the first SMD letter to submit their initial spending plans, which limited opportunities to draft comprehensive plans, collect stakeholder input, and obtain state legislative approvals. CMS’s capacity to streamline operations was also limited, and officials had to work under strict timelines to provide guidance and approve state spending plans. Nearly half of participating states requested extensions to the three-year implementation period to fully expend their ARPA funds for various reasons, including delayed approvals and the administrative workload (including planning, implementation, and evaluation).
Evaluations: Although neither Section 9817 nor CMS guidance required program evaluations, many states incorporated and financed some level of evaluation activities using their ARPA funding. However, state officials reported facing challenges with staff capacity, limited timeframes to conduct evaluations, limited data availability, and difficulty isolating the impact of ARPA-funded initiatives.
Sustainability: Another challenge states faced was the lack of specific parameters in CMS guidance on demonstrating the sustainability of these efforts once ARPA funding lapsed. MACPAC’s 2023 review found that tw0-thirds of states included some report on sustainability and their January 2024 panel revealed that states were sustaining approximately one-third of activities that bolstered the direct care workforce. States also expressed interest in using ARPA to build lasting HCBS infrastructure, but were limited by time and funding constraints, particularly the need to prioritize immediate relief efforts.
Lessons Learned and Next Steps
MACPAC plans to publish an issue brief summarizing their monitoring activities and lessons learned in the coming months. During the Commissioner discussion, members requested feedback on areas the brief should emphasize. Commissioners noted both the benefits and limitations of ARPA funding, stressing the importance of highlighting positive impacts while also identifying opportunities for improvement. One commissioner emphasized that structured evaluation requirements would have helped address current challenges in assessing program impacts. Others recommended highlighting best practices to inform future initiatives and ensuring that timelines are realistic and achievable. Lastly, commissioners suggested including broad recommendations for Congress on how to structure similar emergency or crisis-related investments.
UPDATES ON MEDICARE-MEDICAID PLAN (MMP) TRANISTION INTO INTEGRATED DUAL-ELIGIBLE SPECIAL NEEDS PLANS (D-SNPS)
CMS launched the Financial Alignment Initiative (FAI) in 2012 to test integrated benefits models for dual-eligible beneficiaries. Most participating states opted for the capitated Medicare-Medicaid Plan model (MPP), under which both states and CMS make capitation payments to MMPs to cover nearly all Medicare and Medicaid benefits through a single entity. MMPs have a three-way contract with CMS and the state, which allows for integrated federal and state oversight, as well as medical loss-ratios. CMS ended the FAI in 2022 rulemaking, citing that many MMP features have already been incorporated into Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) and that evaluations of the demonstration did not show clear improvements in quality or reduce spending. CMS directed the eight remaining FAI states to transition MMP enrollees into integrated D-SNPs by the end of 2025.
As part of MACPAC’s interests in integrated care models for dual eligible individuals, the Commission has been monitoring this transition using the framework outlined in their June 2023 report to Congress, which includes the following elements: 1) stakeholder engagement, 2) Medicaid managed care procurement, 3) Information Technology (IT) system changes, and 4) enrollment. As part of this monitoring, the Commission engaged in interviews with four of the remaining FAI states and CMS officials in summer 2025 to inform their analysis on progress in the Medicare-Medicaid Plan Transition.
Commission Analysis – Procurement
All but one demonstration state is expected to transition on time from MMPs to integrated D-SNPs by January 1, 2026. States that conducted procurements have completed plan selections and are moving forward with transitions, despite some having experienced previous delays. CMS officials noted that procurement is a complex aspect of integrated care, as state rules and timelines often do not align with Medicare Advantage application timelines. At the time of the Commission’s interviews, state officials were focused on continuing or completing plan readiness review activities. States are continuing to prioritize a seamless transition process for beneficiaries and expect benefits to remain largely unchanged after the transition.
Commission Analysis – IT Systems
Early planning in 2022 revealed that states would require significant IT system updates, primarily to facilitate enrollment into the new integrated plans. Under FAI, state enrollment brokers enrolled beneficiaries simultaneously in Medicare and Medicaid MMPs. However, under integrated D-SNPs, the plans initiate the process and work with CMS for Medicare enrollment and the state for Medicaid enrollment. This change in process requires states to take on a new role. Both states and CMS expressed confidence in states’ ability to adjust to the D-SNPs enrollment processes.
In most cases, MMP enrollees will automatically transition into an integrated D-SNP offered by the same parent organization. If a parent organization is not offering an integrated D-SNP in 2026, enrollees will receive a non-renewal notice with information about other available options, including other integrated D-SNPs in the state. One challenge that both states and CMS highlighted is that Medicare and Medicaid enrollment timelines do not align, which creates potential for temporary misalignment. States are making system changes and taking other actions to avoid misalignment in the new program.
Commission Analysis – Stakeholder Engagement
In December 2023, the Commission reviewed stakeholder engagement efforts, which included states gathering feedback from beneficiaries, providers, and health plans. As the end of the year approaches, states are again engaging stakeholders to ensure awareness and preparedness. MACPAC observed states are taking varying approaches to communication, with some states limiting the number of messages to reduce confusion, especially if beneficiaries will remain under the same parent organization. Others are requiring plans to send explanatory letters in addition to the CMS required annual notice of change. States are also working alongside plans and advocates to prepare for the transition to ensure that adequate training, guidance, and policy documents are available.
MACPAC will continue to monitor these elements as the end of the year and demonstration approach.
Commissioner Discussion
The session concluded with commissioners raising several issues and areas for continued monitoring. Commissioners emphasized the need to ensure that integration efforts are not undermined by look-alike plans that did not win bids and are enrolling beneficiaries into plans that do not offer integrated benefits. One commissioner also noted that because marketing timelines and guidelines for Medicaid and Medicare are still different, integrated marketing efforts can help reduce confusion among beneficiaries. Another commissioner noted that many states lack capacity and expertise in Medicare financing to adopt integrated Medicare and Medicaid financing structures. They further underscored the importance of greater contracting transparency and the need to monitor the transition’s effects on continuity of care and benefits, ensuring that beneficiaries maintain access to their providers and integrated coverage.
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