On June 15, 2021, the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) released one of their two annual Reports to Congress.[1]^,[2] The June report addresses high-cost specialty drugs in the Medicaid program; access to mental health services for Medicaid and Children’s Health Insurance Program (CHIP) enrollees; the use of EHR (Electronic Health Record) technology among behavioral health providers; and better integrating care through Medicare Advantage dual eligible special need plans (D-SNPs). Additionally, MACPAC includes a congressionally mandated report on Medicaid’s Non-Emergency Medical Transportation (NEMT) benefit.

MACPAC Addresses Accelerated Approval Drugs

MACPAC includes two recommendations on specialty drugs, specifically drugs approved under the Food and Drug Administration’s (FDA) accelerated approval pathway. These recommendations follow work MACPAC has done throughout the term, including an analysis of the drug pipeline and a technical advisory panel of drug policy and pricing experts from academia, the private sector, state Medicaid and federal officials, beneficiary advocates, providers, health plans, and drug manufacturers.

In this chapter, MACPAC makes the following recommendations to Congress with the goal of reducing the net cost for drugs approved through the accelerated approval pathway while preserving beneficiary access to these drugs under the Medicaid Drug Rebate Program (MDRP):

• Increase the minimum rebate amount on accelerated approval drugs. Once the product receives traditional FDA approval the minimum rebate percentage would revert to the standard amount.
• Increase the inflationary rebate on accelerated approval drugs if the manufacturer has not yet completed the confirmatory trial required by the FDA within a certain number of years.

As a result, drug manufacturers would be required to pay larger Medicaid rebates on any of their product going through the accelerated approval pathway.

MACPAC also suggests a new national drug benefit for cell and gene therapies that could allow for new coverage, payment, or rebate requirements without disrupting the MDRP for other outpatient drugs and address the high up-front costs, budget volatility, and uncertainty of these new therapies. MACPAC does not make a formal recommendation on this potential new benefit but the Commission notes that it would require Federal and state statutory and regulatory changes. The report highlights key considerations such as design choices and other implications of such a benefit.

MACPAC Addresses Mental Health Services Covered by Medicaid and CHIP

The June report includes a chapter focusing on the needs of adults with mental health conditions and the role of Medicaid and CHIP in supporting crisis services. The implementation of 9-8-8, the National Suicide Prevention Lifeline, is expected to increase demand for crisis services, and states need to adapt their infrastructure as a result. MACPAC makes the following recommendations, and plans to continue its work on behavioral health in future cycles:

• The Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse & Mental Health Services Administration (SAMHSA) should issue joint subregulatory guidance to states on how Medicaid and CHIP can be used to fund a crisis continuum for those experiencing behavioral health crises.
• CMS and SAMHSA should join in a coordinated effort to provide education and technical assistance to states on establishing and implementing such a behavioral health crisis continuum to respond to people in crisis in real time and consider options for federal funding such programs.

In addition, MACPAC included a chapter addressing the unmet behavioral health needs of children enrolled in Medicaid and CHIP and makes the following recommendations:

• CMS, SAMHSA, and the Administration for Children and Families (ACF) should issue joint subregulatory guidance that addresses the design and implementation of benefits for children and adolescents with significant mental health conditions covered by Medicaid and CHIP.
• These agencies should join in a coordinated effort to provide education and technical assistance to states on improving access to home- and community-based behavioral health services to children and adolescents with mental health conditions and consider options for federal funding such programs.

MACPAC Addresses Integrating Care Through Use of EHRs for Behavioral Health

Throughout this cycle, MACPAC has looked at how Electronic Health Records (EHRs) can be used to strengthen clinical integration and improve patient care, specifically in areas of substance use disorder and mental health conditions. Medicaid beneficiaries experience these at higher rates than those who are privately insured. Adopting certified EHR technology can improve communication between behavioral and physical health providers but adoption of these technologies among behavioral health providers remains low. MACPAC does not make any recommendations but will continue to examine this topic in the next year.

MACPAC Reports on Non-Emergency Medical Transportation

The Senate Appropriations Committee, in their report for Fiscal Year 2020, directed MACPAC to examine data on the benefits of Non-Emergency Medical Transportation (NEMT) from state Medicaid programs and to examine the benefits of improving local coordination of NEMT with public transportation and other Federally assisted transportation services. The Consolidated Appropriations Act of 2021 codified NEMT requirements into the Social Security Act. Prior to this, NEMT was required by regulation but not statute.

MACPAC conducted an environmental scan of state NEMT policies and interviews with state officials, focus groups with beneficiaries who have used NEMT and an analysis of administrative data on NEMT utilization and spending. The analysis found:

• In fiscal year (FY) 2018, there were over 60 million NEMT ride-days. State and federal spending on NEMT was $2.6 billion, excluding managed care payments to providers.
• The share of Medicaid beneficiaries who use NEMT was less than five percent in FY 2018, but NEMT played an important role in access to care for those relying on this transportation.
• The extent to which NEMT programs meet the needs of beneficiaries varies widely across and within states.
• Changes in the use of telehealth during the pandemic may affect the needs and use of NEMT as people will be able to access more care from home, however, NEMT will likely continue to play an important role in beneficiary access to care and addressing health inequities.

MACPAC Addresses Dual Eligible Special Needs Plans

Beneficiaries who are eligible for both Medicare and Medicaid often experience fragmented care and poor health outcomes due to lack of coordination between their program benefits. Integrated care models aim to address these challenges while reducing spending, however, only about ten percent of dual-eligible beneficiaries are enrolled in integrated care. During this cycle, MACPAC looked at ways states can use their contracts with Medicare Advantage dual eligible special needs plans (D-SNPs) to promote enrollment in integrated plans.

MACPAC identified ways states can exercise the authority to contract with D-SNPs given in the Medicare Improvements for Patients and Providers Act (MIPPA) in order to improve integration of services. Few states have fully exercised this authority, which may be due to limited experience using Medicaid managed care for dual eligible beneficiaries, lack of Medicare expertise, and competing priorities. States that have utilized their MIPPA authority have enrolled a large portion of their dual eligible population in integrated care. The Commission does not make formal recommendations on this topic but will continue to explore how federal policies could promote the use of MIPPA strategies and other approaches to integration in the next year.

[1] https://www.macpac.gov/publication/june-2021-report-to-congress-on-medicaid-and-chip/

[2] MACPAC is statutorily required to submit two reports to the Congress by March 15 and June 15 of each year. The reports include policy recommendations and also provide the Congress and public with a better understanding of the Medicaid and CHIP programs.