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MACPAC Issue Briefs

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KFF Issue Brief Outlines Mandatory and Optional Medicaid Eligibility and Benefits

KFF published an issue brief describing federal mandatory and optional eligibility pathways and covered services in Medicaid. The brief explains how federal statute and regulations establish baseline coverage requirements while allowing states flexibility to expand eligibility and benefits beyond federal minimums. It serves as a reference guide for understanding the framework within which states design their Medicaid programs. The document provides foundational information on program structure rather than reporting new policy changes.

MACPAC

Federal Policy·36d ago

Medicaid Transitions for Youth with Special Health Care Needs Face Coverage and Benefit Gaps

Medicaid covers nearly half of all children and youth with special health care needs (CYSHCN), but when they age out of children's Medicaid and transition to adult coverage, they face significant changes to benefits, provider networks, and care coordination. These transitions can result in coverage gaps and disruptions in medically necessary services. The challenges are particularly acute for youth who rely on pediatric specialists, EPSDT benefits, and care coordination programs that do not continue into adult Medicaid. State Medicaid agencies and managed care organizations must address transition planning, benefit continuity, and provider capacity to support this population.

MACPAC

Federal Policy·36d ago

KFF Brief Examines Medicaid Reimbursement for School-Based Services Under IDEA

A KFF brief analyzes how Medicaid finances health and related services delivered in school settings for students with disabilities. Federal law allows state Medicaid programs to reimburse schools for covered services provided to Medicaid-enrolled children when medically necessary and included in an Individualized Education Plan (IEP). The brief addresses the intersection of Medicaid payment policy and Individuals with Disabilities Education Act (IDEA) requirements. This affects state Medicaid agencies' payment methodologies for school-based services and managed care organizations' responsibilities when schools are in-network providers.

MACPAC

Federal Policy·36d ago

CMS Data Shows 89,659 Enrollees in PACE Program as of 2023

The Program of All-Inclusive Care for the Elderly (PACE) served approximately 89,659 individuals in 2023, according to newly released demographic data. PACE provides fully integrated Medicare and Medicaid services to individuals age 55 or older who meet nursing facility level of care criteria but can live safely in the community. The report characterizes the demographic composition of PACE enrollees. PACE operates as an alternative to institutional long-term care, with states and CMS sharing financial responsibility for dual-eligible beneficiaries.

MACPAC

Managed Care·36d ago

MACPAC Brief Examines Children's Behavioral Health Service Use in Medicaid and CHIP

MACPAC published a brief analyzing behavioral health service utilization among children enrolled in Medicaid and CHIP, who experience higher rates of conditions like anxiety, depression, autism spectrum disorder, and ADHD compared to privately insured children. The brief reviews state coverage requirements for pediatric behavioral health benefits under Medicaid and CHIP. It provides context for managed care organizations and state agencies on access patterns and coverage obligations for this population.

MACPAC

Federal Policy·36d ago

KFF Brief Details State Medicaid Enterprise Systems Spending and Federal Oversight

KFF published an informational brief examining the IT systems states use to administer Medicaid programs, including claims processing, eligibility determination, and provider enrollment. The brief covers federal funding mechanisms for state Medicaid IT systems, CMS oversight requirements for systems modernization projects, and common implementation challenges states face. It provides context on how states finance and manage enterprise systems critical to program operations, enrollment, and payment accuracy.

MACPAC

Managed Care·36d ago

KFF Brief Examines PBM Role in Medicaid Drug Spending and Distribution

KFF published an issue brief analyzing pharmacy benefit managers' role in Medicaid drug distribution and their potential impact on program spending. The brief responds to recent policymaker and stakeholder concerns that PBM practices may be driving increased Medicaid drug costs. The analysis comes as states and CMS scrutinize PBM contracts with managed care organizations, including spread pricing, rebate retention, and formulary management practices. The brief provides background for state Medicaid agencies and health plans evaluating PBM contract terms and transparency requirements.

MACPAC

Federal Policy·36d ago

MACPAC Analyzes Fraud, Waste, and Abuse Measurement in Medicaid Program Integrity

The Medicaid and CHIP Payment and Access Commission (MACPAC) released an issue brief examining fraud, waste, and abuse in Medicaid using government data sources. The brief defines these program integrity concerns, reviews measurement methodologies, and provides an overview of federal and state program integrity responsibilities. The analysis identifies documented instances of integrity issues across the Medicaid program. This resource offers Medicaid agencies and managed care organizations a framework for understanding program integrity risks and measurement approaches as they design compliance and oversight strategies.

MACPAC