On September 21 and 22, 2023, the Medicaid and CHIP Payment and Access Commission (MACPAC) held a virtual public meeting. The meeting included sessions on denials and appeals in Medicaid managed care, a panel discussion on unwinding the continuous coverage requirement, and eligibility and enrollment for Medicare Savings Programs. The full agenda for the meeting and presentations for additional sessions can be found here.

MAJORITY OF COMMISSIONERS FAVOR NEW CMS REQUIREMENTS TO HELP STATES ANALYZE MEDICAID MCO DENIALS AND APPEALS

Medicaid managed care organizations (MCOs) provide care to 72% of Medicaid beneficiaries nationwide. As these organizations are responsible for determining the medical necessity of services for the beneficiaries they serve, it is critical that states monitor MCO denial and appeals processes and ensure that beneficiaries have access to covered, medically necessary care. Previous work by MACPAC determined that state oversight of these processes was lacking. There are no federal requirements for states to collect and monitor data on denials, continuation of benefits, or appeals outcomes; for states to conduct audits on whether denials were clinically appropriate; or for states to publicly report any data on denials. While the managed care program annual report (MCPAR) requires states to report appeals data, this data does not include the outcome of appeals. Without data, it is difficult for policymakers to understand whether Medicaid members are receiving proper access to covered services. Accordingly, MACPAC staffers presented four policy options to increase visibility into the MCO denials and appeals processes:

• Option 1. Data Collection and Monitoring: CMS would require states to collect data on denials and appeals outcomes, issue guidance to states on how to collect this data, and provide technical assistance. States would also use this data to improve program performance.
• Option 2. Clinical Audits: CMS would require states to conduct routine audits on certain denials to assess clinical appropriateness, establish requirements and releases guidelines on the process of these audits and criteria for assessing appropriateness, and make the results of the audits publicly available.
• Option 3. Public Reporting: CMS would publicly report all MCPAR data to the CMS website in a standard format and update the MCPAR template to include new fields on denials, appeal outcomes, and, if option 2 were enacted, the findings of clinical appropriateness audits.
• Option 4. Public Reporting for Beneficiaries: CMS would require states to include denial and appeals data on the quality rating system (QRS) website so that beneficiaries can make informed decisions on MCO selection.

While the majority of commissioners were in favor of all four proposals, they raised a number of concerns about implementation and identified areas for further investigation. The primary concern was the lack of a standard definition for denials across states or MCOs. For example, commissioners questioned whether services that are partially denied, but not fully denied, are counted as denials. This definition will vary by state and MCO and will need to be clearly defined for the collected data to facilitate comparisons. Given the slow timelines for implementing data collection initiatives, and how quickly data collection and sharing in healthcare is evolving due to artificial intelligence (AI), one commissioner was also concerned that any data requirements written now could be out of line with technology when they are implemented. Another commissioner echoed concerns about long implementation timelines, and questioned whether Congress should be involved to expedite the process. It was also noted that only a small number of beneficiaries file appeals, and that the problem is probably larger than the data suggests as many beneficiaries who might appeal denials do not have the time, resources, or knowledge to do so. Commissioners also asked for investigations into denial rates across different subgroups and into which states were best at moving MCOs into compliance.

This work will continue at MACPAC’s November meeting when staffers present findings from beneficiary focus groups and present policy options specific to the appeals process.

PANEL DISCUSSION: UNWINDING THE CONTINUOUS COVERAGE REQUIREMENT

In this section, MACPAC commissioners hosted a panel to discuss the unwinding of the continuous coverage requirements in Medicaid following the end of the COVID-19 PHE. The panel included:

• Kate McEvoy, Executive Director, National Association of Medicaid Directors;
• Allison Orris, Senior Fellow, Center on Budget and Policy Priorities; and
• Daniel Tsai, Deputy Administrator and Director, Center for Medicaid and CHIP Services, CMS.

The panelists provided an update on the progress and challenges both states and beneficiaries are facing, as well as the continuous oversight efforts made by CMS.

As the U.S. states and territories have commenced Medicaid renewals and terminations, many positive outcomes of the unwinding can be credited to the establishment and maintenance of stakeholder partnerships, which extend from the 56 individual states and territories to CMS to the general public. As a result, there is heightened public understanding and awareness, especially among policymakers, regarding the impact of the administrative complexities in the redetermination and renewal process. Despite the preparations undertaken by states, a significant number of individuals who meet the eligibility criteria are still experiencing loss of coverage.

States and beneficiaries have faced challenges due to differing state operating systems, procedural terminations from states not following federal laws regarding ex parte renewals, lag time on available data, and the increased burden on reactivating coverage. These, among other challenges, have continued to make the enrollment and re-enrollment process burdensome and complicated. During discussion, commissioners focused on the examination of state unwinding data. Mr. Tsai noted unprecedented, high Medicaid enrollment numbers not seen prior to the pandemic. Balancing federal oversight, compliance, offering waivers/flexibilities, and data management takes time and resources given the number of enrollees. Mr. Tsai noted that two tranches of data have been released since April, and that CMS has posted preliminary state ex parte data. The preliminary overview of state assessments regarding compliance with Medicaid and CHIP automatic renewal requirements can be found here.

The panelists also reviewed how some states are utilizing best practices to work with stakeholders, such as partnerships with community organizations, automated call centers in Colorado, and preparatory/self-help tools like trackers to provide beneficiaries status updates on their renewals/redeterminations. Arizona has partnered with managed care organizations to access resources for direct engagement, and Kentucky is holding town hall meetings open to local citizens to answer their questions regarding the process. The consensus among the panelists was that actions to directly reach the community are the most impactful to beneficiaries in ensuring those who can and should be covered have coverage.

The Commissioners discussed ways to utilize their position to evaluate what levers were most significant in lessening the burden on beneficiaries during the renewal and reconsideration process. These included:

• Evaluating which states best utilized data and technology to remove administrative red tape.
• Creating disability-specific data to evaluate the impact on populations that face the greatest challenges throughout the reenrollment process.
• Evaluating which flexibilities offered to states have been the most impactful to help maintain coverage.
• Monitoring the transition between coverage (Medicaid to Marketplace to employer-sponsored plans and vice versa).
• Evaluating whether there are indicators of retroactive coverage periods, specifically taking a principal stance that no Medicaid enrollee should pay for care they received when they should have been covered.
• Allowing continuous eligibility for children and select adults.

Overall, commissioners discussed utilizing their position to continue moving towards long-term solutions to ensure beneficiaries remain covered and the program runs effectively.

COMMISSION PLANS FOR REFRESHED MEDICARE SAVINGS PROGRAMS ANALYSES

Under the Medicare Savings Programs (MSPs), state Medicaid programs are required to help pay for Medicare premiums, and in some cases, Medicare cost sharing for beneficiaries over the age of 65 and adults with disabilities. There are four different types of MSPs: 1) Qualified Medicare beneficiary (QMB), 2) Specified low-income Medicare beneficiary (SLMB), 3) Qualifying individual (QI), and 4) Qualified disabled and working individual (QDWI). These MSPs vary in terms of eligibility, what they help pay for, and federal asset limits. States determine which programs beneficiaries qualify for.

Historically, MSPs have had low participation. In 2020, just over 10 million people were enrolled in MSPs, with approximately 95% being in QMB and SLMB programs. MACPAC plans to refresh their previous work given that a number of policy changes are affecting MSPs, such as:

• Recently finalized rulemaking from CMS on streamlining eligibility and rulemaking.
• Significant growth in Medicare Advantage, particularly as MA plans have incentives to ensure beneficiaries are receiving assistance when eligible.
• The Inflation Reduction Act increasing low-income subsidy (LIS) eligibility to 150% of the federal poverty level, which differs from Medicaid eligibility for most MSPs. Anyone eligible for MSPs is eligible for the LIS, but beneficiaries eligible for the LIS are not automatically eligible for MSPs. States have the option to align these criteria.
• State treatment of assets, as there is an option for states to be more generous than the federal standard by increasing asset limits or eliminating asset tests.
• The enactment of the Affordable Care Act.

In the June 2020 MACPAC Report to Congress, MACPAC recommended states use the same definitions as the Social Security Administration (SSA) for the purposes of eligibility determinations to align with the LIS program and that SSA should transfer continuing LIS eligibility data to states on an annual basis for purposes of MSP eligibility renewal. In 2016, the Urban Institute prepared a report for MACPAC on participation in MSPs, finding that about 50 percent of eligible individuals enrolled in QMB and SLMB programs across 2009 and 2010. MACPAC is planning to conduct a follow-on analysis of the Urban Institute’s work to see how trends have changed over time and make inferences.

Commissioners supported MACPAC refreshing the MSP work. One commissioner highlighted the importance of seeing updated enrollment data to ensure that people who are eligible for MSPs are enrolled, with another noting that people often do not know MSPs are available to them. Another commissioner noted limitations related to geographic location, particularly in cases where a whole area has a high cost of living (e.g., DC) versus areas with a mix (e.g., Ohio). MACPAC plans to conduct interviews with federal and state officials to gain a better understanding of MSP enrollment and participation, including the role of federal funding, and efforts to facilitate enrollment. Depending on the findings, MACPAC staff will develop potential policy options for Commissioner consideration. MACPAC also hopes to have more data later this or early next year on MSPs and is continuing to consider what the Commission can contribute in terms of data analysis.

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This Applied Policy® Summary was prepared by Emma Hammer with support from the Applied Policy team of health policy experts. If you have any questions or need more information, please contact her at ehammer@appliedpolicy.com or at 202-558-5272.